Alcohol effects in the elderly

Alcohol is a potent drug and must be included in the medication history of the patient. The physician must be alert to the possibility of alcohol abuse by the elderly, in whom typical clues may not be present. Alcohol has a greater dose-related effect in elderly persons because of their decreased total body water, which leads to persistently higher blood alcohol levels. Alcohol causes unique kinds of brain damage, a fact that may aggravate the clinical symptoms of dementia such as Alzheimer's disease, but there is no convincing proof of premature aging because of alcohol abuse. Alcohol potentiates the sedating effects of many drugs acting on the CNS. This is especially serious in elderly patients, and they should be cautioned concerning the use of alcohol and drugs.     

Sleep patterns of aged persons in long-term care facilities

The nursing staff of long-term care facilities are often faced with the decision of whether or not to administer sleep medication when it is ordered 'prn'. This decision should be made on the basis of information contained in the patient's nursing sleep history as well as knowledge regarding the effects of sleep medication. This study was carried out to assess the factors involved in changes in sleep patterns of elderly patients in long-term care facilities and to evaluate the extent of use of the nursing sleep history. The sleep patterns of 102 elderly patients (mean age 78.7 years) in three long-term care facilities were assessed by means of interview questionnaire. Patients' records indicated that 71% were receiving some type of sleep medication on a regular basis. A quantitative analysis of their responses indicated that there were significant shifts in sleep patterns following admission. Only 54% of the patients in this study had a nursing sleep history and this contained only minimal information. The results indicate that the nursing sleep history is under-utilized. A better appreciation of the patient's sleep requirements could lead to a reduction in the amount of sleep medication given and an improvement in the general well-being of the long-term care elderly population.     

Doxazosin in elderly patients with hypertension

Hypertension constitutes a major cardiovascular risk factor of high prevalence in the elderly, and reducing elevated blood pressure has been shown to be of significant benefit in decreasing the incidence of cardiovascular and cerebrovascular disease in this patient population. Elderly patients are more likely to have comorbid disorders, such as dyslipidaemia, diabetes, renal disease, atherosclerosis and, for males, benign prostatic hyperplasia (BPH). Therefore, when choosing an antihypertensive agent for elderly patients, it is particularly important to ensure that treatment does not exacerbate comorbid conditions and does not interact deleteriously with any concurrent medication that the patient is taking. The alpha 1-adrenoceptor antagonist, doxazosin, has been shown to be an effective, well-tolerated antihypertensive therapy in elderly male patients and does not exacerbate--and in some cases improves--some other common disorders. Doxazosin has been shown to be effective in reducing the symptoms of BPH in elderly patients whose blood pressure is well controlled by concomitant antihypertensive medication. In addition, improvements in the symptoms of BPH as well as reductions in blood pressure have been observed in elderly men with mild-to-moderate hypertension. Doxazosin has been shown to have positive effects on lipid profiles and glycaemic control, which make it an attractive choice of therapy for elderly patients with hypertension and diabetes or dyslipidaemia. In addition, doxazosin is administered once daily, either in the morning or the evening, which may aid compliance, an important consideration in the elderly.     

The geriatric implications of fecal impaction

Fecal impactions are a common problem in debilitated elderly people and may present as a life-threatening event. The atypical presentations of fecal impactions are not well-recognized, and the incidence, morbidity and mortality of fecal impactions in the elderly are largely unknown. Elderly debilitated people have reduced organ system reserve. An acute illness may worsen underlying chronic diseases. Fecal impactions may upset the fragile homeostasis of an elderly debilitated person. The signs and symptoms of fecal impaction may not be manifested in the gastrointestinal system; rather, the patient may present with circulatory, cardiac or respiratory symptoms. If the diagnosis of fecal impaction is unrecognized and untreated, signs and symptoms may progress, leading to death. The causes, mechanisms, appropriate history, physical examination, diagnostic techniques, therapy and prevention of fecal impactions in elderly people are presented.     

Depression in the older adult: recognition and nursing intervention

The importance of identifying and intervening in elders with depression cannot be underestimated. The baby boom population is reaching the chronological milestone of being considered older age, which means that the percentage of older adults with depression will result in increased numbers of depressed older adults in all settings needing nursing care. Nurses must be able to recognize symptoms of depression, whether subsyndromal depression or major depression, to be able to intervene effectively. Depressive symptoms interfere with the quality of life and respond to nursing interventions that address psychosocial functioning including loss, educational strategies to increase understanding of depression as a disease, its treatment and adherence strategies, interventions that monitor and improve chronic medical illness, and recognize medication management that has the least likelihood of side effects. The importance of psychotherapies was not stressed above due to limitations in space, but in addition to problem solving therapy, cognitive and interpersonal supportive therapies are also effective. Electroconvulsive therapy is also effective in treating depression in the elderly when the patient is suicidal.     

