Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.     

Diagnosis and treatment of allergic skin disorders in the elderly.

Allergic skin disorders in the elderly may arise from contact with or ingestion of offending allergens. Itching associated with skin allergy must be distinguished from other causes of itching in the elderly such as xerosis, itching due to systemic disease and bullous disease. Although elderly people have somewhat decreased cell-mediated immunity and may be harder to sensitise under experimental conditions, they have had many years to acquire allergic responses, and therefore develop contact dermatitis frequently. Patch testing is a valuable tool to diagnose contact allergy and should be used often in the elderly, particularly in patients at high risk of contact dermatitis, such as those with chronic lower extremity dermatitis or ulcers due to venous stasis. When prescribing topical medications to high risk patients, a knowledge of the common sensitisers is important. In addition to allergy to medicaments and dressings used to treat stasis ulcers, contact allergy to dental prostheses and medications used to treat ocular disease are common in the elderly as a result of increased usage and exposure. Rash caused by ingested allergens is much more commonly due to medications than to food in the elderly. Allergic noneczematous dermatoses in the elderly are commonly drug-induced. Urticarial skin reactions are often associated with the administration of antibacterials, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants or opioids. Morbilliform rashes are a common sign of systemic reaction to anticonvulsants, gold, allopurinol or diuretics. Phototoxic reactions may be associated with the administration of tetracyclines, diuretics, NSAIDs and antihyperglycaemic agents. Patient-specific variables such as HLA type and concomitant medication may affect the likelihood of an allergic response to medication. Many elderly patients take multiple medications, which can make diagnosis of drug allergy difficult because diagnosis is most commonly accomplished by observing clinical response once the medication is withdrawn. In the case of lichenoid cutaneous reactions, clinical improvement may take several months after withdrawal of the offending drug. Laboratory tests to detect drug-induced allergic skin disorders may be available in the future.     

三种老年人不适当用药评估标准的比较

老年人常同时患多种疾病,需要服用多种药物。而且由于其生理病理情况的特殊性和复杂性,药物的药效学和药动学发生改变．使老年人潜在不适当用药风险增加．所以需要有效而实用的老年人合理用药评价标准来减少老年人药品不良反应的发生。本文就Beers标准、STOPP标准、台湾老年人潜在不适当用药标准作一比较,为建立中国老年人合理用药标准提供参考。     

两种标准在老年住院患者潜在不适当用药评价中的应用分析

分析我院老年住院患者的潜在不适当用药情况,探讨STOPP/START标准及《中国老年人潜在不适当用药判断标准》的适用性,为促进合理用药提供依据。分别以STOPP/START标准和《中国老年人潜在不适当用药判断标准》为依据,对我院1196例全科老年住院患者的潜在不适当用药情况进行分析。1196例患者平均年龄为（76.2±7.0）岁,平均用药品种数（15.7±6.5）种。根据STOPP/START标准,368例（占30.77%）患者存在潜在不适当用药现象共491项,其中涉及最多的药物是苯二氮■类药物;293例（占24.50%）患者存在处方遗漏共354项,其中遗漏最多的是血管紧张素转化酶抑制剂未用于有冠心病（史）的患者。根据《中国老年人潜在不适当用药判断标准》,726例（占60.70%）患者存在药物相关的潜在不适当用药现象共1215项,其中在与药物相关的PIM中,涉及药物最多的是氯吡格雷;110例（占9.20%）患者存在疾病状态下的潜在不适当用药现象共116项,全为A级警示药物相关的PIM,其中涉及最多是高血压患者使用非甾体抗炎药。两种标准检出相同的PIM 258例（占21.58%）,共320项,其中可能引起跌倒药物重复检出的频率最高。我院全科老年住院患者存在较多潜在不适当用药情况,并且STOPP/START标准与《中国老年人潜在不适当用药判断标准》在识别潜在不适当用药方面均具有重大意义,应联系实际,合理使用。     

Overcoming 'ageism' bias in the treatment of hypercholesterolaemia : a review of safety issues with statins in the elderly.

