Medication-Related Problems in the Elderly

Medication-related problems are referred to drug therapy that interferes with or can intervene with the preferred health outcomes for a patient. The geriatric populace that almost represents 21% of the whole populace, devours a remarkable deal of drug treatments due to the age-associated physiological changes, pharmacokinetic and pharmacodynamics alterations, consequently developing into medication related problems. The high prevalence of multiple drug use with age-related changes in pharmacokinetics and pharmacodynamics makes elderly patients vulnerable to medication-related problems. A community-based observational study was conducted among the residents who met the inclusion and exclusion criteria belonging to different regions of Dakshina Kannada district. The duration of the study was 6 months and enrolled 150 elderly patients aged 60 years and above of either sex and diagnosed to have any disease except cancer and being bedridden , to assess the prevalence of medication-related problems in elderly patients. Out of 150 elderly patients enrolled in the study, 107 were identified to have Medication Related Problems (MRPs). A total of 196 MRPs were identified amongst those 107 patients. The prevalence of patients with MRPs was found to be 72% in this study. The prevalence of MRPs was found to be varying among males (68.29%) and females (75%), across different age groups & others. So, the study concluded that the number of elderly patients and multiple co-morbidities are increasing consequently with the increase in the number of medications and thus leading to increase in MRPs. So, it's vital to ensure optimum care for positive outcomes in the elderly. Keywords: Medication-related problems, MRPs, elderly patients, geriatric populace

The effectiveness and financial benefit of pharmacist-led annual wellness visits (AWVs) in conjunction with comprehensive medication management (CMM) for older, high-risk patients were examined. Eligible patients were 65 years of age or older with three or more chronic medical conditions, taking five or more long-term prescription or nonprescription medications and receiving primary care in a retirement community clinic. The intervention involved two components, an AWV and CMM. The AWV included all Medicare-required components. All participants saw a clinical pharmacist practitioner for an AWV with CMM and additional CMM visits at three and six months. Outcomes included completion of required AWV components, prevalence of medication-related problems (MRPs), classic return on investment, patient satisfaction, and change in rate of hospitalization. Of the 60 eligible patients contacted, 53 (88%) agreed to participate. Patients' mean ± S.D. age was 82.1 ± 5.5 years, and patients used a median of 12 medications (range, 5-27) at baseline. The pharmacist identified at least 1 MRP in 90.6% of patients at the AWV; all patients had at least 1 MRP identified over six months. A total of 278 MRPs were identified: suboptimal drug (32.7%), insufficient therapeutic monitoring (25.2%), undertreatment of chronic condition (16.9%), and suboptimal dose, frequency, or administration (15.8%). Revenue generated by the pharmacist exceeded costs by 38.1%. The rate of hospitalizations did not significantly change after the intervention. Pharmacists played a beneficial role in the provision of both AWVs and CMM, facilitating the completion of wellness visits and identifying and addressing MRPs in an older, high-risk population.

Traumatic brain injuries (TBIs) pose a significant health concern among the elderly population, influenced by age-related physiological changes and the prevalence of neurodegenerative diseases. Understanding the biomechanical dimensions of TBIs in this demographic is vital for developing effective preventive strategies and optimizing clinical management. This comprehensive review explores the intricate biomechanics of TBIs in the elderly, integrating medical and aging studies, experimental biomechanics of head tissues, and numerical simulations. Research reveals that global brain atrophy in normal aging occurs at annual rates of -0.2% to -0.5%. In contrast, neurodegenerative diseases such as Alzheimer's, Parkinson's, and multiple sclerosis are associated with significantly higher rates of brain atrophy. These variations in atrophy rates underscore the importance of considering differing brain atrophy patterns when evaluating TBIs among the elderly. Experimental studies further demonstrate that age-related changes in the mechanical properties of critical head tissues increase vulnerability to head injuries. Numerical simulations provide insights into the biomechanical response of the aging brain to traumatic events, aiding in injury prediction and preventive strategy development tailored to the elderly. Biomechanical analysis is essential for understanding injury mechanisms and forms the basis for developing effective preventive strategies. By incorporating local atrophy and age-specific impact characteristics into biomechanical models, researchers can create targeted interventions to reduce the risk of head injuries in vulnerable populations. Future research should focus on refining these models and integrating clinical data to better predict outcomes and enhance preventive care. Advancements in this field promise to improve health outcomes and reduce injury risks for the aging population.

