“The Downside of Drug Use in the Elderly” - Use of prescription drugs for treating urologic diseases and their potential effects in elderly patients.
A timely article for November's Chapter Meeting and Presentation on the use of OAB drugs in the elderly population.
ANAHEIM, CA (UroToday.com) - Dr. William Steers, University of Virginia presented on “The Downside of Drug Use in the Elderly” at the Wednesday Plenary Session of the AUA in Anaheim, May 23, 2007.
He focused on the use of prescription drugs for treating urologic diseases and their potential effects in elderly patients. He evaluated how big this problem is, why the elderly are more prone to problems, what are the concerns with drugs used in the elderly and what we can do.
Elderly patients (>65 years) take one-third of all drugs prescribed. Inappropriate medications for the elderly as identified by the “Beers list” are used by 30% of elderly patients. Two of the 5 most prescribed drugs on this list are prescribed by urologists: tricyclic antidepressants and oxybutynin. Overall rates of adverse drug events in long term care facilities occur in 9.8/100 resident-months and are preventable in 4.1/100. Adverse drug reactions lead to 15% of hospitalizations in the elderly. The problem is related to multiple prescribers and multiple pharmacies used by a patient.
The elderly had more reactions to drugs due to decreased liver and renal metabolism. They are often not included in the clinical trials that evaluate toxicity, but then the drugs are prescribed to the elderly. Renal clearance of drugs is significantly decreased in most elderly patients. As a general rule, one should decrease the dose in half in patients over age 80. “Start low and go slow” was Dr. Steers’ slogan for prescribing for the elderly.
Alzheimer’s disease patients are at high risk as they may be on antimuscarinics, which worsens their cognitive function. Antimuscarinics have many effects on the central nervous system. Newer M3 antagonists may be better, but data is not yet available. Significant deficits in elderly on anticholinergic drugs are noted and it may take a month for effects to clear once the drug is stopped. Other side effects such as bowel dysfunction also result.
Alpha blockers result in hypotension, asthenia, dizziness, exacerbation of CHF, and contribute to burred vision and floppy iris syndrome in those undergoing cataract surgery. Regarding LHRH agonists, osteopenia, muscle loss, depression, cardiovascular deaths, DM, metabolic syndrome are all risks. PDE 5 inhibitors contribute to hypotension, GERD, and fecal incontinence. Antimicrobials require decreased dosing and can result in résistance and effect pulmonary reserves. Nitrofurantoin due to hepatic metabolism must be used cautiously.
Urologists can become educated in these aspects and avoid or modify use in elderly patients. There are presently 72 combinations of drugs that can be used to treat LUTS in the elderly, according to Dr. Steers. We can review drug lists of elderly patients and modify them on every visit. We should avoid medications if the benefit is marginal. Finally, he concluded that instructions should be written out clearly for patients.