Special Aspects of Geriatric Pharmacology
Society has traditionally classified everyone over 65 as “elderly,” but most authorities consider the field of geriatrics to apply to persons over 75—even though this too is an arbitrary definition. Furthermore, chronologic age is only one determinant of the changes pertinent to drug therapy that occur in older people. In addition to the chronic diseases of adulthood, the elderly have an increased incidence of many conditions, including Alzheimer’s disease, Parkinson’s disease, and vascular dementia; stroke; visual impairment, especially cataracts and macular degeneration; ath-erosclerosis, coronary heart disease, and heart failure; diabetes; arthritis, osteoporosis, and fractures; cancer; and incontinence. As a result, the need for drug treatment is great in this age group.
Important changes in responses to some drugs occur with increasing age in many individuals. For other drugs, age-related changes are minimal, especially in the “healthy old.” Drug usage patterns also change as a result of the increasing incidence of dis-ease with age and the tendency to prescribe heavily for patients in nursing homes. General changes in the lives of older people have significant effects on the way drugs are used. Among these changes are the increased incidence with advancing age of several simulta-neous diseases, nutritional problems, reduced financial resources, and—in some patients—decreased dosing adherence (also called compliance) for a variety of reasons. The health practitionershould be aware of the changes in pharmacologic responses that may occur in older people and should know how to deal with these changes.
A 77-year-old man comes to your office at his wife’s insistence. He has had documented moderate hypertension for 10 years but does not like to take his medications. He says he has no real complaints, but his wife remarks that he has become much more forgetful lately and has almost stopped reading the newspaper and watching television. A Mini-Mental Examination reveals that he is oriented as to name and place but is unable to give the month or year. He cannot rememberthe names of his three adult children nor three random words (tree, flag, chair) for more than 2 minutes. No cataracts are visible, but he is unable to read standard newsprint without a powerful magnifier. Why doesn’t he take his anti-hypertensive medications? What therapeutic measures are available for the treatment of Alzheimer’s disease? How might macular degeneration be treated?
This patient has several conditions that warrant careful treat-ment. Hypertension is eminently treatable; the steps described are appropriate and effective in the elderly as well as in young patients. Patient education is critical in com-bating his reluctance to take his medications. Alzheimer’s disease may respond temporarily to one of the anticholinest-erase agents (donepezil, rivastigmine, galantamine).Alternatively, memantine may be tried. Unfortunately, age-related macular degeneration (the most likely cause of his visual difficulties) is not readily treated, but the “wet” (neovascular) variety may respond well to one of the drugs currently available (bevacizumab, ranibizumab, pegaptanib). However, these therapies are expensive.