Pharmakotherapie des Morbus Parkinson beim älteren,multimorbiden Patienten

Background

Parkinson’s disease is a frequent neurodegenerative disease, which typically occurs in older age. With progression of the disease, therapeutic complications, such as dyskinesias and fluctuations in the response to medication are common. To embed the medication of Parkinson’s disease into a complex treatment plan of a patient suffering from multimorbidity can be challenging.

Objectives

Not only the cardinal motor symptoms have to be treated properly but also the non-motor symptoms e.g. depression, dementia, autonomic dysregulations and gastrointestinal disorders. Pharmacological treatment and their risks are presented.

Conclusion

Especially in older patients the symptoms need to be treated with regard to multimorbidity and the risks of polypharmacotherapy. The therapeutic strategy needs to be carefully planned in order to achieve a high quality of life and social interaction.     

Schmerztherapie bei älteren Patienten

Given the current demographic changes there are an increasing number of elderly and very elderly patients in outpatient and inpatient care. Elderly and very elderly patients often suffer from pain and musculoskeletal conditions are a common cause of pain in the elderly. An effective pain management should not be withheld from elderly patients with rheumatic diseases. Untreated pain in elderly patients leads to functional impairment and immobility. In addition, the quality of life of patients is negatively affected and can lead to a loss of autonomy and/or social withdrawal. The treatment of elderly and very elderly patients is particularly challenging. There are special features that need to be considered in the choice of treatment. Altered pain presentation, comorbidities, nonadherence, polypharmacy and side effects of pain medications require a critical risk-benefit assessment and ongoing treatment monitoring of this special group of patients.     

Therapie der Stuhlinkontinenz bei älteren Patienten: Untersuchung zur Wirksamkeit eines Biofeedback-Heimtrainingsprogramms

The increased prevalence of urinary and fecal incontinence is one of the most important factors in the loss of independence and mobility in the elderly population. It is also one of the major reasons for elderly people to give up their household and move into a nursing home. Anorectal biofeedback therapy is a very effective treatment for fecal incontinence. However, due to the increased immobility of elderly people, ambulatory biofeedback training programs which require the participants to leave their homes and travel to the next available outpatient clinic on a regular basis, especially when depending on public transportation, may prove particularly difficult for elderly, incontinent subjects. Supervised home biofeedback training programs may offer an alternative for those patients, who are motivated enough and not mentally impaired. Two different age groups of women (between 49 and 63; and between 65 and 78 years old) suffering from fecal incontinence due to external anal sphincter impairment, received a supervised home biofeedback program, after extensive anorectal diagnostics including manometry. The program focused on improving voluntary sphincter contraction. After an average of 9 months, anorectal manometry was repeated, and anal resting and squeeze pressure as well as minimal rectal perception threshold were determined. There was no effect on anal resting pressure and rectal perception. However, anal maximum squeeze pressure as well as squeeze pressure over 10 s was substantially increased with no difference between the age groups. CONCLUSION: Supervised home biofeedback for sphincter insufficiency was effective in improving the voluntary contraction of the anorectum in both age groups. Therefore, biofeedback home training programs may offer an alternative to ambulatory programs for those individuals, who are not mobile enough to regularly attend an outpatient clinic.     

Diagnostik des akuten Myokardinfarkts bei ?lteren Patienten

The early diagnosis of an acute myocardial infarction (MI) is improved by the introduction of novel high-sensitivity troponin assays. These assays can measure low level myocardial injury not detectable by standard troponin assays. Especially in older patients who appear to have a higher basal troponin level, the results must always be judged in the context of the medical history, physical examination, electrocardiogram (ECG) and any further findings. Even small increases in high-sensitivity troponin indicate increased risk for death or MI during follow-up. In the case of MI an invasive strategy results in better survival rates compared with conservative therapy but at the expense of an increased risk of bleeding in elderly patients. This article provides an overview on the diagnosis of MI in elderly patients.     