Diagnosis and treatment of gastroesophageal reflux disease in the elderly

Gastroesophageal reflux disease poses special diagnostic and therapeutic challenges in the elderly. These patients may not report the classic symptoms of dysphagia, chest pain, and heartburn, and they are more likely to develop severe disease and complications such as esophageal ulceration and bleeding. Therapeutic options include lifestyle changes, medication, and surgery. Polypharmacy and changes in renal, hepatic, and gastrointestinal function can complicate treatment. Proton pump inhibitors can help optimize disease management. The most common primary presenting symptoms of GERD in the elderly are regurgitation, dysphagia, dyspepsia, vomiting, and noncardiac chest pain, rather than heartburn. Because the elderly commonly take multiple drugs for various comorbidities, drug interactions and treatment responses must be carefully assessed in this patient population. Nonpharmacologic measures may be helpful but often do not relieve nighttime GERD symptoms.     

Prognostic predictors of technique and patient survival in elderly Southeast Asian patients undergoing continuous ambulatory peritoneal dialysis

The population of elderly patients entering chronic dialysis programmes is increasing. Elderly patients are susceptible to malnutrition and have multiple complicating disorders in addition to uraemia. Selecting appropriate dialysis modality is particularly critical in elderly patients. Continuous ambulatory peritoneal dialysis (CAPD) has many advantages to elderly patients; however, the clinical outcome varies for elderly CAPD patients. In comparison with Westerners, Southeast Asians have a small body mass index and may be more suited to CAPD therapy. To identify the prognostic predictors in elderly Southeast Asian patients, this historical cohort study analysed 144 patients aged > or = 65 years at initiation of CAPD. A group of haemodialysis (HD) patients aged > or = 65 years was utilised as the control group. Survival curves for patient and technique were derived from Kaplan-Meier analysis and were further analysed by Cox-Mantel log-rank test. To elucidate the impact of individual factors on patient survival, various significant univariables were further subjected to multivariate analysis. No significant increase existed for relative risk of technique failure in elderly patients compared with younger patients. This analytical data indicates that CAPD was as good as HD for elderly uraemic patients regarding to the patient survival. Diabetes, dependent patients, low albumin levels and previous HD history were significant poor prognostic factors for survival of elderly CAPD patients. In conclusion, CAPD is an effective modality of renal replacement therapy for Southeast Asian elderly patients. The technique survival was not affected by patient age.     

Selected topics related to occupational exposures. Part V. Occupational cardiovascular disease

Cardiovascular disease is common in the United States. Several occupational exposures, such as carbon disulfide and organic nitrates, are believed to cause occupational cardiovascular disease. In addition some other agents, such as lead and cadmium, may indirectly cause cardiovascular disease through their effects on blood pressure. For other agents (ie, carbon monoxide, solvents, and chlorofluorocarbons), acute exposure and high levels may cause cardiovascular disease but may not cause cardiovascular disease through long-term or low levels. A primary care physician who has a patient with a new or unstable cardiovascular disease should obtain an occupational history to assess whether occupational exposures may be playing a role. An occupational history may indicate potential cardiovascular risks. Such risks can include exposure to certain chemicals and metals, physical factors, exertion, or psychological stress. The primary care physician should be able to assess the situation and advise the patient, as well as the employer, about restrictions or accommodations that may need to be made.     

Digitalis for congestive heart disease in the elderly. A family practice view of the efficacy of long-term therapy

The long-term efficacy of digoxin maintenance therapy must be determined individually for patients with normal sinus rhythm who have a history of congestive heart failure but no remaining signs or symptoms. Predictive factors for successful discontinuation of the agent in the elderly include normal mental status (including absence of depression), ability to adequately perform activities of daily living, general feelings of well-being, absence of multiple organic disease, absence of multiple drug use, and no evidence of existing congestive heart failure or atrial fibrillation. Our findings indicate that physicians and patients need to reexamine the concept that congestive heart failure is necessarily a chronic disease. Certainly, evidence exists that continuing digitalis therapy indefinitely is inappropriate and may be harmful. Further investigation may prove that congestive heart failure in the elderly, like pneumonia, is a common acute occurrence and in many cases not a chronic state for which patients are destined to receive medication indefinitely. We hope that the findings from our small sample will stimulate other investigators to question the indiscriminate long-term use of digitalis in the elderly.     

