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Concepts in Geriatric Clinical Pharmacology

Dror Marchaim, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Victor Dishy, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Ahuva Golik, MD, Department of Internal Medicine A, Asaf-Harofeh Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, IL.

Geriatric clinical pharmacology is considered an established subdiscipline in the field of clinical pharmacology. This review will address some of the effects of aging on drug treatment in general, and will focus on specific classes of drugs commonly consumed by older adults: cardiovascular medications, non steroidal anti-inflammatory drugs, and psychoactive agents.

Key words: clinical pharmacology, older adults, drug metabolism, pharmacokinetics.

Related Terms: Drug Safety, clinical pharmacology, drug metabolism, older adults, pharmacokinetics

Management of Community-Acquired Pneumonia in Older Adults

Ashraf Alzaabi, MD, FRCPC, Respirology Fellow, University of Toronto, Toronto, ON.

Theodore K. Marras, MD, FRCPC, Respirologist, Toronto Western Hospital, University Health Network; Assistant Professor of Medicine, University of Toronto, Toronto, ON.

Community-acquired pneumonia (CAP) in the older adult is a common disease with significant mortality. This review focuses on the management of CAP, with specific reference to the older adult. Common etiologic organisms and organism-specific risk factors that tend to be associated with increasing age are presented. A systematic approach is described to help physicians decide on the best treatment site (ambulatory, long-term care facility, or acute care hospital). The rationale behind initial empiric antibiotic therapy and drug resistance are discussed. Recent guidelines for the selection of empiric antibiotic therapy are compared and a synthesis of guidelines for antibiotic selection and recommendations regarding parenteral to oral switch-therapy are presented. Guidelines are suggested to help the physician safely discharge the patient home.

Key words: pneumonia, management, older adults, guidelines, resistance.

Related Terms: Lung Diseases, guidelines, management, older adults, pneumonia, resistance

CME: Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease in Older Adults

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Jean Bourbeau MD, MSc, FRCPC, Montreal Chest Institute of the Royal Victoria Hospital, McGill University Health Centre; Respiratory Epidemiology and Clinical Research Unit, Department of Epidemiology and Biostatistics, McGill University, Montreal, QC.

With the population progressively aging, the geriatric aspects of COPD deserve special consideration. Older adults with respiratory symptoms and a current or previous history of smoking should be considered for a diagnosis of COPD. Objective demonstration of airflow obstruction is mandatory for the diagnosis of COPD. The majority of older people can adequately perform spirometry for an objective demonstration of airflow obstruction. Nonpharmacological treatment includes smoking cessation, vaccination, self-management education and communication with a case manager, and pulmonary rehabilitation. Bronchodilators are the most important agents in the pharmacotherapy of COPD. Inhaled corticosteroids are indicated for patients with recurrent exacerbations who are already on optimal bronchodilator therapy.

Key words: chronic obstructive pulmonary disease, older adults, diagnosis, spirometry, management.

Related Terms: Lung Diseases, chronic obstructive pulmonary disease, COPD, diagnosis, management, NSAID, spirometry

Dysphagia in Older Adults

Fred Saibil, MD, FRCPC, Staff Physician, Division of Gastroenterology, Sunnybrook and Women’s College Health Science Centre, Associate Professor of Medicine,
University of Toronto, Toronto, ON.

Dysphagia is frequently under-rated as a symptom by both patients and their physicians. This article highlights the common causes of dysphagia in older patients and discusses the potential contributing factors in this age group. Newer therapies are also mentioned.

Key words: dysphagia, presbyesophagus, swallowing, motility.

Related Terms: Genetic Diseases, dysphagia, motility, presbyesophagus, swallowing

Gastroesophageal Reflux Disease in Older Adults: An Update

Mary Anne Cooper, MSc, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Lecturer, Sunnybrook and Women's Health Sciences Centre, Toronto, ON.

Gastroesophageal reflux disease is a common condition responsible for significant morbidity in older adults. It causes disease in the esophagus, and it is increasingly recognized as a cause of extra-esophageal symptoms such as chronic cough, adult-onset asthma, and hoarseness. Despite significant symptoms, endoscopy may be negative. Endoscopy-negative reflux disease may be a unique disease entity within the acid reflux group of disorders that includes erosive esophagitis and Barrett’s esophagus. Regardless of the symptoms or endoscopic findings, treatment remains geared to reducing the contact time between acid and sensitive tissue through lifestyle modification measures, acid suppression, and improved upper gastrointestinal motility.

Key words: GERD, extra-esophageal reflux, endoscopy-negative reflux disease, acid suppression, older adults.

Related Terms: Gastrointestinal Diseases, acid suppression, endoscopy-negative reflux disease, extra-esophageal reflux, GERD, older adults

Pancreatitis in the Older Adult

MV Apte, MBBS, MMedSci, PhD, Pancreatic Research Group, The University of New South Wales, Sydney, AUS.

RC Pirola, MD, FRACP, Pancreatic Research Group, The University of New South Wales, Sydney, AUS.