Prävention unerwünschter Arzneimittelwirkungen bei älteren Patienten

Adverse drug reactions are among the most common adverse events and a significant cause of preventable morbidity and mortality. As multimorbidity and polypharmacy are frequent in this population, the elderly are at special risk for adverse drug events, although the calendar age has not been proved as independent risk factor in this context. In particular falls and delirium are clinically significant and typical adverse drug events in the elderly. In this review mechanisms and factors which determine adverse drug re actions are described, and possible strategies for an effective prevention are given. This covers pharmacokinetic, pharmacogenetic and pharmacodynamic aspects as well as factors influencing individual adherence to drug therapy. A significant portion of adverse drug reaction may be prevented by a thorough indication and prudent monitoring of pharmacotherapy. Also adherence to pharmacotherapy may be improved by tailored and individual means referring to the patient's needs and expectancies. In the elderly functional limitations such as reduced cognitive abilities, reduced visual acuity and impaired dexterity determine an ineffective pharmacotherapy and medication errors. Hereby these functional limitations are significant predictors of adverse drug events in the context of self-management of pharmacotherapy. Testing of functional abilities as provided in the geriatric assessment is helpful to identify these factors. Among altered pharmacokinetic factors in the elderly, reduced renal function is most important to avoid overdosage. Although a precise measurement of renal function is not possible in a bed-side manner, an estimation of actual renal function utilizing estimation-formulas should always take place.     

PräfCheck: Patientenzentrierte Behandlungsplanung mit älteren multimorbiden Patienten

Background

The aim of the study is to develop and test a consultation guide (PrefCheck) for general practitioners (GPs) based on geriatric assessment results. The goal of the consultation guide is to facilitate priority setting and treatment planning based on building a partnership with geriatric patients with multiple chronic diseases.

Methods and aims

The mixed method study consists of three complementary parts: (A) health and treatment priorities of 32 patients and their 8 GPs are determined and explored on the basis of assessment results. These findings lead to the development of the consultation guide, which is subsequently tested in a cluster-randomized controlled intervention study (B) with 40 GPs and 320 patients. The aim of this study is to assess whether PrefCheck results in improved agreement in the number of health and treatment priorities between patients and their doctors. The study concludes with an evaluation study (C) with 5 GPs and 15 patients.

Conclusions

Results will be presented in a future publication. In particular it will be demonstrated whether the consultation guide can strengthen the position of older patients in the doctor–patient relationship, increase the level of information on both sides, and contribute to a shared and holistic treatment planning.     

Kognitive Dysfunktionen nach abdominal-chirurgischen Operationen bei älteren Patienten

Elderly patients often suffer from postoperative cognitive deficits (POCD) after serious surgical operations. The reasons for this are not well understood. We investigated the influence of the invasiveness of the operation and the duration of the operation as well as the patient's preoperative physical status on measures of cognitive dysfunction.In a prospective study 59 elderly patients (mean age 69.2 years) were subjected to a neuropsychological test battery and a questionnaire following an abdominal surgical operation. The postoperative recovery with a focus on memory function was assessed using the Wechsler Memory Scale (WMS) seven days after the operation. Self-reported cognitive deficits were studied using the a questionnaire of experienced attention deficits (FEDA) three months after the operation.Postoperative psychological and self-reported test results varied as a function of the invasiveness and the duration of the operation. After more invasive operations patients reported a stronger deficit in activities of daily living and a reduction in drive than after less invasive operations. In addition, the duration of anesthesia influenced the experienced deficits. The self-reported deficits were more strongly influenced by the features of the operation than the psychological test data. The physical status of the patients according to the American Society of Anesthesiologists (ASA) along with the duration of anesthesia as covariate was identified as a good predictor for the cognitive recovery post operation.     

Prophylaxe und Behandlung von Infektionen beim älteren Rheumapatienten

In general, the risk of serious infections increases with age, mainly explained by immunosenescence and accumulation of comorbidities. Those patients with rheumatoid arthritis who are of advanced age and require treatment with immunosuppressive agents are at particular risk to develop an infectious disease. Actual requirement and kind of treatment on the one hand, and risk of infection on the other hand, have to be considered carefully for each patient. For example, in high-risk patients, it is important to use glucocorticoids in a minimal way, i.e. in low doses and as short as possible. Vaccination, especially against influenza and pneumococci, plays an essential role in preventing infectious diseases, particularly in the elderly. Nevertheless, in cases of suspected bacterial infection, empiric antibiotic therapy should be started promptly. Due to the burden of drugs taken by patients of advanced age, the benefits and possible side effects as well as potential drug interactions have to be carefully considered. In summary, drug treatment of the elderly requires bearing in mind the complete health status of the individual patient.     

Therapie des follikulären Lymphoms

The treatment options for patients with follicular lymphoma have substantially improved in the last years, in particular with the development of innovative, antibody-based therapeutic strategies. Thus, the anti-CD20 antibody rituximab is one of the cornerstones in the therapy of follicular lymphoma today. It is used in combination with chemotherapy or as a single agent therapy for remission induction and as maintenance therapy. Encouraging results were also reported from monoclonal anti-CD20 antibodies, which are conjugated to radionuclides and exploit the high radiosensitivity of lymphomas. An example for this is the anti-CD20 antibody ibritumomab tiuxetan, which is coupled to 90Yttrium and shows comparable activity to rituximab. Current trials are underway testing whether, for example, the sequential application of a rituximab/chemotherapy induction, myeloablative consolidation therapy followed by autologous stem cell transplantation and rituximab maintenance further improves the therapeutic outcome in follicular lymphoma, or even has curative potential in a subgroup of patients with this disease.     

