How to treat the elderly?
Why do medications cause side effects in the elderly without therapeutic
Alexander Hadzhidis, Chief Clinical Pharmacologist of St. Petersburg, explains to the readers of Doctor Peter why a special approach to prescribing medications is needed in geriatrics and what is fraught with thoughtless or illiterate recommendations.
– About 60 percent of pharmacy visitors are elderly people. Taking the purchased medicines, 60 percent of them make mistakes, – Alexander Hadzhidis notes. – If we compare the manifestation of side effects in young and elderly people, it turns out that people over 60 years of age have a 1.5–2 times higher risk of their development than young people. In 70 – 79-year-olds, drug pathology develops 7 times more often than in 20 – 29-year-olds.
The use of medicines for everyone, of course, is fraught with problems, but the older a person is, the more pronounced they are. And this required the development of a whole section of clinical pharmacology of medicines used taking into account the age-related features of pharmacodynamics (the mechanism of action of drugs on the human body) and pharmacokinetics (the regularity of absorption, distribution and isolation of drugs), which lead to a change in the dose/effect ratio of the prescribed medication. The main causes of this phenomenon are: a decrease in the metabolic rate of drugs; a decrease in the penetration of drugs into tissues; a decrease in the functional capabilities of the kidneys; a decrease in the detoxification function of the liver; an increase in the relative content of adipose tissue in the body; deterioration of peripheral blood flow and changes in the permeability of the vascular wall and tissue barriers; a decrease in the binding of drugs to blood proteins; a change in the sensitivity of receptors.
Why older people refuse treatment Elderly people have to be treated for a long time, and considering that in addition to the main disease, a long list of concomitant diseases has already been acquired, they are prescribed a huge amount of medications.
Most often in geriatric practice, psychotropic drugs are used (antidepressants – paroxetine amitriptyline, sedatives – phenazepam, diazepam), hypotensive (diuretics – indapamide, hypothyazide, ACE inhibitors – enalapril, perindopril, beta blockers - bisoprolol, carvedilol, nebivolol, calcium antagonists – verapamil, nifedipine), nonsteroidal anti–inflammatory (dicrofenac, ketorolac, naproxen, ibuprofen, aceclofenac...), hypoglycemic agents, bronchodilators (theophyllins and beta-2 agonists – salbutamol, phenoterol), antianginal drugs (nitroglycerin, mono- and dinitrate preparations).
An increase in the number of prescribed medications and the frequency of their daily intake is one of the main reasons why the elderly often refuse treatment or interrupt it. It has been established that in the elderly, adherence to treatment is also violated for other reasons, these are: the duration of treatment; the need to change life stereotypes; the increasing severity of the disease and, as a consequence, social isolation; the high cost of medication.
Treatment with side effects One of the main problems in geriatric pharmacotherapy is side effects.
Unpredictable side effects depend on individual characteristics, and these effects are almost impossible to predict. But they can also develop as a consequence of an absolute or relative overdose of drugs. The manifestations of side effects and drug complications in elderly and senile people are different, they are often atypical, and can manifest a variety of all possible reactions. They are associated with the use of the following groups of drugs: cardiac glycosides and antiarrhythmic drugs – for example, amiodarone – provokes thyroid dysfunction – in 26.9% of cases, hypotensive agents (ACE inhibitors cause cough, beta-blockers – metabolic disorders, bronchospasm) – 12.3%, nonsteroidal anti-inflammatory drugs (non-selective (dicrofenac, ketorolac, naproxen, ibuprofen, aceclofenac) – provoke damage to the gastrointestinal tract, selective (celecoxib, meloxicam) – increased risk of thrombosis, nimesulide – risk of liver damage with prolonged use) – 19.7%, antibiotics (aminoglycosides – dangerous due to damage to the hearing organs, that is, ototoxic, almost all antibiotics cause antibiotic-associated diarrhea) – in 12.5% of cases.
Depression is one of the most characteristic drug reactions in the elderly, caused, as a rule, by the simultaneous administration of several psychotropic substances with benzodiazepine drugs against the background of increased sensitivity of the central nervous system to drugs (most often it is phenazepam, mesapam, diazepam, alprozolam, as well as in combination with sleeping pills (phenobarbital), neuroleptics, anticonvulsants (carbamazepine, haloperidol). It is especially acute in combination with alcohol.
Absolute overdose most often happens due to the conscious intake of an increased dose, as well as due to forgetfulness against the background of ischemic and sclerotic processes in the brain - the patient can take the dose again. Relative overdose is possible, contrary to the information provided about the dosage of the drug in its instructions, due to the peculiarities of physiology, which were discussed above.
The likelihood of developing withdrawal syndrome is another feature of pharmacotherapy in the elderly and senile age. Example: after the sudden withdrawal of frequently used antihypertensive drugs (listed above, but the syndrome is especially acute when taking old-generation drugs with low selectivity, such as clofellin), a vegetative reaction, tachycardia, and hypertensive crisis quickly occurs.
How to treat the elderly?In accordance with three principles: rationality, controllability, individualization.
The tactics of choosing drug therapy involves the use of low-toxic drugs, the appointment of lower doses compared to the recommended instructions (we are talking about both drugs for oral administration and parenteral administration). It is known that some medications (for example, neuroleptics, cardiotonics, diuretics, etc.) are recommended for the elderly at an initial dose, on average half the dose of a middle-aged person.
Too little attention is paid to the peculiarities of pharmacokinetics and pharmacodynamics of the elderly in the university course. The lack of knowledge in this area among attending physicians in combination with another objective factor (the "different" behavior of the drug in an elderly body) can provoke a rapid manifestation of a side effect in the patient, sometimes without achieving a therapeutic effect at all.
In general, drug therapy for the elderly and the treatment process as a whole, including going to a pharmacy, a medical institution, communicating there with pharmacists and doctors, employees of these institutions at any level, has mainly a psychological effect. Such communication in general gives people hope, faith, and only then assumes the realization of the actual healing ability of the medicine. Therefore, it is extremely important not to deceive our old people at least in their naive hopes, both without overestimating and not underestimating the importance of medicines.
Portal "Eternal youth" http://vechnayamolodost.ru15.10.2014