[Older patients and injectable anticancer drug: Feasibility study of the implementation of pharmaceutical interviews in oncogeriatrics in a hospital center]

INTRODUCTION

In our establishment, pharmaceutical interviews in oncogeriatrics have been developed to reduce drug iatrogenesis. The target patients were older patients (≥65years) with polypharmacy and/or identified at risk of frailty (G8≤14), starting an injectable cancer protocol.

METHODS

The aim of this study is to evaluate the feasibility of implementing pharmaceutical interviews in oncogeriatrics over a period of six months.

RESULTS

In total, 30 patients benefited from a pharmaceutical interview in oncogeriatrics (median age 76 years; 21 patients with G8≤14). Two-thirds of the patients met other interveners during patient care, 4 of whom after referral by the pharmacist. As for medication reviews: 93% of patients required pharmaceutical intervention (average of 3.5 per patient). The majority proposed therapeutic follow-ups and discontinuations of treatment. According to their evaluation by a pharmacist/oncologist pair, 97% of pharmaceutical interventions would have a positive clinical impact, of which 13 % a major clinical impact. The main drug classes concerned by the pharmaceutical interventions were analgesics, drugs used in diabetes and psycholeptics. Among the four pharmaceutical interventions with major clinical impact, nine proposed the optimization of analgesic treatment.

DISCUSSION

The implementation of these interviews allowed us to initiate the creation of a care pathway dedicated to older patients identified as fragile. The pharmaceutical care offered appear to provide added value in the care of these patients. Organizational changes are necessary to promote multidisciplinarity and improve our practices in oncogeriatrics.

The effect of age on clinical dose equivalency of fentanyl and morphine analgosedation in mechanically ventilated patients: Findings from the ANALGESIC trial

BACKGROUND

The dose equivalency of fentanyl vs. morphine is widely considered to be approximately 1:100. However, little is known about the effect of age on this ratio when these agents are used as infusions for analgosedation.

OBJECTIVES

To assess the impact of age on the clinical dose equivalency of fentanyl and morphine when used as infusions for analgosedation in mechanically ventilated intensive care unit patients.

METHODS

We performed a post hoc analysis of the Assessment of Opioid Administration to Lead to Analgesic Effects and Sedation in Intensive Care (ANALGESIC) cluster randomised crossover trial of fentanyl and morphine infusions for analgosedation. Dose and analgosedative clinical equivalency of fentanyl and morphine were assessed by age and by using different body-size descriptors.

RESULTS

We studied 663 patients (338 fentanyl, 325 morphine). Median (interquartile range) hourly dose of fentanyl and morphine were 58.1 (40.0-89.2) mcg and 3400 (2200-5000) mcg, respectively. The ratio of total dose of fentanyl:morphine was 1:93 in the 18- to 29-year-old group and 1:25 in the ≥80-year-old group (p = 0.015), respectively, with fentanyl becoming relatively less clinically effective as age increased. This effect was also seen when comparing dosing by different body-size descriptors with the strongest age-related change when using body surface area as body-size descriptor (p = 0.009).

CONCLUSION

The analgosedative clinical dose equivalency of fentanyl vs. morphine is heterogeneous when used as infusions for analgosedation, with fentanyl becoming relatively less clinically effective as age increases. This information can help guide prescription of these agents during transition from one agent to the other in critically ill patients.

Evaluation of medication safety assessment tools for pharmacist-led medication reviews: the Eastern European pilot project

Background: Pharmacist-led medication reviews (MR) are one of the key methods to support medication safety in polypharmacy patients. The aims of this study were to pilot MRs in Eastern European community pharmacies, describe medication use in polypharmacy patients, and evaluate the usability of medication safety assessment tools. Methods: The MR pilot was undertaken in Estonia, Latvia, Poland, Hungary, Romania, and Bulgaria. Patients who used at least five medicines were directed to the service by their GPs. Data on drug-related problems (DRPs) and adherence were collected by pharmacists through structured patient interviews. Databases for identification of potential drug-drug interactions (pDDIs) and adverse drug reactions (ADRs) named Inxbase/Riskbase, as well as an integrated tool comprising potentially inappropriate medicines (PIMs) lists EU(7)-PIM and EURO-FORTA, were applied retroactively to the MR pilot data to investigate possibilities for their use and to describe medication use and potential risks in the study population. Results: A total of 318 patients were included in the study, 250 of them elderly (≥65 years). One hundred and eighty (56.6%) participants had a total of 504 pDDIs based on Inxbase analysis. On average, there were 1.6 pDDIs per participant. Twenty-five (5.0%) of the 504 pDDIs were in a high-risk category. A total of 279 (87.7%) participants had a potential ADR in at least one of 10 Riskbase categories. One hundred and fifty-four (20.8%) of the potential ADRs were in a high-risk category. Twenty-seven pDDIs and 68 ADRs documented as DRPs during the service were not included in the databases. Using the integrated EU(7)-PIM/EURO-FORTA PIM list, a total of 816 PIMs were found in 240 (96%) of the 250 elderly participants (on average 3.4 PIMs per elderly participant). Seventy-one (29.6%) of the participants were using high-risk PIMs. Twenty-one percent of high-risk PIMs and 13.8% of medium-risk PIMs were documented as DRPs by the pharmacists during the pilot. Conclusion: Medication safety assessment tools can be useful in guiding decision-making during MRs; however, these tools cannot replace patient interviews and monitoring. Tools that include a thorough explanation of the potential risks and are easy to use are more beneficial for MRs.

Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study

BACKGROUND AND OBJECTIVES

Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality.

METHODS

This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald's method.

RESULTS

This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index.

CONCLUSIONS

Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.