Atherosclerosis is a progressive, lifelong condition that is the leading cause of death among middle-aged and elderly individuals aged > or =65 years. Up to 80% of elderly patients are found to have evidence of obstructive coronary heart disease at autopsy. Demographic trends, including the advancing median age and life expectancy of Western societies, suggest that a large share of the burden of atherosclerotic plaque is likely to be borne by elderly individuals. These trends are in part due to increases in a number of chronic diseases associated with adverse cardiovascular outcomes, including metabolic syndrome, diabetes mellitus and chronic kidney disease. Because the elderly have a higher attributable risk of coronary heart disease as a result of hypercholesterolaemia, more coronary deaths and overall events can be prevented via treatment in this age group compared with younger persons with hypercholesterolaemia. The efficacy, safety and tolerability of HMG-CoA reductase inhibitors (statins) have been confirmed in randomised, controlled, multicentre trials involving large numbers of patients aged > or =65 years. Although muscle symptoms such as myalgia are relatively common adverse events, more severe signs of myolysis such as myopathy and rhabdomyolysis are rare, but their risk is elevated by conditions (e.g. concomitant medications) that increase the systemic exposure of these agents. Statins differ in their susceptibility to increases in systemic exposure, but most statins have been demonstrated to be well tolerated and safe when administered to elderly patients. These favourable clinical findings should help clinicians counter highly prevalent 'ageism' bias in statin prescribing, whereby elderly patients, particularly those at highest cardiovascular risk, are often denied the benefits of statins without any meaningful foundation.     

Aspiration and infection in the elderly : epidemiology, diagnosis and management

Aspiration of the oropharyngeal or gastric contents by elderly persons often leads to lower respiratory tract infections, such as aspiration pneumonia or pneumonitis. The existence of dysphagia and aspiration in elderly patients are important factors in the occurrence of aspiration pneumonia, but are not sufficient to cause aspiration pneumonia in the absence of other risk factors. Salivary flow and swallowing can eliminate Gram-negative bacilli from the oropharynx in healthy persons. However, elderly persons may have diminished production of saliva as a result of medications and oral/dental disease, leading to poor oral hygiene and oropharyngeal colonisation with pathogenic organisms. When dysphagic patients aspirate pathogenic bacteria while swallowing food or liquids, they must also have decreased defences, such as impaired immunity or pulmonary clearance, in order to develop aspiration pneumonia.Elderly patients with cerebrovascular disease often have dysphagia that leads to an increased incidence of aspiration. It was previously reported that patients with silent cerebral infarction affecting the basal ganglia were more likely to experience subclinical aspiration and an increased incidence of pneumonia. Basal ganglia infarction leads to the impairment of dopamine metabolism and, as a consequence, a decrease of substance P in the glossopharyngeal nerve and sensory vagal nerves. Therefore, dysphagia and a decreased cough reflex may be induced by the impairment of dopamine metabolism in some elderly patients with cerebrovascular disease, suggesting that pharmaceutical agents which modulate dopamine metabolism may be able to improve swallowing and the cough reflex in patients with basal ganglia infarction.The main strategy for controlling aspiration and aspiration-related pulmonary infection in the elderly is to prevent aspiration of pathogenic bacteria along with the oropharyngeal or gastric contents. Because aspiration pneumonia in the elderly is related to certain risk factors, including dysphagia and aspiration, effective preventive measures involve various approaches, such as pharmacological therapy, swallowing training, dietary management, oral hygiene and positioning.     

Reassessing the MAI: elderly people's opinions about medication appropriateness

Objectives — To identify the criteria that the elderly use to assess the appropriateness of their medications, rank the identified criteria in terms of importance, and compare elderly people's and clinicians' ratings of the importance of medication appropriateness index (MAI) criteria Methods — A qualitative method was used to understand why elders' rankings of appropriateness criteria may or may not differ from clinicians'. Five focus groups with 38 elderly people were completed and content analysed. The participants also completed a written ranking of 10 criteria, indicating them as being of high importance, moderate importance or low importance Key findings — Overall, the group discussion cited indication, effectiveness and drug-drug interactions as most important. The written ranking of the MAI criteria suggested drug-drug interactions and correct directions as being most important. Elderly people appeared to have difficulty ranking the criteria of indication and effectiveness, as there was some evidence that they took these criteria for granted. Differences among focus group participants appeared to be due to their varied medication use experience Conclusion — These findings suggest that drug-drug interactions may be ranked highly important and practicality ranked moderately important when elderly patients' opinions are sought about medication appropriateness. Further research should be conducted to assess whether the MAI is accountable to patient viewpoints     

Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic

Deprescribing aims to reduce polypharmacy, especially in the elderly population, in order to maintain or improve quality of life, reduce harm from medications, and limit healthcare expenditure. Coronavirus disease (COVID-19) is an infectious disease that has led to a pandemic and has changed the lives many throughout the world. The mode of transmission of this virus is from person to person through the transfer of respiratory droplets. Therefore, non-essential healthcare services involving direct patient interactions, including deprescribing, has been on hiatus to reduce spread. Barriers to deprescribing before the pandemic include patient and system related factors, such as resistance to change, patient's knowledge deficit about deprescribing, lack of alternatives for treatment of disease, uncoordinated delivery of health services, prescriber's attitudes and/or experience, limited availability of guidelines for deprescribing, and lack of evidence on preventative therapy. Some of these barriers can be mitigated by using the following interventions:patient education, prioritization of non-pharmacological therapy, incorporation of electronic health record (EHR), continuous prescriber education, and development of research studies on deprescribing. Currently, deprescribing cannot be delivered through in person interactions, so virtual care is a reasonable alternative format. The full incorporation of EHR throughout Canada can add to the success of this strategy. However, there are several challenges of conducting deprescribing virtually in the elderly population. These challenges include, but are not limited, to their inability to use technology, lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and increased risk of severe consequences, if hospitalized. Virtual care is the future of healthcare and in order to retain the benefits of deprescribing, additional initiatives should be in place to address the challenges that elderly patients may experience in accessing deprescribing virtually. These initiatives should involve teaching elderly patients how to use technology to access health services and with technical support in place to address any concerns.     

Treatment of chronic pain in older people: evidence-based choice of strong-acting opioids

In the treatment of chronic malignant and non-malignant pain, opioids are used as strong analgesics. Frail elderly patients often have multiple co-morbidities and use multiple medicines, leading to an increased risk of clinically relevant drug-drug and drug-disease interactions. Age-related changes and increased frailty may lead to a less predictable drug response, increased drug sensitivity, and potential harmful drug effects. As a result, physicians face a complex task in prescribing medication to elderly patients. In this review, the appropriateness of the strong-acting opioids buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone and tapentadol is determined for use in elderly patients. Evidence-based recommendations for prescribing strong opioids to the frail elderly are presented. A literature search was performed for all individual drugs, using a validated and published set of 23 criteria concerning effectiveness, safety, pharmacokinetics and pharmacodynamics, experience, and convenience in elderly patients. First, information on the criteria was obtained from pharmaceutical reference books and a MEDLINE search. The information obtained on the individual drugs in the class of opioids was compared with the reference drug morphine. Evidence-based recommendations were formulated on the basis of the pros and cons for the frail elderly. Using the set of 23 criteria, no differentiation can be made between the appropriateness of buprenorphine, fentanyl, hydromorphone, morphine and oxycodone for use in elderly patients. Methadone has strong negative considerations in the treatment of chronic pain in the frail elderly. Methadone has a high drug-drug interaction potential and is associated with prolongation of the QT interval and a potential risk of accumulation due to a long elimination half-life. In addition, methadone is difficult to titrate because of its large inter-individual variability in pharmacokinetics, particularly in the frail elderly. Because of a lack of empiric knowledge, the use of tapentadol is not recommended in frail elderly persons. Nevertheless, tapentadol may prove to be a useful analgesic for the treatment of chronic pain in frail elderly persons because of its possible better gastrointestinal tolerability. In the treatment of chronic pain in the frail elderly, the opioids of first choice are buprenorphine, fentanyl, hydromorphone, morphine and oxycodone. In order to improve the convenience for elderly patients, the controlled-release oral dosage forms and transdermal formulations are preferred.     

Rosuvastatin in elderly patients

A progressive accumulation of atherosclerotic lesions beginning early in life puts elderly persons at a greater absolute risk of cardiovascular disease and coronary events than other segments of the population. HMG-CoA reductase inhibitor (statin) therapy has been shown to be both efficacious and well tolerated in most elderly patients. Among the statins, rosuvastatin has advantages in treating older patients: at low starting doses it is very efficacious compared with other statins, and thus more likely to enable patients to reach their low-density lipoprotein-cholesterol goals without the need for titration or combination therapy. Lack of clinically significant interactions with most drugs metabolised by cytochrome P450 enzyme 3A4 may also make rosuvastatin safer for patients taking multiple medications. Furthermore, rosuvastatin has shown efficacy in treating patients with many of the co-morbidities common in the elderly, including renal impairment and diabetes mellitus. As yet, however, cardiovascular endpoint data for rosuvastatin are not available.     