The elderly population is increasing worldwide. Due to age-related physiological changes that affect the pharmacokinetics and pharmacodynamics of drugs, the elderly are predisposed to adverse drug reactions. Prescribing of potentially inappropriate medications (PIMs) has been found to be prevalent among the elderly and PIM use has been associated with hospitalisations and mortality. This study aims to identify the prevalence and nature of pre-admission inappropriate prescribing by using the STOPP (screening tool of older people's prescriptions) criteria amongst a sample of hospitalised elderly inpatients in South Australia. Medical, surgical and rehabilitation wards of a public teaching hospital in Adelaide, South Australia. Pre-admission prevalence of PIM. Medication management plans of 100 patients of ≥65 years old were prospectively studied to determine the prevalence of pre-admission PIM use. Sixty-five criteria of STOPP were applied to identify PIMs. The total number of pre-admission medications screened during the study period was 949; the median number of medicines per patient was nine (range 2-28). Overall the STOPP criteria identified 138 PIMs in 60 % of patients. The most frequently encountered PIM was opiates prescribed in patients with recurrent falls (12.3 %), followed by benzodiazepines in fallers (10.1 %) and proton pump inhibitors when prescribed for peptic ulcer disease for long-term at maximum doses (9.4 %). The number of medications were found to have a positive correlation with pre-admission PIM use (r(s) = 0.49, P < 0.01). Pre-admission PIM use is highly prevalent among the studied population. Strategies to reduce PIM use should be undertaken by physicians and pharmacists. The use of the STOPP criteria in clinical practice to reduce prescriptions of inappropriate medications requires further investigation.

Dynapenia refers to the loss of muscle strength that occurs as part of the aging process. It predominantly affects women and has been associated with reduced mobility and the presence of multiple chronic diseases. Objective: To analyze the prevalence and factors associated with dynapenia in elderly women from a population-based study in southern Brazil. Methodology: Cross-sectional population-based study with 393 elderly women from Pomerode, SC, Brazil. Dynapenia was defined as handgrip strength below 20.1 kg. Sociodemographic and economic factors, lifestyle, health conditions, and chronic diseases were investigated, through logistic regression, with odds ratios and their 95% confidence intervals (CI). Results: The mean handgrip strength among participants was 23.4 kg (SD = 5.15), with a dynapenia prevalence of 24.2% (95% CI: 20.0-29.0). Multimorbidity (OR = 2.00; 95% CI: 1.07-3.75) and mobility restriction (OR = 2.06; 95% CI: 1.15-3.68) were independently associated with dynapenia. Conclusion: Dynapenia is independently associated with mobility restriction and the presence of multiple chronic diseases among older women.

Geriatric patients frequently encounter orthostatic hypotension (OH), a multifaceted condition characterized by a significant drop in blood pressure upon assuming an upright position. As the elderly population is particularly susceptible to OH, our review endeavors to comprehensively explore the complex nature of this condition and various factors contributing to its development. We investigate the impact of comorbidities, polypharmacy, age-related physiological changes, and autonomic dysfunction in the pathogenesis of OH. Geriatric patients with OH are faced with an elevated risk of falls, syncope, a decline in their overall quality of life, and hence increased mortality. These implications require careful consideration, necessitating a thorough examination of therapeutic strategies. We evaluate various pharmaceutical and nonpharmacological therapies, delving into the effectiveness and safety of each approach in managing OH within geriatric populations. We explore the role of pharmacotherapy in alleviating symptoms and mitigating OH-related complications, as well as the potential benefits of volume expansion techniques to augment blood volume and stabilize blood pressure. We place particular emphasis on the significance of lifestyle changes and nonpharmacological interventions in enhancing OH management among the elderly. These interventions encompass dietary modifications, regular physical activity, and postural training, all tailored to the unique needs of the individual patient. To optimize outcomes and ensure patient safety, we underscore the importance of individualized treatment plans that take into account the geriatric patient's overall health status, existing comorbidities, and potential interactions with other medications. This review aims to improve clinical practice and patient outcomes by advocating for early detection, properly tailored management, and targeted interventions to address OH in the elderly population. By raising awareness of OH's prevalence and complexities among healthcare professionals, we hope to foster a comprehensive understanding of OH and contribute to the overall wellness and quality of life of this vulnerable demographic.