A Phase 1 Study of Ensitrelvir Fumaric Acid Tablets Evaluating the Safety, Pharmacokinetics and Food Effect in Healthy Adult Populations

BACKGROUND

A reported clinical pharmacokinetics and safety study of suspension formulation of ensitrelvir, a therapeutic agent used in severe acute respiratory syndrome coronavirus 2 infection, demonstrated favorable pharmacokinetics and was well tolerated in healthy male Japanese and White participants. Understanding the safety and pharmacokinetic features of ensitrelvir (using the formulation approved for clinical use) in various populations, and the effect of food, is crucial for optimal clinical use.

OBJECTIVES

The objectives of this study were to (1) assess the safety, tolerability, and pharmacokinetics of ensitrelvir following multiple-dose administration of ensitrelvir tablets in populations with different races, ages, and sex; and (2) assess the effect of food on the pharmacokinetics of ensitrelvir tablets in the fasted or fed state.

METHODS

A phase 1, multicenter, double-blinded, randomized, placebo-controlled study was conducted to evaluate the safety and pharmacokinetics of once-daily ensitrelvir tablets at loading/maintenance doses of 375/125 mg or 750/250 mg for 5 days in healthy Japanese females, Japanese elderly (only 375/125 mg), and White male and female participants. An open-label, two-group, two-period crossover study was also conducted to estimate the effect of food on the pharmacokinetics of ensitrelvir at single dose of 375 mg. The nature, frequency, and severity of treatment-emergent adverse events were evaluated and recorded in safety assessments in both studies.

RESULTS

The maximum plasma concentration (Cmax) and area under the plasma concentration-time curve (AUC) were similar within these populations. The geometric mean half-life of ensitrelvir following multiple-dose administration was 48.7-58.9 h across all cohorts. The Cmax and AUC increased in a dose-proportional manner in Japanese female participants, and increased in a less than dose-proportional manner in White participants. Furthermore, there was no clear relationship between the dose and geometric mean half-life of ensitrelvir. The plasma concentration at 24 h (C24) after an initial dose of 375/125 mg exceeded the target plasma concentration (6.09 µg/mL) in all populations. Regarding the effect of food on the pharmacokinetics of ensitrelvir, although time to Cmax in the fed state was delayed, there was no clinically meaningful difference in the exposure levels (Cmax and AUC) of ensitrelvir between the fasted and fed states. Most treatment-emergent adverse events were mild in nature and had resolved.

CONCLUSION

Ensitrelvir (375/125 mg and 750/250 mg tablet formulation) was well tolerated, without any major safety concerns. The pharmacokinetics of ensitrelvir between all populations in the study were similar and C24 exceeded the target plasma concentration at 375/125 mg. These results suggest that ensitrelvir can be effectively administered with no necessity for dose adjustment for age, sex, and race without food restriction.

CLINICAL TRIAL REGISTRATION

Japan Registry of Clinical Trials identifier: jRCT2031210202, registered on 16 July 2021.

Managing medical and psychiatric multimorbidity in older patients

Aging increases susceptibility both to psychiatric and medical disorders through a variety of processes ranging from biochemical to pharmacologic to societal. Interactions between aging-related brain changes, emotional and psychological symptoms, and social factors contribute to multimorbidity - the presence of two or more chronic conditions in an individual - which requires a more patient-centered, holistic approach than used in traditional single-disease treatment guidelines. Optimal treatment of older adults with psychiatric and medical multimorbidity necessitates an appreciation and understanding of the links between biological, psychological, and social factors - including trauma and racism - that underlie physical and psychiatric multimorbidity in older adults, all of which are the topic of this review.

Age-Related Effects of Exogenous Melatonin on Anxiety-like Behavior in C57/B6J Mice

The synthesis of melatonin (MLT) physiologically decreases during aging. Treatment with MLT has shown anxiolytic, hypnotic, and analgesic effects, but little is known about possible age-dependent differences in its efficacy. Therefore, we studied the effects of MLT (20 mg/kg, intraperitoneal) on anxiety-like behavior (open field (OFT), elevated plus maze (EPMT), three-chamber sociability, and marble-burying (MBT) tests), and the medial prefrontal cortex (mPFC)-dorsal hippocampus (dHippo) circuit in adolescent (35-40 days old) and adult (three-five months old) C57BL/6 male mice. MLT did not show any effect in adolescents in the OFT and EPMT. In adults, compared to vehicles, it decreased locomotor activity and time spent in the center of the arena in the OFT and time spent in the open arms in the EPMT. In the MBT, no MLT effects were observed in both age groups. In the three-chamber sociability test, MLT decreased sociability and social novelty in adults, while it increased sociability in adolescents. Using local field potential recordings, we found higher mPFC-dHippo synchronization in the delta and low-theta frequency ranges in adults but not in adolescents after MLT treatment. Here, we show age-dependent differences in the effects of MLT in anxiety paradigms and in the modulation of the mPFC-dHippo circuit, indicating that when investigating the pharmacology of the MLT system, age can significantly impact the study outcomes.

Population Pharmacokinetic Model for Tramadol and O-desmethyltramadol in Older Patients

BACKGROUND AND OBJECTIVES

Tramadol is commonly prescribed to manage chronic pain in older patients. However, there is a gap in the literature describing the pharmacokinetic parameters for tramadol and its active metabolite (O-desmethyltramadol [ODT]) in this population. The objective of this study was to develop and evaluate a population pharmacokinetic model for tramadol and ODT in older patients.

METHODS

Twenty-one patients who received an extended-release oral tramadol dose (25-100 mg) were recruited. Tramadol and ODT concentrations were determined using a validated liquid chromatography/tandem mass spectrometry method. A population pharmacokinetic model was developed using non-linear mixed-effects modelling. The performance of the model was assessed by visual predictive check.