Optimising drug utilisation in long term care

Providing quality long term care for the elderly while containing costs is presenting major challenges for governments and policy makers. Although international variability exists with respect to the number of medications and other factors influencing suboptimal pharmacotherapy, suboptimal pharmacotherapy among elderly persons is common. This international problem requires a creative and multifaceted approach to improve and rationalise prescribing. We outline the non-regulatory efforts and regulatory means to approaching this problem. The recent introduction of a prospective payment system for long-term care in the US has underscored the importance of a regulatory approach to counter-balance the cost containment efforts which bundle the cost of medications into a prospectively set per diem rate. An examination of how US regulatory bodies are considering improving prescribing is provided. Considering the case of coronary heart disease, we provide data regarding the performance of a quality indicator aimed at stimulating quality prescribing for this medical condition. Although the use of regulatory approaches can improve prescribing, it is also recognised that a more holistic approach involving multidisciplinary teams and greater focus on the patient is the ultimate aspiration. This is particularly the case with the elderly in whom appropriate drug therapy can have a major impact on outcomes. A major cultural shift in the way society views and treats the elderly may be required in order to produce dramatic improvements in long term care for older people.     

What defines abnormal lung function in older adults with chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a very common lung disease most often related to a history of smoking. It becomes more prevalent with increasing age but remains under-diagnosed and under-treated in the elderly population. The Global Initiative for Obstructive Lung Disease (GOLD) programme has been instrumental in providing standard diagnostic criteria as well as recommendations for prevention and management of COPD. GOLD recommendations define COPD as a post-bronchodilator forced expiratory volume in 1 second (FEV(1))/forced vital capacity (FVC) of <70%, with the severity based on the value of FEV(1). This recommendation is different from that of many previous reports that have recommended diagnosing obstruction using the statistically derived lower limit of normal (LLN), which varies for each person according to age, height, ethnicity and gender. While the use of a 70% ratio may be simpler, it may result in under-diagnosis of airflow obstruction in younger people and over-diagnosis in the elderly. This is particularly important as the elderly may be most sensitive to many of the adverse effects of medications used in the treatment of COPD, including corticosteroids and anticholinergic bronchodilators.Most of the studies comparing the LLN and a fixed ratio of 70% have not been performed with post-bronchodilator testing as recommended by GOLD. Generation of post-bronchodilator reference sets and studies comparing the LLN with the post-bronchodilator FEV(1)/FVC ratio of <70% will help resolve this issue. One recent study examined patients admitted to hospitals who had an FEV(1)/FVC ratio of <70% but above the LLN, and found they were at increased risk of death and COPD complications. This would support the use of GOLD criteria. Further studies examining this population are needed.In addition to the uncertainties about what diagnostic criteria should be utilized for diagnosis of airflow obstruction, different organizations make different recommendations on screening spirometry. A conservative recommendation is to perform spirometry in symptomatic individuals. It is important to remember that while COPD is under-diagnosed in the elderly, this group is also at a higher risk of being falsely classified as having airflow obstruction using the 70% ratio recommended by GOLD. This can result in unnecessary use of medications and increased risk of adverse effects to which the elderly are more prone.     

Non‐adherence to antihypertensive medication and impaired cognition: which comes first?

Objective Antihypertensive medications are important in the prevention of serious consequences of hypertension, such as stroke and heart failure. Up to one‐third of elderly hypertensive patients, however, do not adhere to their medication. Adherence to medication decreases with increasing age, and with decreasing cognitive ability, thus elderly, cognitively‐impaired patients have poorer control of blood pressure. Good control of blood pressure is associated with decreased prevalence of dementia and Alzheimer's disease. This study assessed the evidence that antihypertensive medications have effects on the prevalence or severity of mild cognitive impairment, dementia or Alzheimer's disease. Methods The ISI Web of Knowledge database was searched; including replicates, the nine searches identified 14 400 publications since 1952, of which 9.9% had been published in 2009. This review considers the 18 studies meeting the set criteria published in 2009 or later. Key findings Not all antihypertensive medications are equivalent in their positive cognitive effects, with brain‐penetrating angiotensin‐converting‐enzyme inhibitors and possibly angiotensin receptor antagonists being the most effective. Conclusions Based on evidence of blood‐pressure control and cost, UK National Institute for Health and Clinical Excellence guidelines recommend calcium‐channel blockers or thiazide‐type diuretics for the treatment of hypertension in patients over 55 years. These guidelines take no account of the potential cognitive effects of the antihypertensive therapies, consideration of which might lead to a review. There may be benefit in stressing that adherence to antihypertensive medication not only decreases the risk of cardiovascular disease and death, but may also decrease the risk or severity of mild cognitive impairment, dementia and Alzheimer's disease.     