Interdisziplinäre Therapie des Rektumkarzinoms

Due to improved interdisciplinary staging, rectal cancer can be treated in a more individualized manner. Over the last decade, high-quality resection has reduced the incidence of local recurrence. In locally advanced situations, patients receive multimodal treatment, based on preoperative RTx/RCTx, which is completed with chemotherapy after the operation. Further studies concerning dose effects, changing chemotherapeutic agents, adding antibodies, and extending the total mesorectal excision (TME) technique to rectal cancer in the upper third to improve the efficiency of the multimodal therapy are in progress.     

Therapie des hepatozellulären Karzinoms

Today, hepatocellular carcinoma (HCC) represents the leading cause of death in patients with liver cirrhosis; in most western countries the incidence is also expected to increase further. Due to insufficient surveillance of patients at risk, most cases are diagnosed in an intermediate to advanced stage, leading—together with the underlying liver cirrhosis—to limited therapeutic options and a dismal prognosis. Therefore, classification according to stage and interdisciplinary treatment decisions in experienced centers are of paramount importance to provide an individualized treatment plan when considering potentially curative (resection, liver transplantation, local ablation) and palliative (transarterial approaches, sorafenib) treatment options. There is hope that the prognosis of patients with HCC can be improved in the near future by better prevention, stringent surveillance, multimodality treatment approaches, and an expansion of personalized medicine.     

Stadiengerechte Therapie des Hämorrhoidalleidens

Hemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy applied according to the patient’s complaints. The aim of this work was therefore to assess a stage-dependent approach for treatment of hemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of hemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent hemorrhoids. Tailored hemorrhoidectomy is preferable for individualized treatment with respect to solitary or circular hemorrhoidal prolapses.     

Pharmakotherapie des älteren Menschen aus klinischer Sicht

Zusammenfassung Mit zunehmendem Lebensalter erhalten Patienten vermehrt Medikamente verordnet. Die Daten, auf denen eine medikamentöse Therapie beruht, sind aber häufig nicht in dieser Altersgruppe gewonnen, obwohl Veränderungen des alternden Organismus die medikamentöse Therapie stark beeinflussen können. Ebenso sind Arzneimittelinteraktionen bei zunehmender Multimorbidität häufig. Das Risikopotenzial der medikamentösen Therapie wird derzeit zu wenig beachtet, insbesondere bei vulnerablen Patienten mit funktionellen Defiziten. Hier können spezielle Verfahren des Risiko-Assessments helfen, Gefahren rechtzeitig abzuschätzen. Dabei sollte insbesondere Wert auf das Erfassen einer eingeschränkten Nierenfunktion gelegt werden. Außerdem empfiehlt sich ein umsichtiges, klinisches Monitoring der Arzneimitteltherapie.Due to increasing incidence of chronic diseases with advancing age, drugs are predominantly prescribed to elderly patients. But there is a lack of data, representing this age group. As the aging organism shows various physiologic changes that may influence pharmacokinetic parameters, an individualized risk-benefit-analysis is warranted. Moreover, functional limitations may bare additional risks of pharmacotherapy promoting adverse drug reactions. Frequent adverse drug reactions in the elderly are falls, delirium and anticholinergic symptoms. An assessment of potential hazards of pharmacotherapy is therefore essential. It should include physiologic parameters, in particular renal function, possible functional limitations and parameters of compliance. Furthermore a prudent clinical monitoring of drug therapy can limit adverse drug reactions and polypharmacotherapy due to a prescribing cascade.

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Geriatrisches Screening und Assessment bei älteren Patienten mit chronischen Nierenkrankheiten

Age is the strongest predictor of chronic kidney disease (CKD). The median age of incidence in Germany was recently recorded as 71 years. Between 1996 and 2011 the age group over 75 years has doubled and the age group over 85 years has tripled. Treatment guidelines have almost exclusively focused on renal parameters so that typical geriatric characteristics and functional limitations have been neglected. In the face of the prognostic relevance of these non-renal parameters we propose the implementation of a systematic geriatric screening and assessment. An integrative geriatric nephrological care approach including timely assessment of indications for rehabilitative measurements, should improve survival and the quality of life in the elderly CKD population.