Drugs may be ineffective in the elderly because they do not have enough doctors prescribe (z. B. because of increased concerns about adverse effects) or because the compliance is poor (eg. As a result of financial or cognitive impairment).
Associated drug problems occur in the elderly frequently, these include drug ineffectiveness, adverse drug reactions, overdosing, underdosing and interactions with other medications. Drugs may be ineffective in the elderly because they do not have enough doctors prescribe (z. B. because of increased concerns about adverse effects) or because the compliance is poor (eg. As a result of financial or cognitive impairment). Adverse drug effects are effects that are undesirable, unpleasant or dangerous. Common examples are oversedation, confusion, hallucinations, falls and bleeding. For non-bedridden patients ? 65 years of adverse drug reactions occur at a Häufigkeitvon to about 50 events per 1000 person-years. The hospitalization rates due to adverse events are four times higher in older (about 17%) than in younger patients (4%). Reasons for drug-associated problems Adverse drug reactions may occur in each patient, but older people are more vulnerable due to certain features. Older people take for. As often many medications (polypharmacy) and have age-related changes of pharmacodynamics and pharmacokinetics; both of which increase the risk of side effects. Adverse drug reactions can occur at any age, even if the drugs were prescribed and taken correctly; Emerging allergic reactions are for. As unpredictable or avoidable. However, adverse effects are probably preventable in almost 90% of cases in older people (compared with only 24% in younger patients). Certain classes of drugs are often involved: antipsychotics, warfarin, antiplatelet agents, hypoglycemic drugs, antidepressants and sedative hypnotics. In elderly patients, a number of common causes of adverse drug reactions, for ineffectiveness or both preventable (s. Preventable causes of drug-related problems). Some of these reasons include the lack of communication with the patient or between the medical professionals (particularly at transitions within the health care). Preventable causes of drug-related problems Category Definition drug interactions The use of a drug leads to interactions between two drugs, the interaction of drugs with food, with supplements or illness that lead to side effects or reduced effectiveness. Inadequate monitoring a medical problem is indeed treated with the right medication, but the patient is regarding inadequate. Complications monitored and / or efficacy. Inappropriate selection of drugs A medical disorder that requires drug therapy is treated with a sub-optimal drug. Improper handling a patient takes a medication without a valid medical reason. Lack of adherence The right drug to treat a medical disorder is indeed prescribed, but the patient is not taking one. Overdose medical disorder is treated with high doses of the right drug. Inadequate communication medicines continue in an inappropriate manner or discontinued if the supply of providers and / or equipment changes. Inadequate prescribing a medical disorder is treated with small doses to the right drug. Untreated medical disorder A medical disorder requiring medical treatment, but it is used no medication to treat it. Interactions between drugs and diseases that is given to treat a disease A drug can regardless of the age of the patient worsen another disease; Such interactions in the elderly, however, of particular importance. It is difficult to distinguish often barely noticeable adverse effects of effects of the disease (s. Interactions between drugs and diseases in the elderly (after American Geriatrics Society 2012 Beers Criteria Update)), and this can lead to prescribing cascade. A prescription cascade occurs when the unwanted effect of a drug misinterpreted as symptoms or signs of a new disease and a new drug is prescribed to treat them. The new, unnecessary medicine can cause additional unwanted effects that could in turn misinterpreted as another new disease, and unnecessary treatment etc. Many drugs have side effects, the symptoms that are common in the elderly, or similar to age-related changes. In the following examples are given: antipsychotics can cause symptoms that resemble Parkinson’s disease. In the elderly, these symptoms may be diagnosed as Parkinson’s disease and treated, resulting in potentially adverse effects of anti-Parkinson drugs (eg. As orthostatic hypotension, delirium, Überkeit). Cholinesterase inhibitors (eg. As donepezil) patients may be prescribed with