Considering the increase in life expectancy, there is a time-related decline in biological functions. Age-related changes are also observed in the circadian clock which directly leads to appropriate rhythms in the endocrine and metabolic pathways required for organism homeostasis. Circadian rhythms are affected by the sleep/wake cycle, environmental changes, and nutrition. The aim of this review is to show the relationship between age-related changes in circadian rhythms of physiological and molecular processes and nutritional differences in the elderly. Nutrition is an environmental factor that is particularly effective on peripheral clocks. Age-related physiological changes have an impact on nutrient intake and circadian processes. Considering the known effects of amino acid and energy intakes on peripheral and circadian clocks, it is thought that the change in circadian clocks in aging may occur due to anorexia due to physiological changes.

Background: Approximately 13% of the world’s population is more than 65 years old, and they consume major proportion of all medicinal products. Geriatric population constitute the majority of patients for chronic conditions including cardiac disease, malignancies, metabolic disorders, neurodegenerative disorders among others. However, in clinical trials, the elderly population is not adequately represented. In clinical studies, age-related physiological changes that impact the drug’s pharmacokinetics and pharmacodynamics in the elderly are not adequately assessed. Additionally, concomitant medications and comorbid conditions make elderly individuals more vulnerable to side effects. Objective: To analyse the trends of clinical trials involving the geriatric population in India over the past 16 years registered under Clinical Trial Registry of India. Materials and Methods: All clinical trials registered under CTRI from July 2007 to December 2023 were reviewed and analyzed using the key words “geriatrics”, “elderly”, “old age” in the ‘trial search’ section. Data was extracted for the year of study, type of trial, therapeutic area and sites of study. Results: Out of a total of 63,063 studies were registered in CTRI, 254 studies (0.37%) had geriatric population in their inclusion criteria. Of these studies 157 studies (61.8%) were interventional in nature. 29.9% of the studies were related to improvement in quality of life in the elderly. Regulatory clinical trials which included geriatrics to evaluate the efficacy and safety of drugs were only 5.5%. A gradual increase in the number of trials including elderly population was noted over the last 5 years. Conclusion: There is a major dearth of clinical trials that evaluate the geriatric population. However, there is an increasing trend of inclusion of geriatric population in clinical trials over the recent years.

Background: Medication Therapy Management (MTM) is a mandated component of Medicare Part D whereby a pharmacist-patient encounter identifies, resolves and prevents medication-related problems. MTM programs have been shown to improve drug therapy goal attainment while reducing overall costs in cardiac patients; however, MTM has been greatly underutilized. The purpose of this study is to identify the proportion of patients eligible for MTM from those enrolled in the NCDR's outpatient PINNACLE Registry. Methods: MTM eligibility is based on the presence of multiple chronic diseases and medications plus the likelihood of exceeding an annual drug cost threshold ($4000 in 2009 and $3000 in 2010). Patients from PINNACLE (5/1/08 to 9/30/10) with 3 or more of the following diseases were identified: HTN, HF, dyslipidemia, DM, CAD. Patient demographics, cardiac diseases, and cardiac drug classes prescribed (individual drugs not available) were captured. To estimate individual patient drug costs to determine MTM eligibility, a weighted average cost was calculated using nationally representative drug utilization data and average wholesale prices (AWP). Sensitivity analyses for determining MTM eligibility were performed by varying drug costs using AWP for the highest cost and clinician-defined most frequently prescribed drugs in each class. Results: Of the 160,593 Medicare patients enrolled in PINNACLE, 93,089 (58%) were identified with ≥ 3 cardiac diseases. The cohort’s mean age was 74.4 ± 9.2 yrs, 54.4% were male and 86.5% were white. Patients were prescribed a mean of 3.5 cardiac drugs. The table displays drug costs and MTM eligibility results. Conclusions: A substantial number of patients met MTM eligibility requirements with this conservative approach using only cardiac drug costs, although variability existed based on cost method. These data serve to raise cardiologists' awareness of their patients' potential eligibility to receive the benefits of MTM services. Cost Methodology Median Annual Cost (IQR) 2009 MTM Eligibility [N (%)] 2010 MTM Eligibility [N (%)] Weighed average cost $1329 (915,2609) 6,202 (6.7% ) 19,903 (21.4%) Frequently prescribed cost $366 (193,1361) 1084 (1.2% ) 7326 (7.9%) High cost $3,958 (2406,5358) 46,477 (49.9% ) 59,619 (64%) 2009 and 2010 MTM eligibility based on likelihood of exceeding drug cost threshold of $4000 and $3000, respectively. IQR - interquartile range; MTM - medication therapy management.

