Perspective Chapter: Clinical Standard of a Geriatric Patient as a Virtual Target for Correction of Pharmacotherapy of Hypertension and Stroke in the Elderly

*Aleksandr Urakov, Aleksandr Samorodov and Varvara Sokolova*

## **Abstract**

One of the unresolved geriatric problems in neuropharmacology remains the lack of specifically designed drugs and therapeutic and preventive measures for older adults with hypertension and/or stroke. In particular, there are no standards for virtual geriatric patients aged 65–70 years, 70–90 years, and over 90 years, as well as courses of pharmacotherapy for diseases in them. The fact is that modern drugs and standards of their use in the treatment of diseases are still traditionally focused on a virtual object, which represents a person of mature age weighing about 70 kg. Therefore, it is proposed to develop clinical standards appropriate for three groups of geriatric patients. The main characteristics of health status, hypertension and rehabilitation of elderly people after a stroke, as well as the peculiarities of pharmacodynamics and pharmacokinetics of drugs are given. It is hoped that the use of such virtual targets will optimize the adjustment of treatment of hypertension and stroke in elderly people and will reduce drug complications and polypragmasy.

**Keywords:** drug, course pharmacotherapy, polypragmasy, complications, elderly person, longevity, safety

## **1. Introduction**

In recent decades, most countries of the world have experienced an "aging" of society, as, on the one hand, the number of elderly people has increased and, on the other hand, the number of children and youth has decreased. The reason for this phenomenon was the increase in the average life expectancy of people with a simultaneous decrease in their birth rate [1]. The significant increase in the number of elderly patients has led to an increase in the role of geriatric problems in health care and, in particular, in neurology, pharmacology, and pharmacy. The fact is that medicine, as an art of healing, was formed in a period when the bulk of patients consisted of people of young and mature age, because at that time, the average life expectancy of

people did not exceed 30 years [2]. Moreover, patients over the age of 65 were a rarity for the bulk of physicians at the time the foundations of medicine were formed.

That is why the extant basics of therapeutic and surgical treatment of diseases mainly reflect the experience of successful medical treatment of people of young and mature age, but not of the elderly or long-lived. This is clearly demonstrated by the main mysteries of healing, which are reflected in the two most famous aphorisms of Hippocrates [3]:

1.Do no harm (*lat. Noli nocere*).

#### 2.The doctor treats, nature heals (*Lat. Medicus curat, natura sanat*).

The essence of these aphorisms boils down to the following: despite the fact that the doctor prescribes treatment, it is still not the doctor who heals the patient, but nature that sustains his vitality. No one today is likely to argue that these aphorisms reflect the basic mysteries of healing, not of the elderly and the long-lived, but of the young and the mature. Today, they are guided equally by doctors who are adherents of traditional medicine and all sorts of "healers" and herbalists, relying on the methods of nontraditional and folk medicine [4]. Consequently, the extant medical standards of diagnosis and treatment of sick people reflect the state of health and readiness for self-recovery of people of young and mature age.

Analysis of the content of ancient medical treatises, including Hippocratic writings, convinces us that these standards reflect the experience of doctoring not all sick people, but only those of them who voluntarily sought medical care themselves, knowing that they would have to pay for it, and who were able to pay for the costs associated with diagnosis and treatment. In addition, it is important to emphasize that these medical diagnostic standards were developed without the use of most modern diagnostic technologies, and treatment standards did not include modern medications and technologies for their use [5]. In addition, the medical canons discussed were mostly relevant only to patients who believed in God, in the miraculous power of the healer they chose and the medicine they prescribed. At the same time, it is clear to us today that the healer himself successfully healed mostly people no older than 65 years of age, but people of young and mature age. Today, it is unlikely that anyone would argue with the fact that people of young and mature age fell ill, as a rule, by accident, and their illness was a short-term phenomenon. Obviously, the biblical truth that Christ healed many sick people, especially those who believed in him, applies to patients of young and mature age rather than to the elderly and long-lived [6, 7].

Therefore, diagnostic and therapeutic standards that have survived unchanged are suitable mainly for the treatment of people of young and mature age, and are of little use in the treatment of elderly patients. The fact is that aging leads to decrease of physical and mental activity of a human being, depletes reserves of all organs and systems of human body, and finally decreases disease resistance. Moreover, physical health, typical for a person of young and mature age, is not typical for patients older than 65. But as a person ages, it is natural that frailty and exhaustion progress, and diseases begin to take on a prolonged character. It is a bitter truth that man is mortal, and death is more likely in old age than in adulthood and youth.