dementia. These drugs can cause diarrhea or urinary incontinence. The patient an anticholinergic (z. B. oxybutynin) can then be prescribed against the emerging symptoms. Thus, an unnecessary drug is added taken and increases the risk of adverse drug reactions and drug interactions. A better strategy is to reduce the dose of the cholinesterase inhibitor or pull another dementia treatment with a different mechanism of action (eg. As memantine) into consideration. In elderly patients, prescribers should always keep in mind that a new symptom or sign may be due to pharmacotherapy. Interactions between drugs and diseases in the elderly (after American Geriatrics Society 2012 Beers Criteria Update) disease drug Adverse Cardiovascular heart failure Cilostazol, COX-2 inhibitors, dronedarone, calcium channel blockers of the dihydropyridine type * (diltiazem, verapamil), NSAIDs, pioglitazone, Can promote rosiglitazone fluid retention and worsen heart failure. Syncope acetylcholinesterase inhibitors, chlorpromazine, peripheral ?-blockers (doxazosin, prazosin, terazosin), tertiary TZA, thioridazine, olanzapine Increased risk of orthostatic hypotension and bradycardia CNS Chronic seizures or epilepsy bupropion, chlorpromazine, clozapine, maprotiline, olanzapine, thioridazine, thiothixene, Tramadol reduced seizure threshold in patients with well-controlled seizures, where alternative means were not effective, may be acceptable delirium All TCAs, benzodiazepines, Arzne I average with anticholinergic effects, chlorpromazine, corticosteroids, H2-receptor blockers, meperidine, sedative hypnotics, thioridazine Deteriorating delirium in older adults with delirium or high Delirrisiko When the deposition of drugs is regularly should be tapered to avoid withdrawal symptoms of dementia and cognitive impairment antipsychotics (long-term use, and if necessary use), benzodiazepines, drugs that have anticholinergic effects, H2 receptor blockers, zolpidem Adverse effects on the CNS in antipsychotics increased risk of stroke and mortality in patients with dementia falls or fractures i n history anticonvulsants, neuroleptics, benzodiazepines, hypnotics Nichtbenzodiazepin (eszopiclone, zaleplon, zolpidem), TZA, SSRI ataxia, impaired psychomotor function, syncope and other falls; Short-acting benzodiazepines (used Can if safer alternatives are not available) is not safer than long-acting avoid anticonvulsants, except for seizure disorders insomnia Oral applicable decongestants (pseudoephedrine, phenylephrine), stimulants (amphetamine, methylphenidate, pemoline), Theobromine (theophylline, deteriorating caffeine) CNS stimulant effect Parkinson antiemetics (metoclopramide, prochlorperazine, promethazine), antipsychotics (except quetiapine and clozapine) dopamine receptor antagonists have the potential Parkinson’s symptoms (less likely with quetiapine and clozapine) Gastrointestinal tract Chronic constipation drug with anticonvulsant and anticholinergic activity (antipsychotics, belladonna alkaloids, Clidinium-chlordiazepoxide, dicyclomine, hyoscyamine, propantheline, scopolamine, tertiary TCAs [amitriptyline, clomipramine, doxepin, imipramine and trimipramine]), the first-generation antihistamines (brompheniramine carbinoxamine , chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, diphenhydramine, doxylamine, hydroxyzine, promethazine, triprolidine) calcium channel blockers of the dihydropyridine type (diltiazem, verapamil), oral antimuscarinic agents for urinary incontinence (darifenacin, fesoterodine, oxybutynin, solifenacin, tolterodine, trospium) can aggravate constipation; Agents for urinary incontinence: antimuscarinics generally differ in the incidence of constipation; variable react; consider alternative means when constipation developed stomach or Zwölffingerdarmulzera a history of aspirin (> 325 mg / day), non-COX-2 selective NSAIDs aggravating existing ulcers or cause new ulcers Avoid unless other alternatives are not effective and the patient can take a gastric protective agent (eg. as a proton pump inhibitor or misoprostol) renal and urinary Chronosche renal diseases (stages III and IV) NSAIDs, triamterene Increased risk of renal failure Urinary incontinence decrease (all types) in women estrogen, oral and transdermal (without intravaginal estrogen) Aggravated incontinence lower urinary tract symptoms, benign prostatic hyperplasia drug with strong anticholinergic effects (except antimuscarinic agents for urinary incontinence), inhalational agents with anticholinergic effects can urine flow and urinary retention in men cause stress and mixed incontinence ? blockers (doxazosin, prazosin, terazosin) aggravated