Tau becomes abnormally hyper-phosphorylated and aggregated in tauopathies like Alzheimers disease (AD). As age is the greatest risk factor for developing AD, it is important to understand how tau protein itself, and the pathways implicated in its turnover, change during aging. We investigated age-related changes in total and phosphorylated tau in brain samples from two cohorts of cognitively normal individuals spanning 19-74 years, without overt neurodegeneration. One cohort utilised resected tissue and the other used post-mortem tissue. Total soluble tau levels declined with age in both cohorts. Phosphorylated tau was undetectable in the post-mortem tissue but was clearly evident in the resected tissue and did not undergo significant age-related change. To ascertain if the decline in soluble tau was correlated with age-related changes in autophagy, three markers of autophagy were tested but only two appeared to increase with age and the third was unchanged. This implies that in individuals who do not develop neurodegeneration, there is an age-related reduction in soluble tau which could potentially be due to age-related changes in autophagy. Thus, to explore how an age-related increase in autophagy might influence tau-mediated dysfunctions in vivo, autophagy was enhanced in a Drosophila model and all age-related tau phenotypes were significantly ameliorated. These data shed light on age-related physiological changes in proteins implicated in AD and highlights the need to study pathways that may be responsible for these changes. It also demonstrates the therapeutic potential of interventions that upregulate turnover of aggregate-prone proteins during aging.

Geriatric wards represented a very interesting clinical setting in which an increased drugs use rise the prevalence of adverse drug reactions (ADRs) and therapeutic failures (TFs). These are not independent phenomena, but the severe counterposed manifestations of a continuum of phenotypes in which the better drug response is the midpoint. Age-related changes in the regulation of cytochrome P450 (&lt;em&gt;CYP&lt;/em&gt;) genes, encoding the most common drugmetabolizing enzymes, might be responsible of the observed age-associated drift towards ADRs and TFs. In this review article, a complete impression of the CYP pharmacogenetics and epigenetics is reported in the context of increasing age, in which epigenetic &lt;em&gt;CYP&lt;/em&gt;-gene regulation might change. Physiological age-related changes in DNA-methylation, the main epigenetic mechanisms regulating gene expression in humans, results in a physiological decrease in &lt;em&gt;CYP&lt;/em&gt; gene expression with advancing age. This may be one of the physiological changes that, together with an increased drug use, contributed to raise the prevalence of severe responder phenotypes in older age.

BackgroundAccurate risk stratification in older adults presenting to the emergency department (ED) is essential but challenging due to atypical presentations and age-related physiological changes. While vital signs are central to triage, their predictive value for short-term mortality in this population remains unclear. This study aimed to explore the association between initial vital signs and 7-day mortality among older ED patients.MethodThis retrospective cohort study included patients aged ≥ 65 years who visited two EDs in Region Halland, Sweden, during 2018. Vital signs, systolic blood pressure (SBP), heart rate (HR), peripheral oxygen saturation (SpO₂), respiratory rate (RR), body temperature, and level of consciousness (LOC), were extracted from the regional health information system. Descriptive statistics, ROC curve analysis, and logistic regression were used to assess associations between categorized vital signs and 7-day mortality, adjusting for age, sex, and comorbidity.ResultsOf 30 327 ED visits, 25 450 patients had at least one recorded vital sign. The mean age was 78 years; 50% were female. The 7-day mortality rate was 2%. ROC analysis showed limited discriminative ability of individual vital signs (AUC range: 0.49–0.70). Low SBP, high HR, low SpO₂, and impaired LOC were statistically significantly associated with mortality. Multivariable logistic regression confirmed these associations, with SBP (≤ 80 mmHg, AOR 7.79; 95% CI 3.27–18.54), high HR (> 125 bpm, AOR 6.37; 95% CI 1.26–32.16), low SpO₂ (≤ 80%, AOR 3.64; 95% CI 1.75–7.58), and impaired LOC (GCS < 13 (AOR 9.30-18.36)) showing the strongest effects.ConclusionLow SBP, elevated HR, reduced SpO₂, and impaired LOC were independently associated with short-term mortality in older ED patients, though their individual predictive performance was modest. LOC, despite being a strong predictor, was frequently missing, underscoring challenges in routine assessment. These findings highlight the need for more comprehensive, geriatric-informed triage systems that incorporate age-related physiological changes and ensure consistent evaluation of LOC. As frailty and functional status was not available in this dataset, future studies should focus on integrated models that include these factors to improve early risk identification in emergency care for older adults.Clinical trial numberNot applicable.

