Prof. Dr. Walter E. Haefeli
An interview on the lecture ‘Pharmacotherapy in the Elderly – Seven Critical Errors to Avoid’ conducted by Dr. Birgit Teichmann, 23th November 2015.
As the prevalence of multimorbidity progresses with age, it is increasingly likely that the older people become, the more medications they will take. What are the risks involved with using medical products?
Challenges faced by physicians regarding prescribing faults and the damage possibly caused by wrong prescription may include:
- Prescribing all drugs which are necessary (avoiding under-prescription),
- Avoiding potentially hazardous drug interactions (potentially inadequate medication, incorrect dosing while treating excretion disorders such as renal insufficiency),
- Keeping track of prescriptions (a detailed medication planner would be very helpful),
- Customising therapy to each patient’s needs (highlighting the potential benefits of the treatment to the patients) and
- Ensuring that medication therapy is delivered correctly (avoiding ineffective or risky prescriptions).
Challenges faced by patients and their relatives and, in this regard, treatment goals to achieve are:
- Ensuring that therapy has been performed at least up to 80 percent (making therapy part of patients’ everyday lives. Adherence and persistence. Ensuring that patients are able to deal with complex therapy schemes),
- Using medical products correctly (proper usage of devices, no changes to pharmaceutical form, correct swallowing, inhalation, and injection technique),
- Refraining from deliberate change in dosage
- Dealing with rotation of pharmaceutical manufacturers (despite discount agreement, still adhering to therapy),
- Keeping a handy medication planer current and accessible to third parties (transparency of the current treatment situation) and
- Being able to communicate personal preferences (supporting individualised therapy).
Are there any specific medications for the elderly or is it sufficient to adjust dosage alone on the basis of metabolism changes?
Currently, there is no group of medications particularly suitable for use in the elderly, which would have less efficacy in younger patients. There are, however, conditions that typically occur among the elderly, (e. g. benign prostatic hyperplasia, dementia) and consequently, there are medications mainly used in older adults.
Furthermore, it is indeed correct to provide information on the risks of substances associated with a specific age group as applied in the case with prasugrel. It is also correct to reduce recommended maintenance doses of certain new oral anticoagulants due to impaired excretion by kidneys or metabolism. Moreover, people become more medication-sensitive as they age which shows that decreased metabolism alone should not subject to dose reduction such as in the case of psychotropic substances.
Have any older adults been taken into account when conducting clinical studies on efficacy of medications?
There are several reasons why older patients are more likely to be excluded from efficacy trials than younger patients, although it has not yet been proven that they respond similarly to specific medications.
Regrettably, evidence is still not yet adequate. Estimates assume that the share of the appropriately selected patients enrolled in those trials does not exceed 25 percent. Meanwhile, greater account is taken of this problem and it plays an important role especially in tumour treatment.
How the efficacy of medication should be taken into account in regards to overweight or underweight patients?
Body weight does not play a significant role in the dosing of most medications. Nonetheless, an entire series of drugs are administered according either to bodyweight or body surface area, such as substances used for cancer treatment, some of the low molecular weight heparins, and cytokines, including interferon. The list also includes such medications as certain new types of oral anticoagulants, whereby the initial dose has to be reduced according to low weight (e. g. <60 kg), in order to avoid adverse events.
However, it is not sufficiently clear whether, for example, a different dosage is needed for frail patients who, unlike non-frail patients, are usually close to underweight. As a few medications have negative initial reactions among these patients, it is generally recommended to titrate the dosage, starting from a lower initial dose.
Which tools teach patients how medications interact with each other or whether a non-prescription drug taken in combination with a prescription drug will have adverse effects, i.e. will increase or weaken action of a drug?
There are publicly available software systems which provide medical information for laymen such as the online adviser magazine ‘Apothekenumschau’ (http://www.apotheken-umschau.de/Medikamente/Wechselwirkungscheck), but I doubt as to whether laymen can deal well with such kind of information. Consulting a healthcare professional (your physician or pharmacist) would be, in my view, a better option to avoid wrong conclusions from medical databases. I would strongly recommend checking with your healthcare professional about the following substance groups, especially, St. John’s wort preparations which can often decrease the efficacy of the whole pharmacotherapy and also non-prescription pain-relievers which may cause bleeding when used in combination with blood thinners. Furthermore, when used in combination with antihypertensive drugs these medicinal preparations may trigger both renal failure and electrolyte imbalance.
What are your recommendations for the use of medication during heat-waves?
Heat-waves usually trigger lethargy (immobility), fluid loss (both increased liquid requirement and water conservation through kidneys), hypovolemia, and an increase in body temperature (hyperthermia). During a heatwave, there are significant risks associated with diuretic medications when administered without considering both reduced fluid intake due to a diminished sensation of thirst, and thermoregulatory disorders, for example, in patients with decreased perspiration. Heat tolerance may also be affected by ACE inhibitors which decrease the sensation of thirst as well as by perspiration reducing substances, such as anticholinergic ones, including tricyclic antidepressants and neuroleptics. In general, I would recommend wearing loose, lightweight clothing and ensuring that your body gets sufficient liquid. Watch out for certain symptoms of heat exhaustion such as an increased pulse-rate and body temperature.
Which steps can elderly patients take to ensure they receive proper medical treatment?
Healthcare professionals list lack of time as one of their top challenges. For this reason, both patients and physicians will benefit greatly by using their time wisely, including informing the patients as thoroughly as possible and, at the same, providing physicians with all relevant information. Information comprehensively collected by health professionals proves a sufficient time-saver when explaining current treatment regimes to patients. For every visit to the physician office, I would highly recommend keeping at hand an up-to-date medication planner, i.e. one containing all relevant information organised by usual medical criteria. It would then be clear which medications must not be taken.
Please note the following points to get the most out of your doctor’s appointment:
- Bringing the updated medication planner to every appointment will help your physician to better clarify your health issues with less effort.
- Be prepared to answer questions concerning your prescription compliance. Here, it is particularly important to give an honest answer, as physicians are aware that, for various reasons, many patients do not follow the medication instructions. The only way to resolve this issue is to communicate and try to reach an agreement about the treatment (adherence).
- Be prepared to share concerns regarding the side-effects of the medications you are taking.
- Besides, it would be helpful, if patients would be willing to communicate which issues concern them the most, thus the more urgent issues could be addressed first. (patient preference). This would help arrange and apply a successful therapy.