incontinence in women * Avoid Only in patients with systolic heart failure. COX-2 = cyclooxygenase-2, TCA = tricyclic antidepressants. Adapted from The American Geriatrics Society 2012 Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society 60: 616-631, 2012. Clinical Calculator: QT interval correction (ECG) drug interactions Because older people often einnhemen many medications, they are particularly vulnerable to drug interactions. Older people also often medicinal herbs and other dietary supplements (dietary supplements), without saying this to their healthcare providers. Medicinal herbs can interact with prescribed drugs and lead to adverse effects. Ginkgo biloba extract in combination with warfarin z can. B. increase the risk of bleeding, and St. John’s wort in combination with a SSRI the risk of serotonergic syndrome. Therefore, the doctors, patients should specifically for dietary supplements, incl. Herbs and vitamin supplements, ask. Drug interactions in the elderly differ little from those in the general population. However, the induction of cytochrome P-450 (CYP 450) can metabolism (drug metabolism) by certain drugs may be reduced in elderly patients (e.g., phenytoin, carbamazepine, rifampicin.); Therefore, the change (increase) of the drug metabolism in the elderly may possibly be less pronounced. Numerous other drugs inhibit the CYP450 metabolism and thus increase the risk of drug toxicity, which depends on the route of excretion. Because older people usually take a greater number of drugs, they are at higher risk of multiple, difficult to predict CYP450 interactions. Concomitant use of ? 1 drug with similar side effects and the risk or severity of adverse effects erhöhen.Mangelhaftes monitoring can Medicines Monitoring includes documentation of indication for a new drug performing a current list of medications, which occupies the patients in the regarding patient record monitoring the achievement of the goals of therapy and other reactions to new drugs monitoring of the necessary laboratory tests. efficacy or side effects Periodic review whether the drugs are still needed, such measures are especially important for elderly patients. Lack of close monitoring, v. a. by prescribing new drugs, increasing the risk of side effects and ineffectiveness. Criteria in order to facilitate monitoring were developed by the expert panel of the Health Care Financing Administration as part of the assessment criteria for medicinal products. The criteria illuminate a particularly unangemesse dosage or duration of therapy, treatments and possible double Arzneimittelinteraktionen.Unangemessene drug selection A drug is not appropriate if the potential damage is greater than its potential benefits. Inappropriate use of a pharmaceutical composition may involve an unsuitable drug, an incorrect dose, dosing frequency, or duration of therapy double treatments non-compliance with drug-drug interactions and correct indications of a medicament A which is continued by mistake when an acute disease is resolved which may occur (when patients appropriate medication from are laid one setting to another) Adverse effects of inappropriate drugs are responsible for about 7% of the emergency even hospitalization in patients ? 65 years old, and 67% of these hospitalizations are zurükzuführen 4 drugs or drug classes – warfarin, insulin, oral antiplatelet agents and oral agents , Some medicines coffers are in the elderly is of particular importance (categories questionable drug in the elderly). Some drugs are so problematic that they should be completely avoided in the elderly, some should be vermiden only in certain situations, and but others can be used with increased caution. The Beers criteria (. S interactions between drugs and diseases in the elderly (after American Geriatrics Society 2012 Beers Criteria Update)) list of possible unangemesse drug after drug class for the elderly; there are also similar lists. However, there is currently no comparable lists of drugs that should be used in the elderly; doctors must weigh the benefits and risks of therapy in each patient. Despite the Beers- and other criteria unangemesse medications older people are still being prescribed; usually about 20% of elderly residents of unsupervised homes received at least one unangemesses drugs. In such patients, the risk of adverse effects is increased. In patients in the nursing home the improper use also increases the risk of hospitalization and death. In a study among hospitalized patients 27.5% were given a not appropriate drug. Some inappropriate medications are available over