RESULTS

A two-compartment, first-order absorption model with linear elimination best described the tramadol concentration data. The absorption rate constant was 2.96/h (between-subject variability [BSV] 37.8%), apparent volume of distribution for the central compartment (V₁/F) was 0.373 l (73.8%), apparent volume of distribution for the peripheral compartment (V₂/F) was 0.379 l (97.4%), inter-compartmental clearance (Q) was 0.0426 l/h (2.19%) and apparent clearance (CL/F) was 0.00604 l/h (6.61%). The apparent rate of metabolism of tramadol to ODT (k_t) was 0.0492 l/h (78.5%) and apparent clearance for ODT (CL_m) was 0.143 l/h (21.6%). Identification of Seniors at Risk score (ISAR) and creatinine clearance (CrCL) were the only covariates included in the final model, where a higher value for the ISAR increased the maximum concentration (C_max) of tramadol and reduced the BSV in Q from 4.71 to 2.19%. A higher value of CrCL reduced tramadol C_max and half-life (T_1/2) and reduced the BSV in V₂/F (from 148 to 97.4%) and in CL/F (from 78.9 to 6.61%).

CONCLUSION

Exposure to tramadol increased with increased frailty and reduced CrCL. Prescribers should consider patients frailty status and CrCL to minimise the risk of tramadol toxicity in such cohort of patients.

Over-The-Counter Remedies in Older Adults: Patterns of Use, Potential Pitfalls, and Proposed Solutions

Over-the-counter (OTC) products such as pharmaceuticals, dietary supplements, vitamins, and herbal remedies are widely available and copiously used by older adults for health maintenance and symptom management. Owing to physiology, multimorbidity, and polypharmacy, this population is particularly vulnerable to inappropriate use of OTC products, adverse effects, and drug interactions. While OTC pharmaceuticals are bound by FDA-approved standards, dietary supplements are regulated differently, resulting in variable quality and increased possibility for adulteration. Internationally, standards for OTC products vary widely. Accessible educational information, improved provider-patient communication, and revision of regulatory policy could improve safety for older adult users of OTC products.

Quantification of CYP3A and Drug Transporters Activity in Healthy Young, Healthy Elderly and Chronic Kidney Disease Elderly Patients by a Microdose Cocktail Approach

Background: Ageing and chronic kidney disease (CKD) affect pharmacokinetic (PK) parameters. Since mechanisms are related and remain unclear, cytochrome P450 (CYP) 3A and drug transporter activities were investigated in the elderly with or without CKD and compared to healthy adults using a microdose cocktail. Methods: Healthy young participants (n = 20), healthy elderly participants (n = 16) and elderly patients with CKD (n = 17) received, in study period 1, a single dose of microdose cocktail probe containing 30 µg midazolam, 750 µg dabigatran etexilate, 100 µg atorvastatin, 10 µg pitavastatin, and 50 µg rosuvastatin. After a 14-day wash-out period, healthy young participants continued to study period 2 with the microdose cocktail plus rifampicin. PK parameters including area under the plasma concentration-time curve (AUC), maximum plasma drug concentration (C_max), and half-life were estimated before making pairwise comparisons of geometric mean ratios (GMR) between groups. Results: AUC and C_max GMR (95% confidence interval; CI) of midazolam, a CYP3A probe substrate, were increased 2.30 (1.70-3.09) and 2.90 (2.16-3.88) fold in healthy elderly and elderly patients with CKD, respectively, together with a prolonged half-life. AUC and C_max GMR (95%CI) of atorvastatin, another CYP3A substrate, was increased 2.14 (1.52-3.02) fold in healthy elderly and 4.15 (2.98-5.79) fold in elderly patients with CKD, indicating decreased CYP3A activity related to ageing. Associated AUC changes in the probe drug whose activity could be modified by intestinal P-glycoprotein (P-gp) activity, dabigatran etexilate, were observed in patients with CKD. However, whether the activity of pitavastatin and rosuvastatin is modified by organic anion transporting polypeptide 1B (OATP1B) and of breast cancer resistance protein (BCRP), respectively, in elderly participants with or without CKD was inconclusive. Conclusions: CYP3A activity is reduced in ageing. Intestinal P-gp function might be affected by CKD, but further confirmation appears warranted. Clinical Trial Registration:http://www.thaiclinicaltrials.org/ (TCTR 20180312002 registered on March 07, 2018).

Immunosenescence as a reason of individualizing immunosuppressive therapy in kidney transplantation

Transplantation in elderly patients is obviously more challenging due to existing underlying diseases, changes in pharmacokinetics of immunosuppressive drugs, polypragmasy, and transformation of immunoreactivity (immunosenescence). Our review presents data on modification of adaptive and innate immunity during aging. It also considers the possibility of both reduced and adapted immunosuppressive therapy in elderly renal transplant recipients in achieving an optimal balance between efficacy and complications.

Adverse Drug Reactions of Acetylcholinesterase Inhibitors in Older People Living with Dementia: A Comprehensive Literature Review

The rising of global geriatric population has contributed to increased prevalence of dementia. Dementia is a neurodegenerative disease, which is characterized by progressive deterioration of cognitive functions, such as judgment, language, memory, attention and visuospatial ability. Dementia not only has profoundly devastating physical and psychological health outcomes, but it also poses a considerable healthcare expenditure and burdens. Acetylcholinesterase inhibitors (AChEIs), or so-called anti-dementia medications, have been developed to delay the progression of neurocognitive disorders and to decrease healthcare needs. AChEIs have been widely prescribed in clinical practice for the treatment of Alzheimer's disease, which account for 70% of dementia. The rising use of AChEIs results in increased adverse drug reactions (ADRs) such as cardiovascular and gastrointestinal adverse effects, resulting from overstimulation of peripheral cholinergic activity and muscarinic receptor activation. Changes in pharmacokinetics (PK), pharmacodynamics (PD) and pharmacogenetics (PGx), and occurrence of drug interactions are said to be major risk factors of ADRs of AChEIs in this population. To date, comprehensive reviews in ADRs of AChEIs have so far been scarcely studied. Therefore, we aimed to recapitulate and update the diverse aspects of AChEIs, including the mechanisms of action, characteristics and risk factors of ADRs, and preventive strategies of their ADRs. The collation of this knowledge is essential to facilitate efforts to reduce ADRs of AChEIs.

