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Offerhaus, L. (Ed.), 1997, Drugs for the elderly. Retrieved on 12th March 2010 from
http://www.euro.who.int/documents
BNF 58 online http://bnf.org/bnf/bnf/current/index.htm
The prescription of drugs for the elderly poses additional complications than that of typical
medication in the younger populations in the concurrent disease are the norm rather than the
exception. This exposes a much greater risk of adverse interactions and of side effects
(Offerhaus L. (Ed.), 1997)
Loss of manual dexterity, eyesight and deteriorating memory may all contrive to make drug
regime more prone to errors of over or under medications. Exceptions to normal drug kinetics
and dynamics are more common in elderly people and a loss of reserve functional capacity of
heart, liver and kidneys add to the vulnerability of elderly people to drug regimen.
Ageing can affect absorption in a number of ways. Absorption is altered due to increased
stomach pH, decreased intestinal blood flow, changes in intestinal mobility. The distribution
once absorbed changes as body lean mass decreased as does water, an increase in body fat
and a decrease in plasma albumin. As a broad generalisation distribution of water soluble
drugs decreases whilst fat soluble will be better distributed. The changes in plasma levels may
lead to reduce plasma half life of the drugs and more rapid elimination. With kidney disease
the filtration rate is slowed by up to 30% causing delayed elimination of drugs.
Drug interactions as a result of multi administration of drugs is directly related to the number
of drugs prescribed so in the elderly who tend to be taking more concurrent medication this is
a significant problem. Impaired balance leads to more severe and frequent postural
hypertension leading to more falls. Their ability to regulate their own body temperature makes
them more subject to drug related hypothermia.
Adverse drug reaction have been reported in one study at 18% for those on 6 drugs or less
and 80% on more than 6 drugs. Admission to the geriatric ward showed 10-20% are suffering
from adverse drug reactions.
Common drugs in the elderly:
Gastric disorders...
Antacids
Histamine H2 receptor agonists c, Ranitidine (caution renal impairments)
Proton pump inhibitors Omeprazole (caution hepatic impairments)
Anticoagulants
heparin
Anaemia
Iron Ferrous fumurate gluconate sulphate or sulphate dried.
Taken orally can lead to faecal impaction in the elderly.
Cardiac glycosides - control rapid ventricular rate
Digoxin and digitoxin - therapeutic not maintenance too many side effects, renal function
important in dose or digoxin and hepatic function important in digitoxin,
Diureticss effective for cardiac failure as are ACE inhibitors esp enalapril
Diuretics thiazide and related are used in low doses to lower BP. Loop for pulmonary oedema..
Care must be taken in the elderly because of side effects. Should not be used for gravitational
oedema.
Anti arrhythmia drugs
Most depress heart tissue and can cause postural hypotension and heart failure. If tachycardia
in transitory it is important that treatment stop as soon as the patient has reverted to normal
sinus rhythm. Cardiac arrhythmia's in the elderly are frequently caused by drugs. Dioxin can
cause just about any disturbance of rhythm and beta blockers are also frequent culprits.
Membrane stabilizing drugs like mexiletine or quinidine,
Beta blockers
Propafenone
Amiodarone
Calcium agonists like verapamil
Cardiac glycosides
Angina drugs
use of glyceryl trinitrate, adverse reactions are frequent, most useful prophylactically but if
long term treatment is required then beta blockers, calcium antagonists - verapamil,
nifedipine, dilitiazem
or long acting nitrate preparations - isorbide mononitrate and dinitrate can be used.
Beta blockers disappointing in older people, contraindication include athersclerosis, chronic
airflow limitations and cardiac failure. Drugs include propanolo, sotalol, atenolol, metoprolol.
Hypertension
Diuretics - hydrochlorathiazide, bendroflumethiazide, chlortalidone
Beta blockers same as for angina
Calcium blockers all dihydropidine analogues
Ace inhibitors
Lipid lowering for those with high cholesterol
HMG-CoA reductase inhibitors - levostatin, simvastatin, pravastatin
Corticosteroids
To be avoided in the elderly as cause loss of bone and therefore fractures, hypertension,
initiation or exacerbation of peptic ulcer, at best insomnia at worst psychosis, worsening of
diabetes and reduced resistance to infections such as tuberculosis.
There are exceptions but generally not suitable for the elderly even in injection or inhalant
versions.
Thyroid medications levothyroxine
Antithyroid carbimazole, propylthiourcail, potassium iodide, propanolol
Antimicrobial
UTI co-trioxazole, amoxiciliin
Chest penicillin
Bowel erythromycin or metronidazole
Antiarthritis
NSAID all cause gastrointestinal disturbance, fluid retention and neurological function deficit.
Many cause serious interactions with other drugs especially the coumarin anticoagulants.
napraxone
ibuprofen are some of the best tolerated in the elderly.
Antidepressant
Tricyclic
SSRI
+ve
Aspirin Gan Cao reduces side effects of gastro intestinal
-ve
Patient: Male 73 years old has a stroke the previous November, a hemorrhagic type. He had
hemiplegia with spasms, no control of left arm or leg.
Initial prescription:
Shu Di Huang
15 blue pop: not for diarrhea or indigestion
Shan Zhu Yu
5 not in difficult urination
Rou Cong Rong
5 safish
Ba Ji Tian
5 safeish antagonist to Dan Shen
Yin Yang Huo
10 large dose respiratory arrest, could cause hyperkalemia if used with
potassium sparing diuretics.
Shi Hu
15 safeish not for use in early warm disease
Mai Men Dong
15 not with Ku Shen or Bai Mu Er
Shi Chang Pu
5 antagonizes Ma Huang adverse reactions liv wind….also mood, phlegm
Yuan Zhi
5 not with gastrointestinal ulcers….also mood, phlegm
Fu Ling
15 not if frequent copious urination
Wu Wei Zi
5 safeish, heartburn
Subsequent prescription:
Shu Di Huang
Shan Zhu Yu
Rou Cong Rong
Ba Ji Tian
Yin Yang Huo
Huang Jing
Mai Men Dong
Fu Ling
Wu Wei Zi
Tian Ma
Ji Xue Teng
Gou Teng
15
5
5
5
10
10 ????
15
10
5 would affect if paracetamol but not
5 ???? more spasms
5 ???? more spasms
10 ???? more spasms
Enalapril ACE inhibitor for hypertension n/a rchm
Ranitidine H2 antagonist reduces stomach acid /a rchm
Citalopram SSRI for depression n/a rchm
Baclofen for spasms and to relax muscles n/a rchm
Gabapentin GABA mimic relieves neuropathic pain n/a rchm
Metformin anti diabetic (hu lu ba would interact)
Diprobase cream for inflamed, damaged skin - basic moisturiser n/a rchm
Senna laxative (diarrhoa or purgatives) n/a rchm
Simvastatin Statin for high cholesterol (v careful of grapefruit juice and Hong Qu)
Amitryptiline Tricylcic antidepressant n/a rchm
Quinine Sulfate used for leg cramps but is antipyretic, antiinflammatory and analgesic n/a
rchm
No known interactions with any herbs prescribed.
Tongue red peeled, cracks all over, deviated to right, no distended sublingual He dip in tip.
Pulse moderate, regular, present at all positions left thready, right slippery.