the counter; So doctors should ask patients specifically for use of over the counter medicines and advise patients about the potential problems that may cause such preparations. Older people often get medication (typically analgesics, H2 blockers, hypnotics or laxatives) with mild symptoms (incl. Side effects of other drugs), which should be treated better not medically or by dose reduction of the drug that is causing the unwanted effects. The initiation of additional drugs is often not appropriate; the benefits can be low and the cost increases, and the new drug may lead to additional toxicity. To solve the problem of misuse in the elderly, it takes more than just avoiding a short list of medications and the finding of the drugs in question categories. The entire medication a patient should also regularly concerning. The potential benefit or harm rated werden.Mangelnde adherence The effectiveness of drugs is often thwarted by non-adherence in non bedridden elderly. Adherence is influenced by numerous factors, but not the age itself. Up to 50% of elderly patients take a drug improperly, usually less taken as prescribed (lack of / inadequate adherence). The reasons are the same as in younger adults (keeping a medication scheme (adherence, compliance)). In addition, the following reasons contribute to this: Financial and physical limitations that can make the purchase of medicines Cognitive problems that the prescribed medication difficult use of multiple medications use of drugs that are several times to take a day or in a particular kind of difficulty understanding it what effect a drug (benefits) or how to detect adverse effects or treated (damage) a treatment plan with too frequent to rare dosing, multiple medications, or both may be for patients difficult to follow. Doctors, patients should respect health knowledge and the ability to adhere to a medication assess (eg. As dexterity, hand strength, cognition, vision) and try to address their limitations wear-by,. be as provided or recommended: easily accessible containers, labels and patient information in large print, features of the containers with a reminder alarm, loading of containers with daily medication needs, calls for a reminder or medication assistance. Pharmacists and nurses can help by explaining elderly patients at each encounter the regulatory provisions and go with them. Pharmacists can identify a problem by making note of whether patients receive timely subsequent regulations, or whether a prescription illogical or incorrect erscheint.Überdosierung An elderly patient may be prescribed too high a dose of a suitable drug when the doctor’s age-related changes, the pharmacokinetics influence (pharmacokinetics) and pharmacodynamics (pharmacodynamics), not observed. Doses of drugs with renal elimination should be set, for example, in patients with impaired renal function. Even if the required doses vary greatly from person to person, drugs in the elderly should generally be initiated at the lowest dose. Typically, about one-third to one-half the usual dose for adults is for initial doses displayed in a drug with a narrow therapeutic index, or if another fault could be degraded by a drug. The dose is then provided to the desired effect auftritriert as is tolerated. Increasing the dose the patient should be assessed on adverse effects, and the drug levels should be monitored as possible. An overdose can also occur when drug interactions (drug-associated problems in the elderly: drug interactions) increase the available amount of the drug or when different doctors prescribe a drug and do not know that another has committed the same or a similar drug (therapeutic duplication) .Unzureichende the communication insufficient transfer of medical information at transitions (from one setting to the other) caused up to 50% of all medication errors and up to 20% of adverse drug reactions in the hospital. In discharge of patients from the hospital, it may happen that a medication that was begun in the hospital and needed only there (z. B. sedative hypnotics, laxatives, proton pump inhibitors), by another doctor who does not communicate with the previous doctor is unnecessarily continued. Conversely, lack of communication can when incorporated into a medical device for unintended omission of a medicament necessary führen.Unzureichende prescribing For example, for obtaining the maximum effectiveness can few suitable drugs are prescribed / not used. Prescribing appropriate to few drugs can increase morbidity and mortality and reduce quality of life. Doctors should prescribe drugs more drugs in adequate doses and when indicated. are often too little prescribed in the elderly medications used to treat depression, Alzheimer’s disease, pain (eg. as opioids), heart failure, Z. n. myocardial infarction (?