Which of the following are increased risks of elderly patients on drug therapy?

According to the Centers for Disease Control and Prevention, approximately one-third of American adults in their 60s and 70s use five or more prescription drugs regularly, a practice known as polypharmacy. This significantly increases the risk for a host of health problems, making it crucial to understand the answer to the question: Which of the following are increased risks of elderly patients on drug therapy?.

Quick Summary

This article explores the elevated risks associated with drug therapy in the elderly, detailing how age-related physiological changes impact pharmacokinetics and pharmacodynamics. It covers adverse drug events, polypharmacy, increased fall risk, and cognitive impairment, while also explaining why these risks are heightened in older adults.

Key Points

• Altered Drug Metabolism: Age-related declines in kidney and liver function mean drugs are cleared more slowly, increasing the risk of accumulation and toxicity.

• Increased Sensitivity to Drugs: Older adults can have an increased sensitivity to certain drug classes, such as central nervous system depressants, which can heighten their effects and adverse reactions.

• Risk of Polypharmacy and Interactions: The use of multiple medications for multiple conditions (polypharmacy) is common and significantly increases the chances of harmful drug-drug interactions.

• Higher Incidence of Falls: Medications that cause dizziness, sedation, or balance issues are a major contributor to the increased risk of falls in the elderly.

• Risk of Cognitive Impairment: Certain drugs can cause or worsen cognitive problems like confusion, memory loss, and delirium, especially in patients with pre-existing conditions like dementia.

• Greater Adverse Drug Events (ADEs): Older adults experience a higher rate of adverse drug events and are more likely to be hospitalized as a result compared to younger patients.

Why are elderly patients at a higher risk on drug therapy?

The unique physiological changes that occur with aging fundamentally alter how medications affect the body. These changes impact pharmacokinetics (how the body processes a drug—absorption, distribution, metabolism, and excretion) and pharmacodynamics (how a drug affects the body). For example, a decline in kidney and liver function can slow a drug's clearance, allowing it to build up to toxic levels. Alterations in body composition, such as an increase in body fat and a decrease in total body water, can also affect how a drug is distributed throughout the body. An increase in fat can prolong the half-life of lipid-soluble drugs, while a decrease in body water can lead to higher concentrations of water-soluble drugs in the bloodstream. Additionally, aging can alter a person's sensitivity to certain drugs, making them more susceptible to side effects, particularly for medications affecting the central nervous system.

Increased risks related to medication therapy

Elderly patients on drug therapy face several heightened risks. These risks are not mutually exclusive and often interact, creating a complex web of potential harm.

• Polypharmacy: This refers to the use of multiple medications simultaneously, typically five or more. Given that many older adults have multiple chronic conditions, polypharmacy is a common concern. The higher the number of drugs, the greater the risk of adverse effects and interactions. Some studies have shown that patients taking five to nine medications have a 50% chance of an adverse drug interaction.

• Adverse Drug Events (ADEs): These are unintended, unwanted, or dangerous effects from a medication. Hospitalization rates due to ADEs are 4 to 7 times higher in older patients than in younger ones. Common ADEs in the elderly include confusion, oversedation, and falls, often caused by medications like anticoagulants, antibiotics, and psychotropics.

• Increased Fall Risk: Certain medications can increase the risk of falls due to side effects like dizziness, sedation, and impaired balance. These include benzodiazepines, antidepressants, antipsychotics, and muscle relaxants. Falls can lead to serious injuries, such as hip fractures, which significantly impact an older person's quality of life and mortality risk.

• Cognitive Impairment: Medications can either cause new cognitive problems or worsen existing ones like dementia. Anticholinergic drugs, sedatives, and opioids are known to cause confusion, memory problems, and delirium in older adults. The risk is particularly high in patients already experiencing some cognitive decline.

• Medication Non-adherence: While not a direct drug risk, non-adherence—intentionally or unintentionally not taking medication as prescribed—is a significant issue for the elderly. Reasons include complex medication regimens, physical or cognitive limitations, and cost concerns. Non-adherence can lead to poorer health outcomes and hospitalization.

Comparing risks of drug therapy in younger vs. older adults

The table below highlights the key differences in medication-related risks between younger and older adults.

