Age and beta adrenoceptor-mediated function

Decreased maximal heart rate with aging is related to reduced {beta}-adrenergic responsiveness but is largely explained by a reduction in intrinsic heart rate

A decrease in maximal exercise heart rate (HR(max)) is a key contributor to reductions in aerobic exercise capacity with aging. However, the mechanisms involved are incompletely understood. We sought to gain insight into the respective roles of intrinsic heart rate (HR(int)) and chronotropic beta-adrenergic responsiveness in the reductions in HR(max) with aging in healthy adults. HR(max) (Balke treadmill protocol to exhaustion), HR(int) (HR during acute ganglionic blockade with intravenous trimethaphan), and chronotropic beta-adrenergic responsiveness (increase in HR with incremental intravenous infusion of isoproterenol during ganglionic blockade) were determined in 15 older (65 +/- 5 yr) and 15 young (25 +/- 4 yr) healthy men. In the older men, HR(max) was lower (162 +/- 9 vs. 191 +/- 11 beats/min, P < 0.0001) and was associated with a lower HR(int) (58 +/- 7 vs. 83 +/- 9 beats/min, P < 0.0001) and chronotropic beta-adrenergic responsiveness (0.094 +/- 0.036 vs. 0.154 +/- 0.045 DeltaHR/[isoproterenol]: P < 0.0001). Both HR(int) (r = 0.87, P < 0.0001) and chronotropic beta-adrenergic responsiveness (r = 0.61, P < 0.0001) were positively related to HR(max). Accounting for the effects of HR(int) and chronotropic beta-adrenergic responsiveness reduced the age-related difference in HR(max) by 83%, rendering it statistically nonsignificant (P = 0.2). Maximal oxygen consumption was lower in the older men (34.9 +/- 8.1 vs. 48.6 +/- 6.7 ml x kg(-1) x min(-1), P < 0.0001) and was positively related to HR(max) (r = 0.62, P < 0.0001), HR(int) (r = 0.51, P = 0.002), and chronotropic beta-adrenergic responsiveness (r = 0.47, P = 0.005). Our findings indicate that, together, reductions in HR(int) and chronotropic responsiveness to beta-adrenergic stimulation largely explain decreases in HR(max) with aging, with the reduction in HR(int) playing by far the greatest role.

[Evaluation of pulmonary function in the elderly. Intergroupe Pneumo Gériatrie SPLF-SFGG]

Aging is associated with a progressive decrease in lung function. As a consequence of aging, individual's reserve is diminished, but this decrease is heterogeneous between individual subjects. Many factors are involved in the overall decline in lung function. The prevalence of asthma in the elderly is estimated between 6 and 10%. Mortality due to COPD is increasing, especially among older subjects. Older subjects are at an increased risk of developing chronic diseases such as Parkinson's disease, which can have consequences for lung function. Under-nutrition is also common in the elderly and can produce sarcopenia and skeletal muscle dysfunction. The presentation of respiratory disorders may differ in the elderly, especially because of a lack of perception of symptoms such as dyspnea. The impact of bronchodilatators or corticosteroids on respiratory function has not been studied in the elderly. Drugs usually used for the treatment of hypertension or arrhythmias, which are often observed with aging, can have pulmonary toxicity. There is no difference between functional evaluation in younger and older subjects but it is more difficult to find predicted values for older patients. Performing pulmonary function tests in older patients is often difficult because of a higher prevalence of cognitive impairment and/or poor coordination. When assessing pulmonary function in the elderly, the choice of tests will be depend on the circumstances, with the use of voluntary manoeuvres dependent on the condition of the patient.

Cardiovascular drug therapy in the elderly

Pharmacokinetic considerations in the elderly include absorption, bioavailablility, drug distribution, half-life, drug metabolism, and drug excretion. There are numerous physiologic changes with aging that affect pharmacodynamics with alterations in end-organ responsiveness. This article discusses use of cardiovascular drugs in the elderly including digoxin, diuretics, beta-adrenergic blockers, angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, nitrates, calcium channel blockers, alpha-adrenergic blockers, antiarrhythmic drugs, lipid-lowering drugs, and anticoagulants. This article also discusses the adverse effects of cardiovascular drugs in the elderly, medications best to avoid in the elderly, and the prudent use of medications in the elderly.

Intravenous Esmolol is Well Tolerated in Elderly Patients with Heart Failure in the Early Phase of Non-ST Elevation Myocardial Infarction

AIM

To investigate the haemodynamic response to and clinical safety and tolerability of intravenous esmolol (Brevibloc), Baxter Healthcare Corporation, Deerfield, Illinois, USA) in elderly and younger patients with acute non-ST elevation myocardial infarction (NSTEMI) and heart failure.

PATIENTS AND METHODS

We studied 24 consecutive patients, 12 of them elderly (> or =75 years old) and 12 younger (32-74 years old), with NSTEMI and symptoms of heart failure on presentation. After stabilisation of the patient's condition with standard therapy, intravenous esmolol was administered. An infusion rate of 0.05 mg/kg/min for 30 minutes was instituted and, if no adverse effects developed, this was increased to 0.20 mg/kg/min. All haemodynamic parameters were measured before and at the end of each administration using a Swan-Ganz catheter.

