Medicines for Elderly

1. Introduction

Introduction

• Older adults often require medications to manage chronic conditions, but physiological changes with aging can affect drug metabolism and increase the risk of side effects.
• The goal is to use the fewest effective medications to achieve therapeutic goals while minimizing adverse effects.
• Common challenges include polypharmacy, drug interactions, and altered pharmacokinetics.

Key Considerations for Prescribing in the Elderly

1. Physiological Changes Affecting Drug Therapy

• Absorption: Generally unchanged, but conditions like reduced stomach acid may impact some medications (e.g., calcium carbonate).
• Distribution: Increased fat stores lead to prolonged half-life of fat-soluble drugs (e.g., benzodiazepines); reduced total body water affects water-soluble drugs (e.g., digoxin).
• Metabolism: Decreased liver metabolism (Phase I reactions) can prolong drug effects (e.g., opioids, benzodiazepines).
• Excretion: Decline in renal function reduces clearance of renally excreted drugs (e.g., aminoglycosides, NSAIDs).

2. Polypharmacy

• Defined as the use of five or more medications.
• Increases the risk of adverse drug reactions, drug-drug interactions, and non-adherence.

3. Medication Review

• Regularly evaluate the need, effectiveness, and safety of each medication.
• Use tools like the Beers Criteria and STOPP/START criteria to identify potentially inappropriate medications.

Common Conditions and Medicines for the Elderly

1. Hypertension

• Preferred Medicines:
  • ACE inhibitors (e.g., lisinopril).
  • Calcium channel blockers (e.g., amlodipine).
  • Thiazide diuretics (e.g., hydrochlorothiazide).
• Avoid: Alpha-blockers and centrally acting drugs due to increased fall risk and sedation.

2. Diabetes

• Preferred Medicines:
  • Metformin (if renal function allows).
  • DPP-4 inhibitors (e.g., sitagliptin) due to lower risk of hypoglycemia.
• Avoid: Sulfonylureas and high-dose insulin regimens due to hypoglycemia risk.

3. Chronic Pain and Arthritis

• Preferred Medicines:
  • Paracetamol (first-line for osteoarthritis).
  • Topical NSAIDs (reduce systemic exposure).
• Avoid: Long-term oral NSAIDs and opioids unless necessary due to GI, renal, and dependency risks.

4. Insomnia and Anxiety

• Preferred Medicines:
  • Non-drug therapies like cognitive-behavioral therapy (CBT) are first-line.
  • Short-term use of low-dose melatonin or trazodone may be considered.
• Avoid: Long-acting benzodiazepines (e.g., diazepam) and Z-drugs (e.g., zolpidem) due to fall risk and cognitive impairment.

5. Depression

• Preferred Medicines:
  • SSRIs (e.g., sertraline, citalopram).
• Avoid: Tricyclic antidepressants (e.g., amitriptyline) due to anticholinergic effects and risk of orthostatic hypotension.

6. Cognitive Impairment (Dementia)

• Preferred Medicines:
  • Acetylcholinesterase inhibitors (e.g., donepezil).
  • Memantine for moderate to severe cases.
• Avoid: Anticholinergics and benzodiazepines, which worsen cognitive function.

7. Constipation

• Preferred Medicines:
  • Bulk-forming laxatives (e.g., psyllium).
  • Osmotic laxatives (e.g., polyethylene glycol).
• Avoid: Stimulant laxatives for long-term use unless necessary.

8. Heart Failure

• Preferred Medicines:
  • ACE inhibitors/ARBs.
  • Beta-blockers (e.g., carvedilol).
  • Mineralocorticoid receptor antagonists (e.g., spironolactone).
• Avoid: NSAIDs and certain calcium channel blockers (e.g., verapamil).

Commonly Used Medications to Avoid in the Elderly (Beers Criteria)

• Benzodiazepines: Increased sedation and fall risk.
• First-Generation Antihistamines: Anticholinergic effects, cognitive impairment.
• NSAIDs: GI bleeding, renal toxicity.
• Anticholinergics: Confusion, constipation, urinary retention.

Side Effects of Medicines in the Elderly

Common Side Effects

• Drowsiness or confusion.
• Dizziness and increased fall risk.
• Constipation or urinary retention.

Rare but Serious Side Effects

• Delirium from opioids or anticholinergics.
• Renal failure from NSAIDs.
• Hypoglycemia from sulfonylureas.

Monitoring and Follow-Up

• Regular renal and liver function tests for drugs with hepatic or renal metabolism.
• Monitor blood pressure and electrolyte levels for antihypertensives and diuretics.
• Assess for signs of toxicity or side effects during routine visits.

Patient Counseling Points

• Take medications exactly as prescribed; avoid skipping doses or doubling up.
• Use a pill organizer or medication tracker to ensure adherence.
• Avoid self-medicating with over-the-counter drugs or supplements without consulting a doctor.
• Report unusual symptoms like confusion, dizziness, or unusual bleeding promptly.
• Maintain a list of all medications, including supplements, to share with healthcare providers.

FAQs About Medicine Use in the Elderly

Q1: Why are elderly patients more sensitive to medications?

• Aging affects drug metabolism, distribution, and excretion, making older adults more prone to side effects and toxicity.

Q2: What is polypharmacy, and why is it a concern?

• Polypharmacy refers to using multiple medications, increasing the risk of interactions, side effects, and non-adherence.

Q3: How often should medications be reviewed?

• At least once a year or whenever there is a new health condition or medication change.

Q4: Can elderly patients take NSAIDs for arthritis?

• NSAIDs should be avoided or used sparingly due to risks of GI bleeding and kidney damage; paracetamol is safer.

Q5: What should elderly patients do if they miss a dose?

• Take it as soon as remembered unless it’s close to the next dose; never double up doses.

Q6: How can I reduce the risk of falls while on medications?

• Avoid sedatives, ensure proper lighting, and use assistive devices if necessary.

Q7: Can herbal supplements interact with prescribed medications?

• Yes, supplements like ginkgo biloba and St. John’s Wort can interfere with blood thinners and antidepressants.

Q8: Are antidepressants safe for elderly patients?

• SSRIs like sertraline are safer than older drugs like tricyclic antidepressants.

Q9: What medications should be avoided in elderly patients with dementia?

• Avoid anticholinergics and benzodiazepines, as they worsen cognitive impairment.

Q10: How can elderly patients manage medication schedules?

• Use a pill organizer, set reminders, or seek help from caregivers.

Q11: Are there safer alternatives to sleeping pills for the elderly?

• Yes, non-drug therapies like good sleep hygiene and melatonin are safer options.

Q12: Why are diuretics risky for elderly patients?

• They can cause dehydration, electrolyte imbalances, and increased fall risk.

Q13: What are the signs of medication toxicity in the elderly?

• Symptoms like confusion, severe drowsiness, or unusual bleeding may indicate toxicity.

Q14: Can elderly patients use over-the-counter pain relievers?

• Paracetamol is safer than NSAIDs; consult a doctor before use.

Q15: How can caregivers help manage medications for elderly patients?

• Monitor for side effects, help organize medications, and accompany them to doctor visits for medication reviews.