Pharmacogenomics in Older Adults: An Integrative Review

Through pharmacogenomics testing, identifying genetic variants that influence how individuals respond to medications could potentially decrease the "trial and error" approach to prescribing medications, maximize beneficial effects, and reduce risks of adverse drug events. Yet, pharmacogenomics testing is still subject to an ongoing debate over its clinical validity and utility. The purpose of the current integrative review was to examine and synthesize evidence on the clinical application of pharmacogenomics in medication management among older adults. Gaps were found, such as lack of studies investigating the prospective use of pharmacogenomics testing to improve clinical outcomes and lack of strong evidence on the clinical validity and utility of pharmacogenomics testing in the medication management of older adults. However, the review identified evidence for the potential benefits of pharmacogenomics testing to improve older adults' clinical outcomes that warrant further investigation. [Research in Gerontological Nursing, 14(4), 211-220.].

Pharmacokinetic and Pharmacodynamic Considerations in Relation to Calcineurin Usage in Elderly Kidney Transplant Recipients

This review summarizes how possible age-related changes in tacrolimus and cyclosporine pharmacokinetics and pharmacodynamics may influence drug dosing and monitoring in the elderly, and highlights how micro-sampling may be useful in this cohort in the future. Advancing biological age leads to physiological changes that can affect drug absorption, distribution, metabolism and excretion, as well as immune system responsiveness. Some studies have shown that elderly recipients may have higher dose-adjusted exposure and/or lower clearance of the calcineurin inhibitors, suggesting that doses may need to be lowered in elderly recipients. Only one study has examined how aging effects drug target enzyme activity and demonstrated that age does not correlate with the calcineurin inhibitor half-maximal inhibitory concentration. Several studies have shown elderly kidney transplant recipients have increased risk of both morbidity and mortality, compared to younger adults due to increased susceptibility to immunosuppressant side effects, particularly cardiovascular disease, infection and malignancy. Current immunosuppressant dosing and monitoring protocols often make no adjustments for age. Lower maintenance immunosuppressant targets in elderly recipients may decrease patient susceptibility to drug side effects, however, further studies are required and appropriate targets need to be established. Blood draw by micro-sampling may be useful for drug monitoring in this cohort in the future, as blood collection is minimally invasive and less painful than venepuncture. Micro-sampling could also make further pharmacokinetic, pharmacodynamics and outcome studies in the elderly more feasible.

Population pharmacokinetic model of subcutaneous fentanyl in older acute care patients

PURPOSE

Subcutaneous fentanyl injection is commonly prescribed to manage acute pain in older patients; however, there is a gap in the literature describing the pharmacokinetic parameters for this route of administration in this population. The aim of this study was to develop and evaluate a population pharmacokinetic model for subcutaneous fentanyl injection in older patients.

METHODS

Twenty-one patients who received subcutaneous fentanyl injections (50 to 75 μg) were recruited. Fentanyl concentrations were determined using a validated liquid chromatography/tandem mass spectrometry method. A population pharmacokinetic model was developed using non-linear mixed-effects modelling. A base model was selected based on the Akaike information criterion. Age, sex, body weight, number of previous fentanyl doses, number of prescribed medications, creatinine clearance, Charlson Comorbidity Index, Identification of Seniors at Risk score and concurrent use of CYP3A4 inhibitors were covariates considered for inclusion. A p value of < 0.05 was considered statistically significant for inclusion of covariates in the final model by stepwise addition. The simulation performance of the model was assessed by visual predictive check.

RESULTS

A one-compartment, first-order absorption with lag time and linear elimination model was the best to fit to the fentanyl concentration data. The absorption rate constant was 0.136 h^-1 (between subject variability (BSV), 46%), lag time 0.66 h (BSV 51%), apparent volume of distribution 6.28 L (BSV 30%), and apparent clearance 16.3 L.h^-1 (BSV 54%). The Charlson Comorbidity Index was the only covariate included in the final model, where a higher value of the index increased fentanyl exposure and C_max.

CONCLUSION

This is the first report of subcutaneous fentanyl population pharmacokinetic model to evaluate fentanyl pharmacokinetic in older patients. The between subject variability in clearance and subcutaneous absorption rate was relatively high, and some patients recorded high fentanyl concentrations in the context of their titration to effect.

Use of the STOPP and START criteria to address polypharmacy for elderly patients in University Hospital Lewisham Clinical Decisions Unit

Background:

Polypharmacy and inappropriate prescribing are risk factors for adverse drug reactions, which commonly cause complications in older people. The STOPP (Screening Tool of Older Persons’ Prescriptions)/START (Screening Tool to Alert Doctors to Right Treatment) criteria are screening tools, which aim to improve prescribing in the elderly.

Objectives:

The aim was to improve prescribing, using the STOPP/START criteria, for patients aged 65 and above, who were admitted to the Clinical Decisions Unit at University Hospital Lewisham. We focused on the most common prescribing errors in clinical decision unit, an emergency medicine department.

Methods:

We reviewed all patients aged 65 and above admitted to the Clinical Decisions Unit in September. Data was collected from clinical documentation and archived drug charts. This pilot study of 114 patients revealed the most common prescribing errors, of which 8 were STOPP and 11 were START criteria. A plan–do–study–act methodology was implemented over 1 month, involving presentations, emails and posters. Prescribing patterns were then reviewed over 4 weeks in December in 111 patients.

Results:

Focusing on the 8 STOPP and 11 START criteria, there was a significant reduction in the proportion of patients with at least one STOPP error (17.5% to 9%, p = 0.04). However, the decrease in the percentage of patients with at least one START error was insignificant (24.6% to 20.7%, p = 0.24).