RESULTS

Only one patient in the elderly subgroup did not tolerate the augmented infusion rate (because of severe bradycardia) and so had to return to the initial lower infusion rate. The cardiac index (mean +/- SD) was 2.4 +/- 0.9 L/min/m(2) at baseline and decreased to 1.9 +/- 0.4 L/min/m(2) (p < 0.05 vs baseline) at the end of the administration of the second dose of esmolol in the elderly patients and 2.6 +/- 0.5 L/min/m(2) and 2.2 +/- 0.5 L/min/m(2) (p < 0.05 vs baseline), respectively, in the younger patients. Mean pulmonary wedge pressure was 17 +/- 6mm Hg at baseline and increased to 19 +/- 4mm Hg (p < 0.05 vs baseline) at the end of the second dose of esmolol in the elderly patients and 16 +/- 10mm Hg and 18 +/- 10mm Hg (p < 0.05 vs baseline), respectively, in the younger patients. The response of both age groups to esmolol was the same for all of the parameters examined.

CONCLUSION

Intravenous esmolol was safe and well tolerated in the early phase of NSTEMI in patients presenting with symptoms of heart failure and ongoing ischaemia, regardless of their age.

Geriatric pharmacology

With the dramatic demographic change that has resulted in the "graying of the population" has come a compelling interest in the health and health concerns of older adults. The increasing incidence and prevalence of systemic diseases, especially chronic diseases, among older adults, and the concomitant increase in medication use, have provided impetus for the subspecialty of geriatric pharmacology. This article reviews the physiologic changes, nonphysiologic aspects, and pharmacologic changes associated with aging and their implications for dental practice.

The relationship between age and bronchial responsiveness: evidence from a population survey

OBJECTIVES

Increased bronchial responsiveness is a feature of symptomatic asthma, and it predicts the onset of wheezing. We have investigated the relationship between bronchial responsiveness and age in a population sample with an age range of 45 to 86 years.

DESIGN

Cross-sectional population survey.

SETTING

Population of Central Manchester, UK.

PARTICIPANTS

An age-stratified random sample of white adults aged > or = 45 years old and living in Central Manchester. They were recruited from their primary care physician (general practitioner) lists. Patients with confusion and patients who were housebound were excluded.

MEASUREMENTS

Respondents to a mail questionnaire were invited to attend a methacholine bronchial challenge performed using the Newcastle dosimeter method. Respondents with ischemic heart disease or respondents taking oral steroids, beta-blockers, or anticholinergic medication were excluded.

RESULTS

Of the 783 subjects contacted, 92.3% of the subjects responded, and 508 subjects returned enough information for us to deduce their suitability for the bronchial challenge. Of the 395 suitable subjects, 247 subjects participated (62.5% of those invited; 31.5% of the study population), and 208 participants completed the bronchial challenge. Participants were slightly younger than nonparticipants, but they were otherwise representative of the population. Increased bronchial responsiveness (provocative dose of methacholine causing a 20% fall in FEV1 < or = 200 microg) was present in 71 (34.1%) participants. Stepwise multiple regression analysis showed weak, independent, positive associations between bronchial responsiveness and age, and between bronchial responsiveness and the total immunoglobulin E level. There was an independent negative relationship between bronchial responsiveness and the airways caliber (expressed as standardized residuals; R2 = 0.29).

CONCLUSIONS

We have found a high prevalence of increased bronchial responsiveness in this inner-city population of older adults. Bronchial responsiveness showed a weak independent positive association with age.

Pharmacodynamic and pharmacokinetic considerations in geriatric psychopharmacology

Age-associated decreases in metabolism and elimination of drugs are sufficient to give one pause before prescribing drugs in the elderly particularly if multiple drugs are to be used. When one factors in concomitant drugs that may inhibit P450-mediated metabolism of other more toxic drugs, genetic deficiency of P450 enzymes, and medical illnesses such as liver and renal failure that will lead to further elevation of drug levels and delay in drug clearance, the likelihood of adverse events when multiple drugs are used in the elderly becomes truly dizzying. In consideration of the pharmacologic principles discussed, when prescribing drugs in the elderly, one might add to the often heard recommendation, "Start low and go slow," a third admonition, "Keep it as simple as possible!"

Beta-adrenoceptor responsiveness of splenic macrophages in normotensive and hypertensive rats

The aim of the present study was to investigate putative mechanisms implicated in the impaired phagocytic response of spontaneously hypertensive rats (SHR)1. The effect of in vitro treatment with isoproterenol (ISO), a beta-adrenergic drug, on phagocytosis and respiratory burst by splenic macrophages (SpMø) from normotensive Wistar-Kyoto rats (WKY) and SHR with established hypertension, respectively, was evaluated. Furthermore, the relaxant effect of ISO was determined in phenilephrine-precontracted thoracic aorta strips from SHR compared with age-matched WKY rats. Results indicate that exposure of rat SpMø to ISO generate a significant and dose-dependent reduction of phagocytosis and oxidative burst which was antagonized, almost completely, by the beta-adrenergic antagonist propranolol (PRO). Unlike normotensive, in hypertensive rats treatment with ISO fail to modulate phagocytosis and respiratory burst activity by SpMø. At vascular level, aortic relaxation by ISO was reduced in SHR when compared to WKY rats. These findings suggest that SHR exhibit changes not only in vascular, but also in macrophage beta-adrenoceptor-mediated responses. It is postulable that sympathetic overactivity could be responsible for impaired phagocytic functions and beta-receptor alterations observed in SHR.