Psychiatric emergencies

Psychiatric disorders are common in medical inpatient and outpatient populations. As a result, internists commonly are the first to see psychiatric emergencies. As with all medical problems, a good history, including a collateral history from relatives and friends, physical and mental status examination, and appropriate laboratory tests help establish a preliminary diagnosis and treatment plan. Patients with suicidal ideation usually have multiple stressors in the environment and/or a psychiatric disorder (i.e., a major affective disorder, dysthymic disorder, anxiety or panic disorder, psychotic disorder, alcohol or drug abuse, a personality disorder, and/or an adjustment disorder). Of all patients who commit suicide, 70% have a major depressive disorder, schizophrenia, psychotic organic mental disorder, alcoholism, drug abuse, and borderline personality disorder. Patients who are at great risk have minimal supports, a history of previous suicide attempts, a plan with high lethality, hopelessness, psychosis, paranoia, and/or command self-destructive hallucinations. Treatment is directed toward placing the patient in a protected environment and providing psychotropic medication and/or psychotherapy for the underlying psychiatric problem. Other psychiatric emergencies include psychotic and violent patients. Psychotic disorders fall into two categories etiologically: those that have an identifiable organic factor causing the psychosis and those that have an underlying psychiatric disorder. Initially, it is essential to rule out organic pathology that is life-threatening or could cause irreversible brain damage. After such organic causes are ruled out, neuroleptic medication is indicated. If the patient is not agitated or combative, he or she may be placed on oral divided doses of neuroleptics in the antipsychotic range. Patients who are agitated or psychotic need rapid tranquilization with an intramuscular neuroleptic every half hour to 1 hour until the agitation and combativeness are under control. Haloperidol (Haldol) is the safest neuroleptic. Chlorpromazine (Thorazine), perphenazine (Trilafon), and, in the elderly, thiothixene (Navane) can also be useful if haloperidol (Haldol) is not effective and more sedation is needed; these drugs, however, produce more side effects. Violent patients need to be physically restrained and then given antipsychotic medication or, in the case of drug abuse or alcohol withdrawal, the appropriate drug management.(ABSTRACT TRUNCATED AT 250 WORDS)     

Alternative formulations,delivery methods,and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia

Objective: The purpose of this paper was to review alternative formulations, delivery methods, and administration options for psychotropic medications in elderly patients with behavioral and psychological symptoms of dementia (BPSD).Methods: A MEDLINE search was conducted initially in December 2008 and was updated in September 2009, including the search terms pharmacologic treatment and dementia, behavioral and psychological symptoms of dementia, alternative psychotropic medication formulations, alternative dosing methods of medication, drug delivery options, antidepressants and dementia, anxiolytics and dementia, antipsychotics and dementia, mood stabilizers and dementia, cognitive enhancers and dementia, medications and enteral feeding tubes, and hiding medication. Studies were limited to English-language articles dated from 1950 to 2009. Additional relevant articles were obtained by reviewing the references in the initial articles. Drug Facts and Comparisons 4.0 Online, Lexi-Comp Online, and Lexi-Drugs Online were used to obtain additional information. Targeted patients were elderly individuals with BPSD who were considered difficult to treat because they were unable to swallow, were refusing medications, or were not able to eat or drink per physician order.Results: In addition to the standard capsule or tablet given orally, a variety of formulations and delivery methods for psychotropic medications are available. Options include short- and long-acting intramuscular, intravenous, liquid, orally disintegrating, transdermal patch, sublingual, and rectal forms. Additionally, all formulations can be further altered in substance, delivery, or both. For example, tablets may be crushed and capsules opened; this changes their formulation and allows the option of mixing with food or liquids to be taken by mouth or through a tube. Caution must be used, however; in certain cases, alteration of the original form or the intended delivery method is contraindicated. In addition, many alternative administration options are not formally approved for use in the manner in which they are commonly applied and are therefore used with little or no information on tolerability and effectiveness. Ethical and legal issues include patient consent and off-label use.Conclusions: Overall, few studies have examined the use and efficacy of alternative psychotropic formulations and delivery methods in elderly patients with BPSD, and none have specifically addressed drug-alteration and alternative-administration issues. There is no evidence to compare alternative delivery forms (eg, tablet or capsule) of a given medication in terms of efficacy or tolerability. Still, alternative methods may be the only option for treatment of some patients. Practitioners must be familiar with the range of formulations and delivery options available so that they can optimize their patients' medication regimens. More data are needed on the use of alternative formulations, delivery methods, and administration options and their limitations in this population.     