Conclusion:

By identifying problematic areas of prescribing and using targeted interventions, the proportion of STOPP errors made in clinical decision unit reduced significantly. This study highlights the prevalence of prescription errors in the clinical decision unit and the impact of using screening tools to reduce incorrect prescribing.

Analgesia and sedation in patients with ARDS

Acute Respiratory Distress Syndrome (ARDS) is one of the most demanding conditions in an Intensive Care Unit (ICU). Management of analgesia and sedation in ARDS is particularly challenging. An expert panel was convened to produce a "state-of-the-art" article to support clinicians in the optimal management of analgesia/sedation in mechanically ventilated adults with ARDS, including those with COVID-19. Current ICU analgesia/sedation guidelines promote analgesia first and minimization of sedation, wakefulness, delirium prevention and early rehabilitation to facilitate ventilator and ICU liberation. However, these strategies cannot always be applied to patients with ARDS who sometimes require deep sedation and/or paralysis. Patients with severe ARDS may be under-represented in analgesia/sedation studies and currently recommended strategies may not be feasible. With lightened sedation, distress-related symptoms (e.g., pain and discomfort, anxiety, dyspnea) and patient-ventilator asynchrony should be systematically assessed and managed through interprofessional collaboration, prioritizing analgesia and anxiolysis. Adaptation of ventilator settings (e.g., use of a pressure-set mode, spontaneous breathing, sensitive inspiratory trigger) should be systematically considered before additional medications are administered. Managing the mechanical ventilator is of paramount importance to avoid the unnecessary use of deep sedation and/or paralysis. Therefore, applying an "ABCDEF-R" bundle (R = Respiratory-drive-control) may be beneficial in ARDS patients. Further studies are needed, especially regarding the use and long-term effects of fast-offset drugs (e.g., remifentanil, volatile anesthetics) and the electrophysiological assessment of analgesia/sedation (e.g., electroencephalogram devices, heart-rate variability, and video pupillometry). This review is particularly relevant during the COVID-19 pandemic given drug shortages and limited ICU-bed capacity.

An Algorithm for Comprehensive Medication Management in Nursing Homes: Results of the AMBER Project

INTRODUCTION

There are several barriers to conducting medication management in nursing homes. Our project aimed to develop an algorithm that guides and supports pharmacists to perform this clinical service.

METHODS

Phase I of the project examined the practitioner and patient perspectives on the medication process in nursing homes. The mixed methods approach consisted of interviews with qualitative content analysis and a quantitative questionnaire. Phase IIa scoped existing research and comprised a three-stepped systematic review. It was registered in the International Prospective Register of Systematic Reviews (CRD42017065002). Results of the first two steps were assessed for quality. Phase IIb was performed as a Delphi survey. The developed algorithm was tested in nursing homes. The primary endpoint was the number and type of detected drug-related problems. The study was conducted between June 2016 and December 2018 (Deutsches-Register-Klinischer-Studien-ID: DRKS00010995).

RESULTS

Interviews were held with 21 healthcare practitioners and six patients. Frequent and relevant aspects of the medication process in nursing homes were identified. The systematic reviews included 28 reviews, 12 interventional studies and 1450 non-interventional studies. As a result of the Delphi survey, two new aspects were added. Testing of the drafted algorithm was done in 73 nursing home residents. A mean of 6.3 drug-related problems were detected. Sample cases were executed in a mean time of 21 min by community pharmacists.

CONCLUSIONS

The developed and consented algorithm can guide pharmacists in conducting medication management in a timely and effective manner. It might serve as a facilitator to improve collaboration and quality of medication in nursing home residents.

Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm

In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents-that are easily titratable-reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.

Prevention, Treatment, and Monitoring of Seizures in the Intensive Care Unit

The diagnosis and management of seizures in the critically ill patient can sometimes present a unique challenge for practitioners due to lack of exposure and complex patient comorbidities. The reported incidence varies between 8% and 34% of critically ill patients, with many patients often showing no overt clinical signs of seizures. Outcomes in patients with unidentified seizure activity tend to be poor, and mortality significantly increases in those who have seizure activity longer than 30 min. Prompt diagnosis and provision of medical therapy are crucial in order to attain successful seizure termination and prevent poor outcomes. In this article, we review the epidemiology and pathophysiology of seizures in the critically ill, various seizure monitoring modalities, and recommended medical therapy.

Pharmacotherapy options and drug development in managing periprosthetic joint infections in the elderly

INTRODUCTION

Prosthetic joint infections are an increasingly important problem among patients undergoing arthroplasty procedures, and are associated with significant morbidity, reduced quality of life, substantial healthcare costs, and even mortality. Arthroplasties are performed with increasing frequency in elderly patients, who present specific problems.

AREAS COVERED

Surgical therapy is clearly influenced by the clinical status of the patient, which in some case can contraindicate surgery. Antibiotic selection is also affected by comorbidities and underlying diseases, which in some cases reduce therapeutic options. The authors review this together with the changes in pharmacokinetics and pharmacodynamics in the elderly population and the prospects for future research on prevention and treatment.

EXPERT OPINION

The management of PJI in the elderly makes multidisciplinary teams even more mandatory than in other patients, because the complexity of these patients. A frequent scenario is that in which surgery is contraindicated with long-term suppressive treatment as the only available option. Treating physicians must consider the presence of multiple comorbidities, interactions with other treatments and secondary effects when choosing antibiotic treatment. An in-depth knowledge of the alterations in pharmacokinetics and pharmacodynamics in elderly patients is key for a proper treatment selection.

Psychopharmacology and pharmacokinetics

The overall physiologic changes associated with aging lead to changes in both pharmacokinetic and pharmacodynamic actions of many medications. This, in turn, leads to changes in the impact that a wide variety of medications have on older adults when compared to younger, healthy individuals. These pharmacokinetic and pharmacodynamic variations can cause either lesser or greater than expected responses to medication. Knowledge of the physiologic changes that are expected to occur in the elderly can help to identify medications that may require dose adjustments or that should be avoided, due to increased risk in this population. As a general principle, medications should be started at lower doses in the elderly with slow titration schedules to reduce the risk of adverse effects.