Catecholamine responsiveness in human lymphocytes evaluated by intracellular free calcium measurements

Intracellular free calcium concentration [f(Ca2+)i] and cyclic adenosine monophosphate (cAMP) in lymphocytes and basal plasma noradrenaline (NA) were measured in nine healthy male subjects (age 22-72 years). Lymphocytes were stimulated with isoproterenol and the plant lectin concanavalin A (Con A). Con A induced a dose dependent increase in f(Ca2+)i without increasing inositol lipid turnover. The mechanism by which Con A mobilized f(Ca2+)i is not clear, but we found that the level of prostaglandin E2, a metabolite from arachidonic acid, increased after stimulation with Con A, indicating the possibility of arachidonic acid released by phospholipase A2. Isoproterenol inhibited the Con A-induced calcium mobilization in a dose dependent manner in lymphocytes stimulated with both isoproterenol and Con A. This inhibitory effect of isoproterenol is most probably mediated via cAMP. Both isoproterenol induced increase in cAMP and inhibition of calcium mobilization were significantly correlated to basal plasma NA. Taken together our data indicate that the lymphocyte response to a specific stimulus may depend not only on the strength of this stimulus, but also on the level of sympathetic nerve activity.

Impaired bronchodilator response to albuterol in healthy elderly men and women

BACKGROUND

Lymphocytes of normal elderly subjects and young asthmatics display dysfunctional beta-adrenoceptors. If beta-adrenoceptor dysfunction were found in senescent airways, it might help explain the pathogenesis of late onset asthma.

METHODS

The bronchodilatory effects of albuterol after methacholine-provoked bronchoconstriction were compared in 17 healthy young (age 20 to 36 years) and 17 healthy elderly (age 60 to 76 years) volunteer subjects. Albuterol was inhaled via dosimeter (initially 7.8 micrograms, doubling every 7.5 min) with forced expiratory flow at 50% vital capacity (FEF50) measured prior to each dose. Albuterol sensitivity was expressed as the cumulative logarithm of the area under the FEF50 recovery curve (AUC); a greater AUC meant lower sensitivity. On another study day, spontaneous recovery from methacholine was assessed similarly.

RESULTS

There was no intergroup difference in spontaneous recovery. Despite lower methacholine doses provoking similar (35%) FEF50 falls in elderly subjects, albuterol AUC was greater in elderly subjects (6,552%.min.microgram) than young subjects (3,922%.min microgram; p = 0.03). Multiple regression showed that AUC and age were related (p = 0.02).

CONCLUSION

Airway beta 2-adrenoceptor responsiveness is diminished in old age, suggesting that airway beta-adrenoceptor dysfunction may be implicated in late-onset asthma.

Age-related changes in beta-adrenergic neuroeffector systems in the human heart

BACKGROUND

Aging decreases cardiac beta-adrenergic responsiveness in model systems and in humans in vivo. The purpose of this study was to comprehensively evaluate the age-related changes in the beta-receptor-G protein-adenylyl cyclase complex in nonfailing human hearts.

METHODS AND RESULTS

Twenty-six nonfailing explanted human hearts aged 1 to 71 years were obtained from organ donors and subjected to pharmacological investigation of beta-adrenergic neuroeffector systems. When the population was subdivided into the 13 youngest and 13 oldest subjects, total beta-receptor density assessed by maximum [125I]ICYP binding (beta max) was reduced in older hearts by 37% in left ventricles and 31% in right ventricles (both P < .05), and the downregulation was confined to the beta 1 subtype (r = .78 left ventricle beta 1 density versus donor age). Older donor hearts exhibited a 3- to 4-fold rightward shift of ICYP-isoproterenol (ISO) competition curves and demonstrated 43% fewer receptors in a high-affinity agonist binding state (P < .05). Older hearts exhibited decreased adenylyl cyclase stimulation by ISO, by zinterol (beta 2-agonist), and by the G protein-sensitive probes forskolin, Gpp(NH)p, and NaF. In contrast, there was no change in response to manganese, a specific activator of the adenylyl cyclase catalytic subunit. Toxin-catalyzed ADP ribosylation in membranes prepared from older versus younger hearts revealed a 29% to 30% reduction (P < .05) with cholera toxin (Gs) but no difference with pertussis toxin (Gi). The systolic contractile response of isolated right ventricular trabeculae to ISO was decreased by 46%, with a 10-fold increase in ISO EC50 in older relative to younger donor hearts.

CONCLUSIONS

There is a profound decrease in cardiac beta-adrenergic responsiveness with aging. This occurs by multiple mechanisms including downregulation and decreased agonist binding of beta 1-receptors, uncoupling of beta 2-receptors, and abnormal G protein-mediated signal transduction.

Peripheral mononuclear leucocyte beta adrenoceptors and non-specific bronchial responsiveness to methacholine in young and elderly normal subjects and asthmatic patients

BACKGROUND

As beta adrenoceptor dysfunction occurs in both the normal elderly subject and in young asthmatic patients, the hypothesis was examined that age related beta adrenoceptor changes are important in the pathogenesis of late onset asthma in old age.