Feature	Younger Adults	Older Adults
Pharmacokinetics	Generally efficient absorption, distribution, metabolism, and excretion.	Altered by decreased liver mass and renal function, leading to slower drug clearance and potential accumulation.
Pharmacodynamics	Standard receptor sensitivity and homeostatic responses.	Increased sensitivity to central nervous system drugs; blunted homeostatic reflexes.
Polypharmacy	Less common, as typically fewer chronic conditions are present.	Highly prevalent due to multiple chronic diseases, significantly increasing drug interaction risks.
Adverse Drug Events	Lower incidence and typically less severe.	Much higher incidence and severity, often requiring hospitalization.
Fall Risk	Generally lower, with specific medications (e.g., opioids) being potential triggers.	Significantly higher due to drug-related effects, altered physiology, and pre-existing mobility issues.
Cognitive Impact	Uncommon unless affected by specific drugs or underlying conditions.	Increased risk of confusion, delirium, and memory issues, especially with psychotropics and anticholinergics.

How to mitigate the risks

Careful management and communication are crucial for mitigating medication risks in older adults. Healthcare providers should review medication lists regularly, particularly during transitions of care. The 'start low and go slow' approach to dosing, where a medication is started at a lower dose and slowly titrated upwards, is often recommended for the elderly. Pharmacists can also be a valuable resource for identifying potential drug-drug interactions and simplifying complex regimens. Additionally, non-pharmacological alternatives should always be considered when appropriate. For example, cognitive-behavioral therapy for insomnia can be tried before prescribing a hypnotic medication.

Conclusion

Elderly patients face a disproportionately high risk of complications from drug therapy due to a combination of physiological changes, multimorbidity, and polypharmacy. The increased risks include higher rates of adverse drug events, falls, and cognitive impairment. Recognizing and proactively managing these risks requires a collaborative approach involving patients, caregivers, and the healthcare team. By prioritizing regular medication reviews, using conservative dosing strategies, and exploring non-pharmacological options, the safety and well-being of older adults can be significantly improved.

Which of the following are increased risks of elderly patients on drug therapy?

• Heightened Adverse Drug Events: Due to altered pharmacokinetics and pharmacodynamics, older adults are more susceptible to unwanted, uncomfortable, or dangerous drug effects.
• Increased Risk of Falls and Accidents: Certain medications, such as sedatives and antidepressants, cause side effects like dizziness and sedation, which increase the risk of falls.
• Accelerated Cognitive Impairment: Drugs can cause or worsen cognitive problems, including confusion, delirium, and memory issues, especially with medications affecting the central nervous system.
• Increased Potential for Drug Interactions: A higher likelihood of polypharmacy (taking multiple drugs) raises the risk of complex and unpredictable drug-drug interactions.
• Medication Accumulation and Toxicity: Reduced kidney and liver function can decrease drug clearance, leading to a build-up of the drug in the body and a higher risk of toxicity.

Frequently Asked Questions

What is polypharmacy in the elderly?

Polypharmacy is the regular use of multiple drugs, typically five or more, by an individual. It is particularly common in older adults who have multiple chronic health conditions that require medication.

Why does medication clearance decrease with age?

With age, both kidney function and liver blood flow tend to decline. Since these organs are primarily responsible for filtering and metabolizing drugs, their reduced efficiency can lead to a buildup of medication in the body, increasing the risk of side effects and toxicity.

Which types of medications most commonly increase fall risk in older adults?

Medications that affect the central nervous system are frequently associated with an increased fall risk. These include sedatives (like benzodiazepines), antidepressants, antipsychotics, and opioids, which can cause dizziness, sedation, and impaired balance.

Can drugs cause or worsen confusion in the elderly?

Yes, many drugs can cause or worsen cognitive issues like confusion and delirium in older adults. Anticholinergic drugs, sedatives, and opioids are common culprits, and the risk is higher in those with pre-existing cognitive impairment.

How can medication non-adherence be addressed in older adults?

Addressing medication non-adherence involves simplifying drug regimens, using once-daily dosing when possible, providing patient-friendly written information, and enlisting the help of caregivers. A pharmacist or doctor can also help identify and address any barriers, such as cost or difficulty opening bottles.

What is a 'prescribing cascade' and how does it affect the elderly?

A prescribing cascade occurs when a new medication is prescribed to treat a side effect of another drug, mistaking the side effect for a new medical condition. This can increase polypharmacy and heighten the risk of adverse effects.

What is the 'start low and go slow' approach?

This is a best practice for prescribing to older adults, where a new medication is started at a lower dose than in younger adults and slowly increased as needed. This approach helps minimize potential adverse effects and allows time for the body to adjust.