JS Wilson, MD, FRACP, FRCP, Pancreatic Research Group, The University of New South Wales, Sydney,

AUS.Pancreatitis (inflammation of the pancreas) has both acute and chronic manifestations. Gallstones are the predominant cause of acute pancreatitis in older adults, while chronic pancreatitis is usually due to alcohol abuse (although an idiopathic, late-onset form of chronic pancreatitis is also recognized). The majority of cases of acute pancreatitis are mild and self-limiting, and supportive therapy is usually sufficient. Increasing age is a known risk factor for the development of severe acute pancreatitis. In contrast to the reversible nature of acute pancreatitis, chronic pancreatitis is characterized by progressive loss of pancreatic structure and function. Management of chronic pancreatitis involves treatment of pain, maldigestion, and diabetes. The most serious complication of chronic pancreatitis is pancreatic cancer; the risk of developing pancreatic cancer increases with increasing age.

Key words: acute pancreatitis, chronic pancreatitis, pancreatic pain, maldigestion.

Related Terms: Gastrointestinal Diseases, acute pancreatitis, chronic pancreatitis, maldigestion, pancreatic pain

Diarrhea in the Older Patient

Jill M. Watanabe, MD, MPH, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
Christina M. Surawicz, MD, FACG, Department of Medicine and Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, USA.

The principal causes of diarrhea are infectious and inflammatory in origin, but the diagnosis and management of diarrhea in older patients may be complicated by age-related vulnerabilities and comorbidities. Several studies have indicated that the bacterial composition of feces may change with increasing age1 and that immune response at the mucosal surface may also diminish.2 Outbreaks of infectious diarrhea, including Escherichia coli 0157:H7 and viral origins, have occurred in the long-term care setting.3,4 It is also known that a wide spectrum of medications can cause diarrhea through various mechanisms. Older patients are at greater risk of developing mesenteric or colonic ischemia due to underlying atherosclerotic disease and risk of embolic events from atrial fibrillation, valvular heart disease, or cardiomyopathies.7,8 This article highlights the age-related considerations for the diagnosis and management of diarrhea in the older adult.

Key words: mesenteric ischemia, ischemic colitis, Escherichia coli 0157:H7, Clostridium difficile, microscopic colitis, radiation colitis

Related Terms: Gastrointestinal Diseases, 5-alpha-reductase inhibitors, Clostridium difficile, Escherichia coli 0157:H7, mesenteric ischemia, microscopic colitis, radiation colitis

Treatment of Nausea and Vomiting in the Older Palliative Care Patient

Hannah I. Lipman, MD, Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA.

Diane E. Meier, MD, Hertzberg Palliative Care Institute, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY, USA.

Nausea and vomiting are common problems in the care of the older palliative care patient. Depending on the population studied, incidence is as high as 60%. Distress associated with nausea and vomiting may be relieved in the majority of cases by careful determination of the underlying cause and selection of one or more antiemetic agents. Pathophysiology of nausea and vomiting involves complex interactions among multiple neurotransmitter systems. Antiemetic agents work via modulation of neurotransmitter signalling. Pharmacologic agents are reviewed and geriatric dosing recommendations are made.

Key words: palliative, end of life, geriatric, nausea, vomiting

Related Terms: Gastrointestinal Diseases, end of life, geriatric, nausea, palliative care, vomiting

Diagnosis and Management of Dementia in Parkinson’s Disease

David F. Tang-Wai, MDCM, Department of Medicine (Neurology), University of
Toronto, University Health Network, Toronto, ON.

Keith A. Josephs, MST MD, Department of Neurology, Mayo Clinic, Rochester, MN, USA

Neurodegenerative diseases commonly affect cortical and subcortical structures, resulting in clinical features of mixed dementia and parkinsonism. Dementia, albeit an uncommon presenting feature of Parkinson’s disease, may become a complication with disease progression. In this review we discuss the relationship of dementia and parkinsonism. We outline a clinical approach to the diagnosis and management of dementia with Lewy bodies and emphasize the importance of understanding the complexity of the disease, for which in-depth knowledge of medication side-effect profiles is a must if treatment is to be undertaken. We also briefly discuss progressive supranuclear palsy, corticobasal syndrome, and vascular dementia with parkinsonism.

Key words: Parkinson’s disease, dementia with Lewy bodies, visual hallucinations, fluctuations, acetylcholinesterase inhibitors.

Related Terms: Dementia, cholinesterase inhibitors, dementia with Lewy Bodies, fluctuations, Parkinson’s disease, visual hallucinations

Combined Afterload Reduction in Heart Failure: The Pros and Cons of Combined ACE Inhibitor/Angiotensin Receptor Blocker Therapy in Older Adult

Robert E. Hobbs, MD, The Kaufman Center for Heart Failure, Department of
Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA.

Guidelines for managing heart failure recommend angiotension-converting enzyme (ACE) inhibitors, beta-blockers, diuretics, digoxin, and aldosterone antagonists as standard therapy in order to improve morbidity and mortality. Angiotensin receptor blockers (ARBs) are considered second-line agents for patients who are intolerant of ACE inhibitors due to cough or angioedema. Because ACE inhibitors do not completely block the formation of angiotensin II and aldosterone, add-on therapy with an ARB has been evaluated in several clinical trials. In general, the results were mixed. Combination therapy with an ACE inhibitor and an ARB may improve morbidity and probably mortality, but with an increased incidence of hypotension, hyperkalemia, and azotemia. This approach could be considered in patients who remain symptomatic despite optimal doses of standard agents.

Key words: angiotensin receptor blockers, ACE inhibitors, heart failure, vasodilators, hyperkalemia.

Related Terms: Cardio-Cerebrovascular, ACE inhibitors, angiotensin receptor blockers, heart failure, hyperkalemia, vasodilators
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