METHODS

Subjects were non-smokers who comprised 17 young normal subjects of mean (SE) age 29.4 (1.3) years, 17 elderly normal subjects of 67.2 (1.3) years, seven young asthmatic patients of 31.0 (2.8) years, and 17 elderly asthmatic patients of 68.5 (1.4) years. All asthmatic patients withheld inhalers for 12 hours and oral treatment for 24 hours before each study day. Subjects underwent an inhaled methacholine challenge (Newcastle dosimeter method) on two nonconsecutive days. The slope of the flow at 50% of the vital capacity (FEF50) dose-response curve was derived from the percentage fall in FEE50 divided by methacholine dose (sFEF50). Beta-adrenoceptor density (Bmax) and affinity (%KH) were determined with (125I)iodocyanopindolol as the radioligand in membranes prepared from mononuclear leucocytes.

RESULTS

Log sFEF50 was shown to be reproducible (repeatability coefficient 0.41) on the two study days and was inversely related to %KH but not to Bmax. Multiple regression analysis (all 58 subjects, overall R2 = 0.57) revealed an inverse relation between log sFEF50 and %KH, and between log sFEF50 and Bmax. The inverse relation between log sFEF50 and %KH was preserved whereas that between log sFEF50 and Bmax was lost when young asthmatic subjects or when all asthmatic subjects were excluded from multiple regression analysis.

CONCLUSIONS

The beta adrenoceptor dysfunction observed in late onset asthma may be similar to that seen during ageing. Thus late onset asthma may represent the extreme of a spectrum of age associated beta adrenoceptor dysfunction.

Vascular beta-adrenoceptor-mediated responses in hypertension and ageing in rats

1. In normotensive Wistar (W) and spontaneously hypertensive (SHR) rats between 5 and 20 weeks of age, there was an age-related increase in blood pressure (r2 = 0.770 and r2 = 0.801 respectively). Except for adrenaline (r2 = 0.979) in SHRs, plasma catecholamines and age were unrelated. 2. In ring segments of thoracic aorta from 5, 10, 15 and 20 week old rats, the respective EC80s (-log M) for phenylephrine (PE)-induced contractions were 8.20 +/- 0.37, 7.96 +/- 0.10, 7.15 +/- 0.12 and 7.12 +/- 0.21 in W and 7.73 +/- 0.13, 7.72 +/- 0.16, 7.37 +/- 0.08 and 7.40 +/- 0.03 in SHR tissues (means +/- SEM; n = 5-7). 3. In PE-preconstricted rings, the respective EC50s (-log M) for isoprenaline (IPNA)-induced relaxation were 7.97 +/- 0.11, 7.74 +/- 0.10, 6.96 +/- 0.19 and 6.57 +/- 0.26 in W and 8.03 +/- 0.24, 7.62 +/- 0.08, 6.88 +/- 0.13 and 6.73 +/- 0.14 in SHR tissues (n = 5-7). 4. In PE-preconstricted rings from 5 and 20 week old rats, a single concentration of IPNA (approximating the respective IPNA EC50s) induced relaxation which was sustained over 2 h in W but not SHR tissues. The SHR:W ratios of the net relaxant responses, at 5 and 20 weeks, were 0.6461 and 0.6167 respectively. 5. Thus, W rats exhibit an age-related loss in both vascular alpha- and beta-adrenoceptor responsiveness which appears unrelated to plasma catecholamines. SHRs also exhibit an age-related loss in vasodilator beta-adrenoceptor responsiveness, which may involve adrenaline-induced desensitization, but appear to maintain vasoconstrictor alpha-adrenoceptor responsiveness. It is proposed that an age-related decline in beta-adrenoceptor responsiveness coupled to maintenance of alpha-adrenoceptor responsiveness may lead to chronic blood pressure elevation, as observed in SHRs, while a parallel decline in both alpha- and beta-adrenoceptor responsiveness, as observed in W rats, may preclude hypertension development.

Intravenous atenolol in elderly patients in the early phase of acute myocardial infarction

The aim of this study was to assess the hemodynamic response to intravenous atenolol in elderly patients with acute myocardial infarction. We studied 14 elderly men, aged 64-85 years, and 14 younger men, aged 29-48 years, in the early postfibrinolytic phase of acute myocardial infarction. All the patients were in Killip class I. A triple-lumen Swan-Ganz thermodilution catheter was introduced into the right heart chambers. The patients received 5 mg intravenous atenolol over 5 minutes. All hemodynamic parameters were measured before and 10 minutes after atenolol. The hemodynamic characteristics and the location and extent of acute myocardial infarction were the same in both groups before atenolol. The hemodynamic changes after atenolol administration were the same in the two groups, but the stroke volume and cardiac indexes decreased to a greater extent in the elderly (p = .01 and p = .0001, respectively). These results indicate that intravenous atenolol in the early postfibrinolytic phase of acute myocardial infarction is safe in Killip class I elderly patients, although the cardiac and stroke volume indexes decrease, and the increase in the total systemic resistance is more in older than in younger patients.