Strong age but weak sex effects in eye movement performance in the general adult population: Evidence from the Rhineland Study

1. Presbycusis, age-related hearing loss, is an ever increasing problem in our aging society. It involves changes in both the peripheral and central portions of the auditory system. The inferior colliculus (IC) has been shown to display age-related changes including decreased gamma-aminobutryic acid (GABA) levels, decreased glutamate decarboxylase levels, and decreased binding by GABAB receptors, as well as rearrangement of axon terminals in aging Fischer 344 (F344) rats. Age-related physiological changes have also been noted in the ICs of C57 and CBA mice. 2. Given the age-related alterations in the inhibitory neurotransmitter system, we hypothesized that aged F344 rats would show alterations in the physiological response properties of their IC neurons due to an imbalance in the relative levels of inhibition and excitation affecting the neuronal firing. 3. In vivo extracellular single-unit recordings were made from 297 IC neurons in ketamine/xylazine-anesthetized aged (24 mo) F344 rats. Locations of recorded units were determined from the electrode track marks and horseradish peroxidase marks. Results were compared with those obtained from young adult (3 mo) animals. 4. Average threshold increased from 25.4 dB SPL in young rats to 56.1 dB SPL in aged rats. 5. Although there was a reduction in the percentage of units recorded at either extreme of the frequency range in aged animals, the characteristic frequency (CF) range and mean did not differ between the two groups. 6. For the IC as a whole, no differences were noted in spontaneous activity, first spike latency, dynamic range, percentage of units with nonmonotonic contralateral CF tone rate/intensity functions (RIFs), or percentage of units sensitive to change in CF tone presentation rate. 7. In aged rats, a higher percentage of units was poorly responsive to auditory stimulation. 8. In the aged rat, there was a 12% reduction in the maximum discharge rate, a 12% increase in the percentage of units classified as onset in their temporal response pattern, and an 18% increase in the breadth of the isointensity functions at 30 dB above threshold. 9. Age-related changes in the central nucleus of the IC (CIC) frequently differed from those observed in the external cortex of the IC (ECIC). The percentage of units classified as having nonmonotonic contralateral tone RIFs decreased with age in the CIC but increased with age in the ECIC, and the percentage of units classified as onset in their temporal response pattern increased with age in the CIC but did not change with age in the ECIC. 10. The results of this study support the hypothesis that there is an age-related shift to higher intensities in the working range of most CIC units along with a small, selective deficit in inhibitory processing. When considered in conjunction with the mouse aging studies conducted by other researchers and with the results of a similar study of single units in the visual system (lateral geniculate nucleus) of young and aged rhesus monkeys, these results suggest that compensatory mechanisms are highly active in sensory systems as animals age. Despite deficits that lead to reduced input to the IC and neurochemical changes affecting neurotransmitter levels, IC neurons in aged rats are able to respond to most simple auditory stimuli in a fashion quite similar to that observed in young rats.

Objectives: As the early form of OA is characterized by elevated water content in the cartilage tissue, the purpose of this study was to verify in vivo if age-related changes in patellar cartilage in healthy volunteers can be detected using quantitative MRI with T2 mapping and volume measurement MRI methods. Design: Thirty healthy volunteers of various classes of age (18 to 65 years old) were enrolled in this study. MR images of the patellar cartilage were acquired at 1.5T. Patellar cartilage volume and T2 maps were determined. Results: Despite non-significance, there was a trend in reducing cartilage volume with ageing (r: −0.25). In contrast global T2 slightly increased with ageing (r: 0.46). BMI (r: 0.51) and bone volume (r: 0.69) are well correlated to cartilage volume. Conclusion. Age-related physiologic changes in the water content of patellar cartilage can be detected using MRI. The proposed T2-mapping method, coupled with other non-invasive MR cartilage imaging techniques, could aid in the early diagnosis of OA.