Prescribing medications for older patients presents its own set of challenges. Many medications need to be used with caution while suggesting them to the elderly because of age-related adjustments that affect pharmacokinetics (absorption, distribution, metabolism, and excretion) and pharmacodynamics (physiologic effects of the drug). Unfortunately, premarketing drug trials often do not include geriatric patients and therefore, doses are not adjusted for or approved for this population.
The process of prescribing for older adults is therefore, a complex one that includes selecting the appropriate drug, determining an age-appropriate dose and schedule, monitoring its effectiveness and toxicity, educating the patient about expected side effects, and including indications for seeking consultation. The drug therapy must be customized to optimally care for an older person as inappropriate prescription patterns may result in adverse consequences.
The increased composition of body fat relative to skeletal muscle increases the volume of distribution. The natural decline in renal function due to aging decreases the capacity to expel the drug from the body and leads to increased plasma drug concentrations in older people.
A previous study published in The British Medical Journal found a correlation between antidepressants and increased death rates and other adverse consequences among the elderly. It also revealed that the new antidepressants or selective serotonin reuptake inhibitors (SSRIs) may have greater risks than those associated with tricyclics or previous generations of antidepressants. SSRIs were associated with higher death rates, attempted suicide, falls, fractures, upper gastro-intestinal bleeding and heart attacks although they have been known to have fewer side-effects (e.g., dry mouth, constipation and cardiovascular complications). The study therefore questions their relative safety on older adults.
In a new study, researchers in Norway found that older adults with hip fracture due to fall had plasma levels containing antidepressants and anti-anxiety drugs at the time of hospital admission more frequently than the general older population, despite no information available in patients’ medical records. 250 patients above 65 years of age provided plasma samples for testing psychotropic drugs, weak opioid analgesics, and alcohol. The median age of the study population was 84 years, and most of the patients (76 percent) were women. Study results were published in the British Journal of Clinical Pharmacology in March 2017.
Of the 250 patients, 63 percent (158) had psychotropic drugs or analgesics or both, while alcohol was detected in 7.6 percent (19) patients. The researchers were surprised to find that most of the patients had diazepam, nitrazepam, SSRIs and mirtazapine in their blood— and doctors were not aware of their consumption. The findings indicated that several of the detected drugs increase the risk of falling.
Although the sample size for the study was much smaller than the reference population, it was found that use of antidepressants and anti-anxiety medications were more common among the patients admitted for hip fracture than in the prescriptions of older adults in the community.
Multiple medications including prescription-based and over-the-counter (OTC) ones are widely used by older adults due to associated health complications. Clinicians are often challenged with the need to maintain a balance so as not to over- or under-prescribe. Older adults are especially vulnerable to adverse side effects from inappropriate prescribing. Some even develop addiction to certain medications when used over time while others have to bear the side effects.
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