Challenges and innovations of drug delivery in older age

Both drug delivery performance and various age-related physical, mental and physiological changes can affect drug effectiveness and safety in elderly patients. The many drug delivery systems developed over the years include recent novel transdermal, nasal, pulmonary and orally disintegrating tablets that provide consistent, precise, timely and more targeted drug delivery. Certain drug delivery systems may be associated with suboptimal outcomes in the elderly because of the nature of drug present, a lack of appreciation of the impact of age-related changes in drug absorption, distribution and clearance, the limited availability of pharmacokinetic, safety and clinical data. Polypharmacy, patient morbidity and poor adherence can also contribute to sub-optimal drug delivery systems outcomes in the elderly. The development of drug delivery systems for the elderly is a poorly realised opportunity, with each system having specific advantages and limitations. A key challenge is to provide the innovation that best meets the specific physiological, psychological and multiple drug requirements of individual elderly patients.

Factors related to excessive polypharmacy (≥15 medications) in an outpatient population from Colombia

AIMS

To determine the frequency of excessive polypharmacy (≥15 medications) in an outpatient population from Colombia and the variables associated with this condition.

METHODS

A cross-sectional study using a systematised database of 6.2 million affiliates of the Colombian Health System. All patients treated uninterruptedly with 15 or more medications for 3 months (January-March 2017) were included. Sociodemographic, pharmacological, potential drug interactions, and prescribers' variables were identified.

RESULTS

A total of 264 patients with prescriptions of ≥15 medications were identified; with an estimated prevalence of excessive polypharmacy of 108.4 per 100 000 people. The mean age was 67.7 ± 17.8 years and 60.6% were females. The mean number of medications per patient was 20.1 ± 4.5 and 48.9% (n = 129) had 20 or more. The most used were antiulcer medications (89.0%; n = 235), antihypertensives (85.6%; n = 226), analgesic/antipyretic (80.3%; n = 212), psychiatric/neurologic medications (78.5%; n = 207), statins (67.4%; n = 178), acetylsalicylic acid (59.5%; n = 157), and vitamins (57.2%; n = 151). On average, each patient had 21.0 ± 11.4 drug-drug interactions and were attended by 6.2 ± 3.1 physicians. Being treated by seven or more physicians (OR: 5.09; 95% CI: 1.64-15.79) increased the probability of receiving more than 20 medications.

CONCLUSIONS

Drugs for treatment of chronic conditions prevailed, especially in elderly patients with multiple chronic conditions; however, some groups of medications without clear indications, such as antiulcer medications or vitamin supplements, also had extensive use. A main factor that increases the probability of polypharmacy greater than 20 drugs is care by seven or more physicians, which shows a fragmentation in patient care by the country's health system, without achieving co-ordination and integration between the different agents involved in medical care, also influenced by different physicians' practice patterns.

Predicting the Risk of Adverse Drug Reactions in Older Inpatients: External Validation of the GerontoNet ADR Risk Score Using the CRIME Cohort

BACKGROUND

Adverse drug reactions (ADRs) in older people are often preventable, indicating that screening and prevention programs aimed at reducing their rate are needed in this population.

OBJECTIVE

The aim of this study was to externally validate the GerontoNet ADR risk score and to assess its validity in specific subpopulations of older inpatients.

METHODS

Data from the prospective CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) cohort were used. Dose-dependent and predictable ADRs were classified as type A, probable or definite ADRs were defined according to the Naranjo algorithm, and diagnostic accuracy was tested using receiver operating characteristic (ROC) analyses. Sensitivity and specificity were calculated for a cut-off point of 4.

RESULTS

The mean age of the 1075 patients was 81.4 years (standard deviation 7.4) and the median number of drugs was 10 (range 7-13). At least one ADR was observed in 70 patients (6.5%); ADRs were classified as type A in 50 patients (4.7%) and defined as probable or definite in 41 patients (3.8%). Fair diagnostic accuracy to predict both type A and probable or definite ADRs was found in subpopulations aged <70 or ≥80 years with heart failure, diabetes, or a previous ADR. Good accuracy to predict type A ADRs was found in patients with a low body mass index (BMI; >18.5 kg/m²) and a Mini-Mental State Examination (MMSE) score of >24/30 points, as well as in patients with osteoarthritis. The cut-off point of 4 points yielded very good sensitivity but poor specificity results in these subpopulations.

CONCLUSION

This study suggests that the GerontoNet ADR risk score might represent a pragmatic approach to identifying specific subpopulations of older inpatients at increased risk of an ADR with a fair to good diagnostic accuracy.

Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases

INTRODUCTION

Adverse drug events (ADEs) are common in older people and contribute significantly to emergency department (ED) visits, unplanned hospitalisations, healthcare costs, morbidity and mortality. Many ADEs are avoidable if attention is directed towards identifying and preventing inappropriate drug use and undesirable drug combinations. Tools exist to identify potentially inappropriate prescribing (PIP) in clinical settings, but they are underused. Applying PIP assessment tools to population-wide health administrative data could provide an opportunity to assess the impact of PIP on individual patients as well as on the healthcare system. This would open new possibilities for interventions to monitor and optimise medication management on a broader, population-level scale.

METHODS AND ANALYSIS

The aim of this study is to describe the occurrence of PIP in Ontario's older population (aged 65 years and older), and to assess the health outcomes and health system costs associated with PIP-more specifically, the association between PIP and the occurrence of ED visits, hospitalisations and death, and their related costs. This will be done within the framework of a population-based retrospective cohort study using Ontario's large health administrative and population databases. Eligible patients aged 66 years and older who were issued at least 1 prescription between 1 April 2003 and 31 March 2014 (approximately 2 million patients) will be included.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Ottawa Health Services Network Ethical Review Board and from the Bruyère Research Institute Ethics Review Board. Dissemination will occur via publication, presentation at national and international conferences, and ongoing exchanges with regional, provincial and national stakeholders, including the Ontario Drug Policy Research Network and the Ontario Ministry of Health and Long-Term Care.