Adverse reactions as a cause of hospital admission in the aged

Truly elderly people comprise an increasingly large fraction of the population and consume a disproportionate amount of drugs. Over the last 25 years a number of different studies have illustrated that advancing age is associated with adverse drug reactions (ADRs). Advancing age is also associated with polypharmacy and multiple pathology, and this complex inter-relationship makes it difficult to conclude that age itself is a causative factor for ADRs. ADRs resulting in hospital admission have been the subject of study for many years, but it has not been consistently demonstrated that advancing age is a predisposing factor. Early studies used the method of intensive inpatient monitoring and identified digoxin, diuretics, aspirin, psychotropics and cytotoxics as drugs of concern. Smaller more recent studies have used more sophisticated statistical techniques to identify predisposing factors. Nonsteroidal anti-inflammatory drugs have been added to the list of drugs that may cause ADR-related hospital admission. Polypharmacy, and altered pharmacokinetics and pharmacodynamics are possible causative factors; however, variable compliance and multiple pathology may cause difficulties with attributing causality. Some basic guidelines for sensible prescribing would almost certainly result in fewer ADRs in the elderly, including those ADRs severe enough to result in hospital admission.

Hypertension in the elderly with a special focus on treatment with angiotensin-converting enzyme inhibitors and calcium antagonists

Age-related changes (e.g., decrease in plasma renin activity and total body potassium, increase in plasma catecholamines, volume depletion) need to be taken into account when selecting an antihypertensive agent for the elderly patient. A number of large scale clinical trials (e.g., Systolic Hypertension in the Elderly Program, Veterans Administration Cooperative Study, European Working Party on High Blood Pressure in the Elderly) have demonstrated that antihypertensive therapy with diuretics substantially reduced cardiovascular mortality and stroke incidence. However, since diuretics, even potassium-sparing agents, may induce hypokalemia, newer antihypertensive agents (angiotensin-converting enzyme [ACE] inhibitors and calcium antagonists) may also be appropriate as first-line monotherapy for this patient population. ACE inhibitors are effective antihypertensive agents and are associated with a lower rate of adverse effects than diuretics, beta blockers, and centrally acting agents. Nevertheless, periodic monitoring of serum potassium, creatinine levels, and renal function is advisable. An important feature of calcium antagonists is that they lower blood pressure with no negative effect on serum lipids or glucose metabolism. Typically, they have few side effects, peripheral edema being the most commonly reported. A recent double-blind randomized study comparing a new sustained release nifedipine formulation and the ACE inhibitor lisinopril found the 2 drugs equivalent in efficacy with no differences in the rate of adverse events.

Drug use and effects in older adults in the United States

Aging markedly influences drug use and drug effects. The purpose of this review is two-fold: (i) to examine how social, economic, and psychological factors, compliance, and prescribing patterns affect drug use in institutionalized and non-institutionalized older adults in the United States, and (ii) to illustrate how physiological aging, actions of drugs, and adverse drug reactions influence drug effects. Recommendations for further study include identification of adverse reactions, and examination of drug taking behavior in older adults who are alone or debilitated. Research is especially needed for those in nursing homes and for those who are old-old (over 85 years).

The effects of age on the pharmacokinetics, antihypertensive efficacy and general tolerability of dilevalol

1. This study investigated the influence of age on the pharmacokinetics, pharmacodynamics, general tolerability and concentration-effect relationships in 18 patients with essential hypertension (age range 23-73 years) during treatment with dilevalol, a non selective beta-adrenoceptor antagonist with vasodilator properties. 2. There were no significant age-related changes in pharmacokinetics for either acute or chronic treatment with dilevalol, although there were significant changes in elimination half-life from 7.8 to 11.7 h (P less than 0.05) and in AUC from 261 to 352 ng ml-1 h (P less than 0.005) following translation from acute to chronic dosing. 3. In absolute terms, dilevalol treatment (as compared with placebo) produced numerically larger falls in average blood pressure in the six oldest as compared with the six youngest patients: for example, supine blood pressure fell by, respectively, 29/15 and 10/7 mm Hg during chronic treatment. 4. Using an integrated kinetic-dynamic model, blood pressure responsiveness was characterised by relating the fall in blood pressure (mmHg) to the plasma drug concentrations in each individual patient. No independent age-related effect was demonstrated. There was a significant relationship between response and the height of initial blood pressure which tended to be higher in the elderly patients. 5. Patient tolerability was generally satisfactory and there was no differential age-related effect. 6. This study has shown that the antihypertensive efficacy of dilevalol is not attenuated in the elderly and that there are no significant age-related differences in pharmacokinetics or pharmacodynamics.

Effect of age on lymphocyte beta 2-adrenergic responsiveness

Beta-adrenergic receptor agonists and antagonists are among the most widely used classes of agents in the US today. Heterogeneity in pharmacologic response among humans exists. This article reviews the influence of age on lymphocyte beta 2-adrenergic receptor responses. Evidence obtained in humans indicates that beta-adrenergic receptor numbers on peripheral blood cells may differ, although the direction of the change is not consistent among laboratories. Drug-induced regulation of receptors either up or down appears to be similar among age groups. The affinity of beta-adrenoceptor binding sites for isoproterenol decreases with aging. Events distal to the receptor recognition site itself exhibit age-related differences, presumably due to a decrease in the coupling of beta-adrenoceptors to adenylate cyclase. Mechanisms of decreased catecholamine responsiveness during aging remain to be defined. The precise definition of these alterations may contribute useful insights into the changes that occur with aging in response to catecholamines, other hormones, and neurotransmitters.