A striking sign of old age in humans and animals is the wear of teeth, increased hardness of skeletal muscles, thickening of the walls of blood vessels, the appearance of cholesterol plaques in blood vessels, increased blood pressure, impaired blood supply to the brain and heart, as well as malignant neoplasms in various organs [8, 9]. Earlier the

#### *Perspective Chapter: Clinical Standard of a Geriatric Patient as a Virtual Target for Correction… DOI: http://dx.doi.org/10.5772/intechopen.110671*

above mentioned manifestations of old age were rarely encountered in medical practice due to the fact that very few people lived to old age. Nowadays, due to the continuing "aging" of society, these manifestations of old age are more frequent and therefore require their resolution more often. It is becoming more and more evident that it is very important to be able to treat this or that disease not so much in people of young and mature age, but in the elderly and in long-lived people. At the same time, the progress of geriatric medicine is hindered by the absence of special "geriatric" drugs and medical standards for diagnosis and treatment of such "manifestations" of old age such as adentia, hypertension, stroke, ischemic heart disease, and myocardial infarction.

## **2. The modern virtual average patient as the medical standard mature patient without hypertension and stroke**

Despite the fact that the modern practice of neurologists has replaced young and mature patients with elderly patients, "geriatric" standards of care have not yet been developed. Under these circumstances, when providing medical care to patients over the age of 65, physicians apply the same medical standard that they do when treating young and mature patients. It is true that doctors have remembered since college that the pharmacodynamics and pharmacokinetics of all medications depend on the health status, gender, and age of patients, so these factors must be taken into account. However, the existing medical standards inhibit the initiative of physicians because it does not contain specific recommendations for adjusting the diagnosis and treatment of elderly patients and long-livers with, in particular, hypertension and stroke [10, 11].

Nevertheless, when treating hypertension and stroke in the elderly, each neurologist compares the anatomical and functional features of each elderly patient with the features of a virtual average ("standard") patient of young and mature age. In doing so, the physician seeks to identify the difference between them independently in order to use it to "geriatricize" the treatment of the disease in the elderly patient. These skills are very important because currently they are the only ones that can help the physician find a successful solution to most of the geriatric problems that have accumulated in the medical-pharmaceutical field.

It is no secret that throughout the history of medicine and drug-making, the role of the average statistical patient has implied an average (virtual) person who was of average age (ranging from 18 to 65 years) [2, 12, 13]. In other words, it was not a person of advanced age by modern standards. Also implicit was the following: Although each patient represented either a man or a woman of childbearing age, the virtual standard person was assumed to represent something statistically average between a man and a woman (figuratively speaking, this patient represented the "middle" sex). Therefore, the role of this subject was not a girl and/or a woman during menstrual bleeding, fertilization, pregnancy, childbirth, and/or lactation.

To this we should add that in the opinion of pharmacists and healers, a standard virtual patient had an average statistical body structure, an average statistical state of health, and could unexpectedly "fall ill" and relatively quickly improve his health himself, more precisely—without doctors and without using traditional (or nontraditional) medicines. It was implied that the virtual standard patient had normal blood pressure, and also did not have a stroke, did not die either before or in the process of healing (i.e., conventionally speaking, lived "forever"). It was also assumed that the virtual standard patient had a body weight of about 70 kg, was not an alcoholic, drug addict, or substance abuser, had never previously taken any medications, had no drug addiction and led a daytime lifestyle, and ordinary diseases plagued him only during his waking period (namely, during the day) [7, 14].

On this basis, all generally accepted diagnostic and treatment standards (including pharmacological, pharmaceutical, and neurological technologies (diagnostic and treatment methods)), devices (medical instruments and devices), and means (drugs) are still not directly relevant to each specific person (patient) and not in each specific moment of his life. In particular, modern pharmacological, pharmaceutical, and neurological standards are relatively directly relevant only to those people of young and mature age (patients) who by the characteristics of their anatomo-functional state come close to the similar state of the virtual average patient currently accepted as a standard (conventional norm).

Thus, the main characteristics of the anatomical–functional state of the modern statistical average standard patient can be described by the following main indicators of his "nature": average age, average sex, average weight, and average state of health.

From this "rule," in particular, it follows that modern tablets of medicines are produced by pharmaceutical companies around the world with such mechanical, physical, chemical, and other properties, which are optimal for enteral administration in conditionally healthy people aged 18–65 years, who have intact chewing and speech apparatus and gastrointestinal tract. However, no one denies that modern drug tablets are prepared by pressing dry powders, so they are essentially quite strong artificial stones with varying hardness, which, by the way, is not controlled worldwide [15]. In this regard, it is no coincidence that pills, which are considered of high quality today, can cause local damage to the teeth, gums, and stomach walls not only in some patients, but also in healthy people. In this regard, there is reason to remind ourselves that man is not a bird. Humans are designed to swallow elastic, soft, and slippery chewing lumps, not hard stones [16].

Despite these paradoxes, tablets continue to be the top-selling drug among other dosage forms worldwide for the treatment of many diseases in people of all age groups, including the treatment of hypertension and stroke.

Under these conditions, in the complete absence of drugs produced in the form of special "geriatric" tablets, neurologists have no choice but to prescribe drugs to all elderly people in the form of the most common tablets, regardless of whether patients have teeth, dental prostheses, as well as the condition of the chewing and speech system and the gastrointestinal tract. At the same time, all physicians are informed that prescribing modern tablet medications strictly according to the accompanying "Instructions for Use" is correct only when treating people of young and mature age. Therefore, when prescribing medications in such "tablets" for the elderly and seniors, adjustments to the quality of the tablets, changes in the dose of the drugs they contain, and the technology of their enteral administration are required. However, pharmacological handbooks, instructions, and medication guidelines do not provide specific recommendations for turning "adult" pills into "geriatric" pills [17, 18]. The lack of precise instructions for neurologists on how to turn "adult" pills into "geriatric" pills does not optimize pharmacotherapy for diseases of the elderly, including the treatment of hypertension and stroke.