TRIAL REGISTRATION NUMBER

Registered with clinicaltrials.gov (registration number: NCT02555891).

Pharmacotherapy in the ageing patient: The impact of age per se (A review)

A literature search was carried out to review the influence of 'ageing' on pharmacotherapeutic decision-making, specifically how 'age' is defined and considered in the utilisation of medication. Embase, Medline, International Pharmaceutical Abstracts, and Google scholar were canvassed in a three-tiered search according to pre-established inclusion criteria. In tier 1, a total of 22 studies were identified highlighting the underutilisation of medication in elderly patients, with a particular focus on warfarin. Four studies highlighted an age-bias in medication-prescribing for elderly patients, specifically in relation to medicines for rheumatoid arthritis, angina, and hypertension. Tier 2 identified diverse definitions for 'elderly', including biological age, chronological age, physiological age, as well as various descriptions of 'elderly' in clinical trials and guidelines. Finally, medication optimisation tools were identified through the third tier, emphasising the use of chronological age to describe the 'elderly'. Old age influences pharmacotherapeutic decision-making at various levels, however, what complicates the situation is the absence of a comprehensive definition of 'elderly'. Clinical recommendations need to be based more on objective factors known to affect medication effectiveness and safety.

Potentially inappropriate prescribing (PIP) in long-term care (LTC) patients: validation of the 2014 STOPP-START and 2012 Beers criteria in a LTC population--a protocol for a cross-sectional comparison of clinical and health administrative data

INTRODUCTION

Potentially inappropriate prescribing (PIP) is frequent and problematic in older patients. Identifying PIP is necessary to improve prescribing quality; ideally, this should be performed at the population level. Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Beers criteria were developed to identify PIP in clinical settings and are useful at the individual patient level; however, they are time-consuming and costly to apply. Only a subset of these criteria is applicable to routinely collected population-level health administrative data (HAD) because the clinical information necessary to implement these tools is often missing from databases. The performance of subsets of STOPP/START and Beers criteria in HAD compared with clinical data from the same patients is unknown; furthermore, the performance of the updated 2014 STOPP-START and 2012 Beers criteria compared with one another is also unknown.

METHODS AND ANALYSIS

A cross-sectional study of linked HAD and clinical data will be conducted to validate the subsets of STOPP/START and Beers criteria applicable to HAD by comparing their performance when applied to clinical and HAD for the same patients. Eligible patients will be 66 years and over and recently admitted to 1 of 6 long-term care facilities in Ottawa, Ontario. The target sample size is 275, but may be less if statistical significance can be achieved sooner. Medication, diagnostic and clinical data will be collected by a consultant pharmacist. The main outcome measure is the proportion of PIP missed by the subset of STOPP/START and Beers criteria applied to HAD when compared with clinical data.

ETHICS AND DISSEMINATION

The study was approved by the Ottawa Health Services Network Research Ethics Board, the Bruyère Continuing Care Research Ethics Board and the ethics board of the City of Ottawa Long Term Care Homes. Dissemination will occur via publication, national and international conference presentations, and exchanges with regional, provincial and national stakeholders.

TRIAL REGISTRATION NUMBER

NCT02523482.

Potentially inappropriate medication use in institutionalized older adults according to the Beers Criteria

The need for specific care, coupled with new family arrangements, has contributed to the increasing institutionalization of elderly members. The purpose of this study was to evaluate drug use by institutionalized older adults according to Beers Criteria. This prospective, longitudinal study was conducted in the three non-profit long-stay geriatric care institutions of Campo Grande, in the Central-West region of Brazil. All subjects aged 60 years and above on November 2011 were included and followed until November 2012. Eighteen subjects were excluded and the final sample consisted of 133 individuals aged 60 to 113 years. Overall, 212 medications were used at geriatric care institution A, 532 at B, and 1329 at C. Thirty-four drugs were inappropriately prescribed 89 times at geriatric care institution A (41.98%), 49 prescribed 177 times at B (33.27%), and 91 prescribed 461 times at C (34.68%). Statistical differences in the inappropriate drug use were found between genders (p=0.007). The most commonly used potentially inappropriate medication were first-generation antihistamines (15.34%). There was a high frequency in the use of potentially inappropriate medications which can initiate marked side effects and may compromise the fragile health of institutionalized elderly. Thus, adopting the Beers Criteria in prescribing medication contributes to minimize adverse reactions and drug interactions.

Gastrointestinal drug interactions affecting the elderly

With the burgeoning elderly population in the United States, drug interactions are an increasing concern because of altered drug metabolism associated with age and polypharmacy. This article describes interactions between drugs used in common gastrointestinal diseases, including acid peptic disease, diarrhea, constipation, endoscopic procedural sedation, and inflammatory bowel disease, and those used to treat 5 common geriatric primary care diseases: hypertension, diabetes, hyperlipidemia, arthritis, and psychiatric illnesses.

Individualization of drug therapy in older people

Older people are high consumers of prescription drugs and are at increasing risk of polypharmacy and adverse reactions. Pharmacokinetic and pharmacodynamic modifications due to age and co-morbidities are an important consideration, but pharmacological background evidence to guide safe and effective therapeutic approaches are often inadequate since the older population is under-represented in clinical trials. We review the pharmacokinetic and pharmacodynamic changes that are characteristic in old age and consider evidence regarding potentially safer prescription and monitoring of drugs commonly used in older patients. We also introduce the possible role of pharmacogenomics and therapeutic drug monitoring as tools to guide the individualization of drug therapy.