Neuroendocrine mechanisms and cardiovascular homeostasis in the elderly

Reduced homeostatic capacity is typical of the aging process and is particularly apparent in changes in the neuroendocrine control of cardiovascular homeostasis. Not only is there reduced beta-adrenoceptor responsiveness, but reduced baroreflex function also occurs with age. These result in increased sensitivity to the therapeutic and postural hypotensive effects of diuretics and vasodilators. Increased total body sodium and reduced activity of the renin-angiotensin-aldosterone system may also contribute to the therapeutic effect of diuretics and salt restriction in elderly hypertensives. In addition, atrial natriuretic peptide levels are increased in the elderly and may in part be responsible for the suppressed renin and aldosterone levels found in older groups. Vasopressin secretion and thirst are also disturbed with age, and may act in concert with declining renal function to predispose the elderly to disturbances of water balance. An understanding of these neuroendocrine changes with age is important to maximize therapeutic benefit and to minimize adverse effects in the treatment of hypertension in the elderly.

Absence of correlations between plasma catecholamine levels and mononuclear leukocyte beta 2-adrenergic receptors in the elderly

To assess the effects of aging on catecholamine plasma levels and mononuclear leukocyte (NML) beta 2-adrenergic receptors and on the possible relationships between these two parameters, we evaluated two groups of human subjects: 18 elderly volunteers (age 65-70 years) and 13 young volunteers (age 21-35 years). Norepinephrine plasma levels were significantly higher in the elderly subjects compared to the younger ones (P less than 0.05), whereas plasma epinephrine levels were not different. Also MNL beta 2-adrenoceptor density was significantly higher in elderly subjects (P less than 0.05). The binding dissociation constants were not significantly different. In young subjects there was a significant (P less than 0.02), inverse relationship between receptor densities and plasma norepinephrine levels; this relationship was not present in elderly persons. Our data suggest that the increase in beta 2-adrenoceptors may be due to a compensatory phenomenon, owing to the reduced beta-adrenergic sensitivity observed in the elderly subjects; moreover, the regulation of beta-adrenoceptors by plasma catecholamines seems to be altered by aging.

Required beta blocker profile in the elderly

In the truly elderly, a complex balance between compensatory processes and impaired organ function allows reasonably normal physical function. It is argued that beta blockade should have certain desirable qualities to minimize any impairment of organ function, thereby upsetting the quality of life. Thus a simple pharmacokinetic pattern without hepatic metabolism is less likely to cause unexpected variation in blood levels of the beta blocking agents and to have fewer risks of interactions with other drugs including nicotine. Renal-excreted beta blockers--such as atenolol, nadolol, and celiprolol--do, however, need downward dose adjustment when the glomerular filtration rates fall. The elderly are frequently categorized as having a low renin profile, which in the view of some workers may make a vasodilatory beta blocker more desirable. Hemodynamic advantages of such agents include the prime site of attack in hypertension on the increased peripheral vascular resistance, increasingly fundamental with a prolonged duration of hypertension and therefore with the aging process. Furthermore, a normal heart rate with a sustained cardiac output may avoid symptomatic bradycardia. In the elderly, respiratory function may be impaired so that loss of elastic recoil causes elderly emphysema. A highly cardioselective beta blocker should be an advantage. Finally, minimal interference with glucose and lipid metabolism should also be desirable goals.

Developmental changes in alpha 1-adrenoceptor coupling to G-protein in bovine aorta

Differences in epinephrine binding to alpha 1-adrenoceptors, epinephrine-induced contractile potency, susceptibility to phorbol ester (PDBu) modulation, and differences in membrane fluidity were studied in bovine aorta from young (3-8 weeks) and adult or mature (6-8 years) animals. Membranes prepared from aorta of adult animals exhibited a two-fold higher receptor density while [3H]prazosin affinity was unchanged. Epinephrine displacement studies revealed both high- and low-affinity binding in membranes from the aortas of young animals whereas, preparations from adult animals exhibited only a single class of low-affinity sites. In low-temperature binding studies, membranes prepared from aortas of adult animals exhibited both high- and low-affinity agonist binding, in proportions about equal to those of young animals. The ability of PDBu to uncouple alpha 1-adrenoceptor from G-protein interaction is demonstrable in young but not in adult animals which raises the possibility of prior phosphorylation of receptors in the latter tissues. Aortas from young animals showed increased contractile potency to epinephrine and, in addition, were significantly more fluid as compared to aortas from adult animals. Alterations in the membrane environment or phosphorylation state of the alpha 1-adrenoceptor may thus provide age-dependent modulation of its function.

