[Drug therapy of elderly patients from the viewpoint of the clinical pharmacologist]

[Age 70 and older a criterion for inclusion - not exclusion]

BACKGROUND

Although older people are frequently prescribed more drugs than younger people, they are rarely included in clinical trials. Elderly patients often suffer from multimorbidity and are prescribed many drugs simultaneously. With age, physiological changes occur that can affect the pharmacokinetics and pharmacodynamics of the drugs used, e.g., changes in the duration of action. There are several problematic implications to this, particularly relating to tolerability and possible negative effects for patients.

OBJECTIVES

Not only are guidelines for the treatment of elderly patients lacking, but also basic information about efficacy, tolerability, and interactions of drugs that are commonly prescribed to the elderly often missing. Physicians sometimes have no choice but to estimate the correct dosages for the elderly.

METHODS

Evaluations of secondary data and clinical trials, discussion, and analysis of basic research work on the basis of expert analysis.

RESULTS

There are very few clinical trials that include people over the age of 70. On the one hand, elderly people receive more drug prescriptions due to multimorbidity, compared with younger people, while on the other hand the risk of adverse drug reaction increases for precisely these individuals.

CONCLUSIONS

In order to improve treatment safety in older people in terms of duration and dosage, randomized control trials (RCT) are essential to provide evidence of the benefits of a drug to patients. For this reason, the call for clinical trials after as well as before authorization, on patients treated with these drugs-and that especially means elderly patients-is long overdue.

Non-steroidal anti-inflammatory drug use in chronic pain conditions with special emphasis on the elderly and patients with relevant comorbidities: management and mitigation of risks and adverse effects

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently used drugs, and this widespread use is complicated by safety issues.

METHOD

A Literature review was conducted.

RESULTS

NSAIDs are a leading cause of drug-related morbidity, especially in the elderly and patients with comorbidities. Most adverse effects are related to generalized inhibition of the major targets of NSAIDs: cyclooxygenases I and II. These enzymes are not only involved in pain and inflammation pathogenesis but are also required in the gastrointestinal (GI) tract for mucosal protection and gut motility, and in the kidneys for functional integrity. Thus, the mechanisms of NSAID toxicity are well understood, but the consequences are largely uncontrolled in clinical practice. GI ulcers, including bleeding ulcers, may occur in several percent of all chronic unprotected, high-dose NSAID users. Renal side effects may precipitate renal failure, resulting in acute dialysis and chronic retention. This includes sodium retention, resulting in arterial hypertension, heart failure, and atherosclerotic events. Cardiovascular risk may be tripled by chronic high-dose NSAID use in long-term clinical trials though "real-life studies" indicate lower risk ratios. Off-target side effects include allergic reactions, drug-induced liver injury, and central nervous system effects.

CONCLUSIONS

Management of pain and inflammation must consider those risks and find alternative drugs or approaches to limit the negative impact of NSAIDs on mortality and morbidity. Alternative drugs, low-dose/short-term use, but especially non-pharmacologic approaches, such as physiotherapy, exercise, neurophysiologic measures, and local therapies, need to be further utilized. The appalling equation "less pain-more deaths/morbidity" ultimately necessitates treatment optimization in the individual patient.

[What is the meaning of safety in hospitals?]

Patient safety in hospitals is difficult to define and is not measurable by operational safety parameters as in other fields. So-called adverse events (AE) are a collective of complications, failures, mistakes, errors and violations. Estimations of at least 9.2 % AEs in surgery with 0.1 % fatalities are given worldwide but there are no correlations between objective quantification of AEs and subjective or public perception of safety during the perioperative period. Patient safety during this period is mostly endangered by wound infections (safety 98 %) and nosocomial infections (safety 97 %). In spite of these facts, safety parameters for problems in anesthesia, blood transfusion, in retaining surgical instruments and so-called index events, such as patient and side identification errors are much higher. Patient safety is maintained in hospitals by objective means (surgical). Checklists have been proven to improve safety and critical incidence reporting, training and changing of attitudes could have further advantages but they are difficult to measure.