Opioid treatment of chronic pain in patients with addiction

Patients with a history of drug or alcohol addiction may present to physicians with pain complaints. The medical literature is weak on the treatment of pain with opioids in patients in recovery or active addiction. This is because inconsistent criteria were used to define addiction and the types of chronic pain. There are clear differences between physical dependence, tolerance, and addiction. Addiction is different from pseudoaddiction and must be determined by the patient's behavior after appropriate pain management. Long-acting opioids are often the medications of choice for moderate to severe pain control. Short-acting opioids can be used for breakthrough pain. There are many other medications that can enhance pain control as adjunctive analgesics. Drug-seeking behavior may be seen with either active addiction or pseudoaddiction, or as part of deviant behavior such as drug diversion. A way to distinguish between these conditions is by giving the patient appropriate pain medication and observing the pattern of behavior to determine which is causing the drug-seeking behavior. Safe prescribing of medications with abuse potential includes use of a medication agreement, setting goals with the patient, giving appropriate amounts of pain medication, monitoring with pill counts and drug screens, and careful documentation. Even patients with a history of addiction can benefit from opioid pain medications if monitored appropriately.     

Barnidipine: a new calcium channel blocker for hypertension treatment

Although it is commonly agreed that all antihypertensive medications have similar efficacy, there are important differences related to safety, tolerability, patient adherence, cost effectiveness and effects on the prevention or retardation of associated disease progression. It is desirable for antihypertensives to have a long duration of action so that once-daily dosing is possible. In addition, antihypertensive medication must be able to be administered concomitantly with other drugs likely to be taken by the patients. This is particularly critical in the elderly population. Barnidipine, a novel, long-acting calcium antagonist, has met these challenges of modern pharmacotherapy. Its once-daily dosing, good tolerability and durable antihypertensive effect contribute to excellent patient adherence and make this drug a valuable addition to the antihypertensive formulary.     

Hyperosmolar nonketotic diabetic coma

Hyperosmolar nonketotic coma occurs most frequently in the elderly patient with underlying renal impairment. It often has an insidious onset, and may be precipitated by an identifiable illness, medication or procedure. Various neurologic manifestations may occur and obscure the diagnosis. Rapid recognition and appropriate treatment can greatly reduce the high mortality rate.     

Barnidipine: a new calcium channel blocker for hypertension treatment

Although it is commonly agreed that all antihypertensive medications have similar efficacy, there are important differences related to safety, tolerability, patient adherence, cost effectiveness and effects on the prevention or retardation of associated disease progression. It is desirable for antihypertensives to have a long duration of action so that once-daily dosing is possible. In addition, antihypertensive medication must be able to be administered concomitantly with other drugs likely to be taken by the patients. This is particularly critical in the elderly population. Barnidipine, a novel, long-acting calcium antagonist, has met these challenges of modern pharmacotherapy. Its once-daily dosing, good tolerability and durable antihypertensive effect contribute to excellent patient adherence and make this drug a valuable addition to the antihypertensive formulary.     

Falls in the elderly: what can be done?

AIM: This article gives information about falls in the elderly. BACKGROUND: The evaluation of an older patient who has fallen includes a focused history with an emphasis on medications, risk factors and physical examination. The article also discusses the aetiology and prevention of falls. CONCLUSION: Risk factors for falls in the elderly include increasing age, medication use, cognitive impairment and sensory deficits. To reduce the incidence of patient falls, clinicians and researchers have developed a variety of risk assessment tools to aid in the identification of patients at greater risk of falling.     

20 challenges of geriatric care

Responding to incidents involving geriatric patients presents multiple challenges and considerations for care. A variety of changes occur to the human anatomy, the physiological functions of the body and emotional state as an individual ages. Understanding these changes, their effect on medication administration and treatment options is important for the EMS provider. The elderly represent a rapidly growing segment of our prehospital patient population. More people will reach age 65 by 2020 than at any other time in the world's history. Many of these individuals will present to the EMS system in need of emergency care and may have multiple chronic conditions that will complicate your patient assessment and available treatment options. Knowing the relationship between aging and a patient's overall health provides the best basis for treating this precious population.