Beta-adrenergic responses and airway reactivity in healthy adults

Healthy adults aged 18-90 years were tested for lymphocyte and granulocyte cyclic AMP responses to isoproterenol and prostaglandin E1 (PGE1), beta-adrenergic receptor density and antagonist binding properties, and for airway reactivity to methacholine. Our hypothesis was that reduced beta-adrenergic responses occur with aging and are associated with increased airway reactivity. This hypothesis was not supported by the data. Lymphocyte stimulation ratios (cyclic AMP level with stimulation/baseline cyclic AMP level) at higher concentrations of isoproterenol and PGE1 increased significantly with age. There were no significant age trends for any of the other variables. None of the beta-adrenergic responses or receptor properties correlated with airway reactivity to methacholine. beta-Adrenergic responses in lymphocytes and granulocytes from the same subject were weakly correlated at high concentrations. Prior studies which suggest that reduced beta-adrenergic responses and increased airway reactivity are concomitants of normal aging may differ from the present study in subject selection. In healthy older subjects, there appears to be no reduction in leukocyte beta-adrenergic responses or receptor properties and no change in airway reactivity.

Catecholamine-induced lipolysis in adipose tissue of the elderly

Age-dependent alterations in the effects of catecholamines on lipolysis were investigated in 25 young (21-35 yr) and 10 elderly (58-72 yr) healthy, nonobese subjects using isolated adipocytes obtained from abdominal subcutaneous tissue. Basal lipolysis was not affected by aging, while the rate of catecholamine-stimulated lipolysis was reduced by 50% in the elderly subjects (P less than 0.005). To elucidate the mechanisms behind this phenomenon lipolysis was stimulated with agents that act at well-defined steps in the lipolytic cascade, from the receptor down to the final step: the activation of the protein kinase/hormone-sensitive lipase complex. All agents stimulated lipolysis at a 50% lower rate in elderly as compared with young subjects (P less than 0.05 or less). However, half-maximum effective concentrations of the lipolytic agents were similar in both groups. The antilipolytic effects of alpha 2-adrenoceptor agonists were also the same in young and old subjects. Moreover, the stoichiometric properties of the beta- and alpha 2-receptors did not change with increasing age. In vivo studies performed on the same individuals likewise demonstrated an impaired lipolytic responsiveness, with 50% lower plasma glycerol concentrations during exercise in the elderly subjects (P less than 0.05), in spite of a normal rise in plasma norepinephrine. The plasma glycerol levels correlated strongly to the glycerol release caused by catecholamine-stimulated lipolysis in vitro in both young and elderly subjects (r = 0.8-0.9, P less than 0.001). In conclusion, a decreased activation of the hormone-sensitive lipase complex appears to be the mechanism underlying a blunted lipolytic response of fat cells to catecholamine stimulation in elderly subjects. This finding may, explain the age-dependent decreased lipolytic response to exercise in vivo.

Platelet alpha-adrenoceptor function and aging

The effect of aging on platelet alpha-adrenoceptor binding of 3H-dihydro-alpha-ergocryptine (3H-DHE) and alpha-adrenoceptor response expressed as cAMP decrease, after the addition of noradrenaline 10 microM to intact platelets in vitro were examined and correlated with adrenaline induced platelet aggregation in a group of twelve young volunteers (mean age 21 years), and twelve old volunteers (mean age 88 years). The binding by platelets of 3H-DHE was considerably higher in the young than in the old group (mean 292.70 +/- 40.79 and 167.90 +/- 18.30 fmol/mg protein respectively, p less than 0.02). The affinity (Kd) was also influenced with values of 1.49 +/- 0.21 in the young and 3.32 +/- 0.45 nM in the old, p less than 0.01). Stimulation of platelets with noradrenaline caused a greater decrement of cAMP in the old than in the young group (mean 4.44 +/- 0.87 as compared with 0.32 +/- 0.75 pmol/10(9) platelets. Platelet sensitivity to adrenaline, when expressed as aggregation increased in the old group. These data suggest that the enhanced sensitivity to adrenaline as observed in old people is not the result of increased alpha-adrenoreceptor number of affinity, but related to changes in the platelet membrane possibly not related to the alpha-adrenoceptors.

Responses to intravenous and oral diltiazem in elderly and younger patients with systemic hypertension

Diltiazem concentrations and blood pressure, heart rate, PR interval and forearm vascular resistance responses to intravenous (25 and 50 mg) and oral (120 mg) diltiazem were compared in 13 elderly persons (mean age 68 +/- 4 years) and 10 young persons (mean 30 +/- 5 years) with essential hypertension. Diltiazem elimination was slower in the elderly. After a dose of 25 mg, clearance was 13 +/- 4 ml/min/kg in the elderly and 23 +/- 7 in the young (p less than 0.05); after 50 mg, 16 +/- 6 and 21 +/- 12 ml/min/kg (p less than 0.05); and after oral administration, 22 +/- 9 and 35 +/- 14 ml/kg/min (p less than 0.02). No age-related differences in volume of distribution (by model or area methods) were seen. Elimination half-lives were 4.5 +/- 2.2 hours in the elderly and 3.8 +/- 0.7 hour in the young persons (p less than 0.01); 4.5 +/- 1.6 and 3.3 +/- 0.7 hours (p = 0.10); and 4.7 +/- 1.5 and 3.3 +/- 1.8 hours (p = 0.08) after 50, 25 and 120 mg. Maximal decreases in mean blood pressure were from 113 +/- 14 to 91 +/- 12 mm Hg (19%) in the elderly patients and from 108 +/- 8 to 99 +/- 9 mm Hg in the younger patients (8%) after 50 mg; from 106 +/- 13 to 93 +/- 14 mm Hg and from 109 +/- 11 to 99 +/- 13 mm Hg, respectively, after 25 mg; and from 113 +/- 10 to 97 +/- 10 mm Hg and from 109 +/- 11 to 97 +/- 8 after 120 mg orally.(ABSTRACT TRUNCATED AT 250 WORDS)