Can medication management review reduce anticholinergic burden (ACB) in the elderly? Encouraging results from a theoretical model

BACKGROUND

Review of recent journal articles and various relevant current textbooks provides strong evidence to show that anticholinergic burden is a material issue in frail and at-risk patients. This study assesses the anticholinergic burden in a group of patients in residential care facilities and then applies a theoretical intervention model. It is based on a scoring system known as the Anticholinergic Cognitive Burden (ACB) scale, and attempts to reduce the anticholinergic burden while maintaining therapeutic benefits.

METHODS

A database of 691 patients was analyzed for each individual's ACB based on the scale of scoring produced by groups of experts in the area. A theoretical intervention was then conducted using relevant, evidence-based practice guidelines for clinical therapeutics in Australia. The intervention had the aim of reducing the total ACB without affecting the apparent intended effectiveness of the prescribed therapy.

RESULTS

Of the 35% (n = 242) patients who score at least 1 point on the ACB, a reduction is achievable in 59% of the cases. In particular, the reduction from a clinically significant score of 3 or above to 2 or below for 49 of those patients is possible in 85% of the cases. Overall, this represents a reduction from 7.10% to 1.01% for the entire population. It is also found that of the 246,960 counts of items dispensed (both prescription and non-prescription) for these patients, 47,334 (or 19.2%) of these were of agents on the ACB scale.

CONCLUSIONS

The study found that it appears to be possible that the total ACB of a group of 691 patients can be significantly reduced.

Prescribing opioids in older people

People are living to older age. Demographic pressures are driving change. Opiate analgesics are the most powerful known pain relievers. Persistent pain, both cancer and non-cancer types is frequent in older adults. The use of opioid analgesics is appropriate in the treatment of moderate to severe persistent pain. The challenge of prescribing opioids in older adults is to understand the factors involved in making appropriate choices and monitoring the beneficial effects of pain relief while managing the side-effects. This article will review the current concepts, evidence and controversies surrounding opiate use in the elderly. An approach is outlined which involves: pain assessment, screening for substance abuse potential, deciding whether you are able to treat your patient without help, starting treatment, monitoring effectiveness of pain control and managing opioid-associated side-effects. The goal of pain management using opioids is the attainment of improved function and quality of life.

Medication safety in rehabilitation medicine

Rehabilitation medicine is practiced in a variety of settings. Physiatrists are an integral part of the care provided in many of these settings and are often consulted to provide diagnostic and therapeutic services and expertise to individuals with a variety of diagnoses. In this role, it is imperative that physiatrists have a working knowledge of various medications as well as the principles of medication safety. This article provides a foundation in the general and specific aspects of medication safety as they apply to the practice of rehabilitation medicine.

Digoxin therapy in the elderly: pharmacokinetic considerations in nursing

Digoxin is effective in controlling ventricular rhythm in atrial fibrillation and is used in heart failure when angiotensin converting enzyme inhibitors and diuretics are ineffective. Because use of more than 1 drug is often required with these conditions, pharmacokinetic considerations, including those related to complementary medicine, are important. Increased awareness of drug action in the elderly is important because there is often an increase in body fat and leaner muscle mass as well as changes in organ function, such as that of the kidney, which alters drug activity. Nurses have an important role to play in the safe administration of digoxin.

Pharmacist Approach to Geriatrics

Pharmacists have traditionally focused on the appropriate use of medications to enhance the functional status of the elderly patient. However, in the proper provision of pharmaceutical care, the influence of lifestyle factors on the use and misuse of medications cannot be ignored. The pharmacist collaborates with other members of the health care team to ensure that drugs are dosed according to known changes occurring with age such as pharmacokinetic and pharmacodynamic alterations. Also, medications that may decrease cognitive function, impair gait/balance, or reduce sensory stimulation must be avoided. The appropriate use of medications can improve the functional status and reduce morbidity in the elderly patient, and drug adherence issues should be addressed to ensure that the elderly patient can receive the optimal benefit from his or her medication regimen. Pharmacists, in collaboration with physicians and other health care providers, can help to ensure that a comprehensive approach to patient care occurs, one that involves medications, diet, and exercise as it embraces the mind, body, and spirit.

Clinical pharmacology of analgesics in old age and frailty

There is a high prevalence of pain in older people. Optimal assessment and management of pain in this population is challenging. The pharmacokinetics and pharmacodynamics of analgesic medications are affected by ageing and frailty, as well as by intercurrent medical conditions and their treatments. This review describes what is currently understood about the impacts of old age and frailty on the clinical pharmacology of commonly used analgesics, to provide a rational basis for the use of these medicines. In view of the wide age-related inter-individual variability in pharmacokinetics and pharmacodynamics of analgesic medications, monitoring of clinical response and adverse effects is essential to optimize pain control in older people.

Pharmacokinetics and drug metabolism in the elderly

Aging involves progressive impairments in the functional reserve of multiple organs, which might also affect drug metabolism and pharmacokinetics. In addition, the elderly population will develop multiple diseases and, consequently, often has to take several drugs. As the hepatic first-pass effect of highly cleared drugs could be reduced (due to decreases in liver mass and perfusion), the bioavailability of some drugs can be increased in the elderly. Significant changes in body composition occur with advancing age. Lipophilic drugs may have an increased volume of distribution (Vd) with a prolonged half-life, and water-soluble drugs tend to have a smaller Vd. In the elderly, hepatic drug clearance of some drugs can be reduced by up to 30% and CYP-mediated phase I reactions are more likely to be impaired than phase II metabolism, which is relatively preserved in the elderly. Concerning the most important CYP3A4 studies with human liver microsomes and clinical studies with the validated probe, midazolam, it is indicated that there are no significant differences in CYP3A4 activity between young and old populations. Finally, renal excretion is decreased (up to 50%) in about two thirds of elderly subjects, but confounding factors such as hypertension and coronary heart disease account also for a decline in kidney function. In conclusion, age-related physiological and pharmacokinetic changes as well as the presence of comorbidity and polypharmacy will complicate drug therapy in the elderly.