-blockers), atrial fibrillation (warfarin), hypertension, glaucoma and incontinence , Also, vaccinations are not always carried out as recommended. Opioids: doctors prescribe older patients with cancer or other chronic types of pain often reluctant to opioids, typically due to concerns about side effects and the development of dependence (eg, sedation, constipation, delirium.). Opioids are prescribed, the doses are often not sufficient. The lack of prescribing opioids for some elderly patients mean unnecessary pain and discomfort; older patients more likely to report insufficient pain treatments than younger adults. ?-blockers: These drugs reduce in patients with myocardial infarction and / or history of cardiac failure the mortality and hospitalization; this is also true for older patients at high risk for complications (eg., patients with lung disease or diabetes). Antihypertensive agents: There are guidelines for the treatment of hypertension in the elderly is available, and the treatment appears to have benefits (and to reduce the risk of stroke and major cardiovascular events). Nevertheless, studies show that hypertension is often not brought under control in the elderly. Pharmacotherapy in Alzheimer’s disease: For acetylcholinesterase inhibitors and NMDA (N-methyl-D-aspartate) antagonists has been shown to benefit patients with Alzheimer’s dementia of them. It is unclear how much of the benefit is, however, patients and relatives should be the possibility of an informed decision on their applications granted. Anticoagulants: Anticoagulants reduce the risk of stroke in patients with atrial fibrillation. Although there is an increased risk of bleeding with anticoagulants, some older adults who could still benefit from anticoagulation, they do not receive. Vaccinations: Older adults have an increased risk of morbidity and mortality from influenza, pneumococcal infection and herpes zoster. The vaccination rates in older adults can be improved. In elderly patients with a chronic disease acute or related disorders may be undersupplied (hypercholesterolemia can be untreated with emphysema z. B. in patients). Doctors can refuse these treatments because they are concerned about Nebenwirkunsgrisikos or because of the time required to benefit from the treatment. Doctors may think the treatment of the primary disorder is all that patients can treat or want, or that the patient could not afford the additional drugs. Patients should be involved in the decision about the drug treatment, so doctors can understand the priorities and concerns of patients. to reduce prevention before attaching a new drug To reduce the risk of adverse drug reactions in the elderly, the doctor should do the following before a new drug is set: A non-drug treatment considering goals of care with the patient to discuss the indication for the new drug document ( to avoid unnecessary medications) check Age-related changes in the pharmacokinetics or pharmacodynamics and their effect on the required dosage observe the safest possible alternative select (eg. as acetaminophen instead of NSAIDs in non-inflammatory arthritis) potential interactions of drugs with disease and with other medications with a low dose begin So few Me dikamente as necessary using comorbidities and their chance to contribute to adverse drug reactions, determine the use and side effects of each drug explain Clear instructions feedbacks about how patients should take their medication (incl. Drug and brand name, spelling each drug name, indication for each drug and explanation of formulations containing more than one active ingredient) and how long the drug will probably be necessary to foresee confusion caused by similar sounding drug names and point out all the names that could be confused (. eg Glucophage and Glucovance®) after application of a drug, the following should be done after preparation of a drug: Walk to the evidence to the contrary from the assumption that a new symptom is drug-related (to avoid prescribing cascade). Überwachen Sie die Patienten auf Anzeichen von unerwünschten Arzneimittelwirkungen, inkl. Wirkstoffspiegelbestimmungen und anderen notwendigen Labortests. Dokumentieren Sie das Therapieansprechen und erhöhen SIe die Dosen nach Bedarf, um die gewünschte Wirkung zu erzielen. Die Notwendigkeit, die medikamentöse Therapie fortzusetzen und Medikamente, die nicht mehr erforderlich sind, abzusetzen, sollte regelmäßig neu bewertet wer