Aging and platelet beta-adrenoceptor function

Ten young volunteers (mean age 20 years) and ten elderly volunteers (mean age 89 years), including equal numbers of healthy men and women, were tested regarding adrenaline-induced platelet aggregation in vitro, platelet cyclic AMP content before and after beta-adrenoceptor stimulation with isoprenaline, as well as binding by platelet membranes of 125I-hydroxybenzylpindolol. In the aged patients there was a highly significant decrease in the concentration of adrenaline needed to produce irreversible platelet aggregation, as compared with the young. Platelet basal cyclic AMP content did not differ but the response to isoprenaline stimulation, expressed as the percentage rise of cyclic AMP content above the unstimulated level, was significantly decreased in the old subjects. The beta-adrenoceptor number was unchanged but the affinity decreased significantly in the old group. The data suggest that the increased aggregation response to adrenaline in old people could be due in part to a diminished functional capacity of the platelet beta-adrenoceptor.

Age and sex related differences in some rat renal NADPH-consuming detoxification enzymes

Age- and sex-associated changes in some renal drug-metabolizing enzyme activities (NADPH-cytochrome c reductase, the glutathione peroxidase-glutathione reductase system, and thioredoxin reductase) were investigated using male and female Wistar rats (ages ranging from -4 days to 24 months). During aging the activities of NADPH-cytochrome c reductase and thioredoxin reductase showed a marked decrease (approximately 50% in both enzymes compared to adult stage). Glutathione reductase activity presented similar values in adulthood and aging, and glutathione peroxidase activity showed an increase with age (30% compared with the adult values). A marked sex difference was observed in young rats for glutathione peroxidase and thioredoxin reductase activities. However, during aging this difference disappears for glutathione peroxidase activity, but it remains for thioredoxin reductase activity (the specific activity in male old rats was approximately two-fold that obtained from female old rats). The variations in these enzymatic activities may be important when determining the changes in susceptibility of the kidneys to toxic chemicals with aging.

Hormone and forskolin-stimulated cyclic AMP accumulation in human lymphocytes: reliability of longitudinal time measurements

Reliability of measurement of lymphocyte cyclic AMP synthesis in intact cells was estimated by taking 3 successive blood samples during a one-month period from 11 healthy volunteers. Isoproterenol and prostaglandin E1-stimulated cyclic AMP accumulation were used to evaluate the activity of these two receptor activities in human lymphocytes. Forskolin-stimulated cyclic AMP accumulation was used to evaluate the activity of the Ns/catalytic subunit. Only for forskolin was significant reliability observed. For isoproterenol and prostaglandin E1 significant reliability was observed only for male subjects.

The effect of age and sodium depletion on cardiovascular response to orthostasis

To test the hypothesis that normal age-related limitations in cardiovascular homeostasis may become clinically significant under stress, the cardiovascular response to postural change was assessed in six young and six old healthy subjects before and after modest diuretic-induced sodium depletion. Before diuresis, systolic blood pressure was maintained (from 110 +/- 4 to 113 +/- 6 mm Hg) while heart rate increased 22% (from 67 +/- 2 to 82 +/- 5 beats/min) at 3 minutes after 60-degree upright tilt in young subjects. After a significant diuretic-induced weight reduction and natriuresis, the young again maintained systolic blood pressure (from 110 +/- 4 to 110 +/- 6 mm Hg) and increased heart rate 49% (from 68 +/- 2 to 101 +/- 5 beats/min; p less than 0.05, compared with prediuresis values) in response to the same postural stimulus. During the prediuresis tilt, the older subjects showed no change in systolic blood pressure (from 132 +/- 4 to 134 +/- 6 mm Hg) and a 9% increase in heart rate (from 68 +/- 3 to 74 +/- 2 beats/min). After a similar significant weight reduction and sodium loss, the older subjects showed a significant reduction in systolic blood pressure (from 132 +/- 6 to 108 +/- 6 mm Hg; p less than 0.05) and a 17% increase in heart rate (from 69 +/- 4 to 81 +/- 3 beats/min; p less than 0.05) during tilt compared with values in young subjects. Three of six elderly subjects noted postural symptoms. These results suggest that, although the healthy old may appear well compensated under optimal conditions, decreased cardiovascular reserve renders them susceptible to postural change following mild sodium depletion.

Age-related changes in drug handling in man

Persons older than 65 years constitute 10% of the U.S. population but require approximately one-third of its health care service. A significant proportion of their disease states is related to adverse reactions to prescribed drugs. The origins of this disturbingly high incidence of untoward consequences from drug therapy are multiple and complex. They include: (1) alterations in expected patterns of drug handling associated with physiologic changes of the aging process itself, (2) alterations in responsiveness to specific types of drugs and (3) frequent occurrence of chronic and acute diseases. The data documenting pharmacokinetic changes in aging subjects are rudimentary, and the physician is commonly aware only of pharmacokinetic profiles derived from studies in healthy, young subjects. Without a firm basis on which to rest pharmacologic therapy, the clinical approach to drug treatment in the elderly patient must be cautious and conservative.