Stumbling blocks in medication of the elderly – and how to get around them

26.11.2019

Stumbling blocks in medication of the elderly – and how to get around them

Medication of the elderly is spoken about quite a bit, and we've gotten to read about problems with medications among the elderly in the media. Issues with medication have appeared extensively and frequently, particularly in different assisted living units. Hopefully, this blog will stimulate consideration of the characteristics of medication of the elderly and open up thinking about avoidance of the hazards of medication.

The percentage of elderly people in Finland's population is growing all the time, and thanks to new drugs and the development of pharmaceutical care, polypharmacy is on the rise

WHO has defined polypharmacy as a situation when a person takes at least five medications. It must be noted that the use of multiple medications does not necessarily cause problems even among the elderly. On the other hand, unsupervised polypharmacy can cause problems for patients of all ages, but especially the elderly are the most susceptible to adverse effects from medication. As an example, we can take the patient with well-managed blood pressure or Type2 diabetes, who can easily have "Käypä Hoito" -compliant medication resulting to as many as four drugs for each individual disease.  So, many medications for the same person do not necessarily cause a problem if the medical care is judicious and under control. As mentioned before, the elderly react more sensitively to adverse effects from medication. This follows from changes in the system caused by aging, increased occurrences of ailments, increased amount of medications, and the weakening functionality of the senses and cognition. How early and how quickly these changes develop depends on the individual. Hence, the fact that everyone ages at a different rate muddles the picture further.  The elderly are thus not a heterogeneous group.

According to a 2015 report by the WHO, serious adverse reactions affect disproportionally the elderly and people with multiple prescription drugs

According to a 2015 report by the WHO, as many as one half of the factors causing serious adverse events could have been prevented if those involved had paid attention to the factors causing medication-related risks during the various stages of the medication process.

This is rather bleak to read and requires action and additional know-how from all healthcare professionals in order to reduce the problems. Medication problems among the elderly are common, and in addition to the increase in uncontrolled polypharmacy, also under-dosing, "leftover" medications, harmful medication interactions, and deficiencies in care follow-up cause problems. The challenge in addressing medication problems is that identifying a person with a medication problem isn't always easy, and often goes unnoticed. A solution to this problem would be that all professionals who are involved in the treatment of an elderly patient, such as physicians, pharmaceutical professionals, nurses, and patient/relatives, would get involved in identifying the medication problem.

For the patient and their relatives, monitoring the medication requires easily accessible information

It's a good idea to pay attention to informing the patient and those close to the patient. When you know which medications are being used and why, you can better follow their effects and tell about them. Other important issues to inform about are the use of the medications, problems and checks.

Thorough information is needed from everyone who works with elderly medical care: medical practitioners, nurses and pharmaceutical professionals.

I've noticed in my work that in particular getting patients to come to check-ups causes challenges to the elderly. The health care providers do not necessarily have the resources to invite all of their patients individually to annual (or more frequent) pharmaceutical and health checks. Making sure this happens requires that the elderly patient is able to make contact with the healthcare provider on his or her own and make an appointment for a check-up. One of my clients had several basic illnesses, which would have required at least annual controls. He said he had received his current medication years ago, and thought that the medication didn't require any changes, as no one had called him for a check-up.

Impaired kidney function should be taken into account in medication

Thus, changes in the body pose challenges from many points of view, but one of the major causes of problems is lowered kidney function due to aging. As the person ages, the blood flow of the kidneys and the number of nephrons (functional units of kidneys) are reduced. Kidney function is most commonly monitored by measuring creatinine in blood tests. However, creatinine level alone isn't a reliable measure, but GFR (glomerular filtration rate), which is calculated using the creatinine level gives a much better understanding of kidney function.

In general, it's estimated that roughly about 50 % of the kidney function is still remaining when a person is 75 years old.

Due to kidney deterioration with age, the renal function should be monitored with the elderly. This monitoring would make sense even if the problems hadn't occurred before. Renal insufficiency can be asymptomatic. Renal insufficiency causes many challenges in the medication of the elderly.

Due to renal insufficiency, the dose of the medication may need to be reduced, and some oft he medicine/herbal products/minerals are completely unsuitable.

So, if you have been diagnosed with renal insufficiency (i.e. kidney deficiency), you should always inform your health care professional. The same is true if you're purchasing any natural products, vitamins or minerals. In this case, the suitability and dosage of the medicinal product can be reviewed while taking renal insufficiency in consideration. Wrong drug choices and dosages can cause renal function to backpedal.

Aging causes changes at the receptor level

Changes in the number and sensitivity of receptors in the body (mediating the effects of drugs) occur with aging. As a result, in particular the sensitivity to the effects of medication is increased, and this is particularly noticeable with benzodiazepines, opiates and anticholinergics. In the elderly people, benzodiazepines are more likely to cause clumsiness and memory problems. On the other hand, anticholinergic medication causes dry mouth, constipation, memory lapses, confusion and other cognitive disruptions for the elderly.

Drug-induced orthostaticism (dizziness) is also more common with the elderly than with younger population. Orthostaticism causes a drop in blood pressure when getting up from lying down. As a result, the patient may experience dizziness on getting up or even faint. The underlying cause of orthostaticism is the deterioration of the circulatory system due to aging and, as a result, the person is more susceptible to drug-induced hypotension. Several antipsychotics, antihypertensive and cardiac drugs, some prostate drugs (eg. tamsulosin) and opiates cause orthostaticism.

The medication of the elderly requires a lot of monitoring and planning

In general, the medication of the elderly requires a lot of attention, scrutiny, and monitoring by all health care providers. Generally speaking, the disadvantages occur more easily, and therefore medication is often started with a low dose. Increasing of the dose is conducted under careful monitoring. The importance of monitoring of treatment and assessing medication is emphasized in the elderly.

Fortunately, good tools are available for healthcare professionals to monitor and evaluate the medication of the elderly. These tools allow the evaluation of the medication and take into account renal safety, adverse effects, drug interactions, and potentially unsuitable drugs.

It's a good idea for everyone who participates in the medical treatment of the elderly to know and apply them in practice. Smartly administered medication can have dramatic effects on the well-being of the elderly patients, and bring many additional good years with their loved ones.

Mika Wallin

Pharmacist

The author works in a pharmacy and meets elderly patients daily. In addition, he trains health care professionals and writes content for Causalus.

Sources: 

Kivelä and Räihä: Iäkkäiden lääkehoito [medication in the elderly], Kapseli 35 (2007)

Kaisu Pitkälä, Helka Hosia-Randell, Minna Raivio, Niina Savikko, and Timo Strandberg:Vanhuksen lääkehoidon karikoita [hazards in the medication of the elderly],

Lääketieteellinen aikakauskirja Duodecim 2006;122(12):1503-12

Terveysportti.fi, Renbase & Riskbase

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