The challenges of gout management in the elderly

Gout is common in the elderly and its management is frequently complicated by the presence of co-morbid conditions and medications prescribed for other conditions. The management of gout is 2-fold: (i) treatment of the acute attack to rapidly resolve the pain and inflammation; and (ii) long-term urate-lowering therapy (ULT) to prevent further gouty episodes. NSAIDs, colchicine, corticosteroids and more recently interleukin (IL)-1 inhibitors are effective treatments for acute gout. The choice of agent is determined by the patient's age, co-morbidities and concomitant medications. Renal impairment is of particular concern in the elderly and may preclude the use of NSAIDs and colchicine. The IL-1 inhibitors are rapidly effective but data in the elderly are limited. ULT aiming for a serum urate <0.36?mmol/L, or lower in severe tophaceous gout, is critical for the long-term management of gout. Urate lowering can be achieved by inhibiting the production of uric acid through xanthine oxidase inhibition (allopurinol, febuxostat), increasing uric acid excretion via the kidneys (uricosuric agents: probenecid, benzbromarone) or dissolving uric acid to the more water soluble allantoin (recombinant uricases: pegloticase, rasburicase). Allopurinol is the most commonly used ULT, but there is no consensus on dosing in renal impairment. Febuxostat is effective at lowering serum urate, but there are limited data in the elderly and patients with renal impairment. Furthermore, there are concerns about cardiovascular safety. Probenecid is ineffective in patients with renal impairment (creatinine clearance <60?mL/min) and the availability of benzbromarone is limited because of concerns about its hepatotoxicity. The recombinant uricases provide an exciting new therapeutic option, but there are limited data for their use in the elderly. These agents may be particularly useful in patients with a high urate burden (e.g. those with tophi); however, they may precipitate a severe flare of gout and this will require treatment in its own right. Careful consideration of the patient's concomitant medications is required as many drugs increase serum urate. Successful urate lowering will ultimately reduce gout flares and thereby improve patient quality of life.     

The doctor's duty to the elderly patient in clinical trials

The ethical principles of beneficence (or non-maleficence), respect for persons and justice apply to both good medical practice and clinical research. Doctors have a duty to offer to their patients, of all ages, the opportunity to take part in clinical trials and to ensure that research is appropriately designed and conducted.Barriers to participation of elderly patients in clinical trials include complex protocols with onerous outcome measures, a research focus on aggressive therapies with substantial toxicity, restrictive entry criteria unnecessarily excluding concurrent conditions and medication, patients' and families' limited expectations of benefits and lack of financial, logistic and social support.Participation is encouraged when attitudes of care staff towards research are positive, altruistic motives are acknowledged, approval of family members is gained and protocols are designed for patient rather than staff convenience. Special consideration should be given to ensuring that patient consent is fully informed and freely given.Elderly patients may have more difficulty comprehending consent information and particular attention should be given to compensating for communication and sensory deficits, improving readability of information sheets and consent forms, and considering the use of innovative consent procedures. Those with cognitive impairment and the institutionalised are vulnerable to exploitation and require special consideration and management.     

依据Beers标准评价老年患者不合理用药

目的：关注老年患者用药安全,促进合理用药。方法：以Beers（2012年版）标准为主要依据。对我院3012位老年患者进行潜在性不合理用药（PIM）评价分析。结果：根据Beers标准判断,共有162例（5.4%）至少发生了一种PIM,其中129例（4.6%）使用了老年人应避免使用的药物,46例（1.5%）使用了老年人应慎用的药物,13例存在两种PIM情况。354例（11.8%）发生了Beers标准未包括的PIM。尚未发现与诊断或疾病状态相关的潜在性不适当用药。结论：Beers标准是专业判断的重要补充,门诊老年患者潜在不当用药需要综合评价标准。