The NO TEARS structure can aid efficient medication review within a 10-minute consultation. It is a flexible system that can be tailored to the individual practitioner’s consultation style:
Need/indication
Open questions
Tests
Evidence
Adverse effects
Risk reduction
Simplification/switches
Key words: medication review, NO TEARS, primary care, older adults, polypharmacy.
Recent research has shown that close to 10% of the older population have at least one potentially inappropriate prescription, placing them at risk of acute hospitalization due to overdose or harmful drug interactions. The problem of polypharmacy in the aged is growing. Primary care physicians are obliged to take responsibility for coordinating the patient’s care and must be aware of various aspects of medication use such as cumulative drug exposure, chronic comorbidities, changing pharmacokinetics, and prescribing habits of consultants.
Key words: polypharmacy, older adult, adverse drug reaction, compliance.
Anxiety in older patients, when excessive in degree and duration, can cause significant impairment and, if left untreated, may result in profound comorbidity--in particular, depression. Anxiety symptoms emerging in the older patient necessitate an extensive medical and psychosocial workup. There is a paucity of data for pharmacological treatment of anxiety disorders in older adults. In this review, we will discuss some of the research in the area of diagnosis and treatment of anxiety in older adults. We will also summarize some practice parameters common in our clinic when data are absent or lacking. The use of psychotherapies (such as cognitive behavioural therapy) and of medications such as the SSRIs, as well as benzodiazepines and other agents including the atypical antipsychotics, are discussed. The differential diagnosis of anxiety symptoms in the older patient, including careful attention to underlying medical and neurologic causes of anxiety, are emphasized.
Key words: SSRIs, benzodiazepines, psychotherapy, anxiety, depression, dementia.
Antimicrobial agents are essential for the treatment of patients with bacterial infectious diseases. Unfortunately, the global escalation of antibiotic resistant pathogens in both the community and hospital settings have compromised the use of some compounds for treating both common and uncommon infections. Over the past three to four years, several new or modified compounds have been approved and may have applicability in treating a wide range of infections in older patients. Some brief characteristics of these compounds and their appropriate indications are summarized.
Key words: older adult, antimicrobial agents, antibiotics, fluoroquino-lones, ketolides.
Frontotemporal dementia (FTD or Pick’s disease) is a relatively common but underdiagnosed form of presenile dementia. Estimated prevalence is 20% of dementias and 50% of dementia in patients under age 65. Common presentations are disinhibition with indifference; progressive aphasia; semantic dementia; unexplained falls, vertical gaze palsy, and dysarthria; and dementia with motor neuron disease. Neuroimaging is essential to exclude a slow tumour. Tau mutations are found in some families. Atypical neuroleptics and antidepressants can effectively treat some of the characteristics of FTD.
Key words: frontotemporal dementia, Pick’s disease, primary progressive aphasia, corticobasal degeneration, progressive supranuclear palsy.
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.
Randy Harris, MSW, RSW, Mental Health Therapist, Community Geriatric Mental Health Services, Calgary Health Region, Calgary, AB.
Substance abuse experienced by older clients is frequently seen in medical practices. This article reviews approaches to assessing and treating older adults, including practical ideas for conducting interviews with older clients. A philosophical stance that recognizes a client’s readiness to change is also discussed.
Key words: older adults, substance use, stages of change, assessment, intervention.
Amit Morris, BSc, School of Medicine, Queen's University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.
Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and
Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.
Insomnia is very common among older adults and may have serious consequences. The assessment of insomnia can be challenging, given the number of possible causes and the fact that insomnia is often not a presenting complaint. Inquiring about patients’ sleep and performing a thorough evaluation of any concerns will allow a rational and targeted approach to treatment.
Key words: insomnia, sleep, older adults, aging, diagnosis.
Serge Gauthier, MD, FRCPC, McGill Centre for Studies in Aging, Montréal, QC.
Functional disability is an important component of Alzheimer’s disease. A number of scales are available to measure activities of daily living (ADL) throughout the course of disease, including instrumental as well as self-care activities. A randomized clinical study comparing donepezil to a placebo in moderate-to-severe stages of AD showed a stabilization of ADL decline over six months for patients on donepezil. Less time for ADL care was required by caregivers of patients on donepezil compared to those on placebos.
Key words: Alzheimer, therapy, activities of daily living, donepezil, caregiving time
Introduction
The importance of decline in activities of daily living (ADL) in older adults with dementia has been recognized in the condition’s diagnostic criteria, described as “significant impairment in social or occupational functioning” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
G.A.E. Wong, MBChB, MRCP(UK), and N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.
Cutaneous adverse drug reactions are a common problem affecting ambulatory and hospitalized patients. Older patients may be predisposed to adverse drug reactions due to inappropriate medication prescription, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathologies, and use of drugs with a narrow therapeutic margin. In this second of two articles, the management of cutaneous adverse drug reactions
is reviewed.
Key words: adverse drug reaction, skin, cutaneous, rash, drug eruption, treatment, management.