## **3. Basic geriatric syndromes and diseases—their importance in the treatment of hypertension and stroke in the elderly**

The lack of "geriatric" drugs specifically designed to treat hypertension and stroke in elderly patients, as well as the progressive depletion of adaptation reserves to many

#### *Perspective Chapter: Clinical Standard of a Geriatric Patient as a Virtual Target for Correction… DOI: http://dx.doi.org/10.5772/intechopen.110671*

diseases that occur with aging, predetermines the inevitable protracted nature of pathology and low efficiency of natural and/or medical rehabilitation of patients. Nevertheless, sometimes the patient's organism can retain some part of reserves and protective forces, which, for various reasons, are not involved in rehabilitation, but with the participation of a doctor can be used for this purpose. That is why in order to really improve the results of treatment of all patients, regardless of their age, all doctors must strive to unlock all available adaptation reserves of each patient to the fullest extent possible. That is why it is advisable to bring together as soon as possible all the accumulated positive experience in the treatment of hypertension and stroke in elderly and long-lived patients.

There is no doubt that elderly patients differ from young and mature patients in less reactivity of the body and a longer period of illness and rehabilitation after an illness. With increasing age, the reactivity of the body and the severity of its response not only to disease but also to drugs decreases. At the same time, aging leads to a decrease in the quality of life of people. Instead of the former curiosity, initiative desire to learn and succeed in learning observed in young years, in old age, people's craving for cognitive activity decreases. At the same time, such geriatric syndromes as senile asthenia, sarcopenia, depression, delirium, decreased skeletal-muscular mobility, and increased bone fragility, urinary incontinence, sensory deficits, oral disabilities (masticatory-speech apparatus dysfunction) develop [19–22].

It so happened that neurologists encountered difficulty in solving geriatric problems earlier than physicians in other specialties. This is explained by the fact that the increase in the average life expectancy of people first created the problem of high mortality and disability, which was caused by the increasing frequency of cardiovascular diseases. That is why neurology, cardiology, angiology, hematology, laboratory diagnostics, resuscitation, and anesthesiology and other allied medical specialties, including pharmacology and pharmacy, were developed at a rapid pace to address the above geriatric problems at that time. As a result, significant advances have been made in the prevention and medical treatment of hypertension, strokes, coronary heart disease, thrombosis, cardiopulmonary failure, and hypoxic cortical cell damage [23].

Only then, among other problems related to complications arising in the elderly from cardiovascular diseases, did the problems of rehabilitation of patients related to their musculoskeletal disorders begin to be developed. At the same time, the foundations for solving these geriatric problems were laid not in pharmacy and pharmacology, but in neurology. The fact is that initially, similar problems (paresis, paralysis, and even strokes) were often encountered in the practice of neurologists because they arose due to congenital, traumatic, ischemic, and/or hypoxic lesions of the brain cells in patients of young and mature age. In particular, thanks to neurologists, it has been conclusively proven that speech disorders are often a consequence not just of "old age," hypertension, and/or stroke, but rather of co-morbidities such as ischemic heart disease, diabetes, chronic lung, liver and kidney inflammation, and neurosurgical interventions. It has been shown that speech disorders can cause ischemic and/ or hypoxic brain disorders, which, in turn, can manifest as aphasia and dysarthria, often combined with pathology of other higher mental functions (various types of agnosia and apraxia), impaired swallowing function, and motor and mental disorders (depression, severe neurotic states, and suicidal thoughts) [24–27]. Due to the efforts of neurologists and cardiologists, in recent years, some medications, in particular oral anticoagulants, have been additionally included in the list of causes of disability associated with provoking stroke, thrombosis, and bleeding [28].

Neurologists, through their established practice of collaborating with speech–language pathologists and physical therapists, have thoroughly investigated the effectiveness of various rehabilitation options for older patients with hypertension and stroke. The results they obtained allowed them to highlight the most effective methods and procedures. In particular, based on the experience of comprehensive rehabilitation of the masticatory-speech apparatus impaired in patients as a result of stroke and craniocerebral trauma, neurologists gave preference to the method of restorative training of patients [29–31].

It is noteworthy that aphasia, dysarthria, articulatory apraxia, speech, and swallowing disorders, encountered in the practice of neurologists when treating patients of young and mature age, were the consequence of local irreversible damage to the brain areas. And, as we know, dead brain cells do not regenerate. Today, however, it is becoming clear that rehabilitation based on teaching (training) of patients can accelerate the recovery of lost nervous system functions resulting from the death of some brain cells. The fact is that as a result of specially designed regular training, living neurons can take over the function of the damaged parts of the brain. Studies have shown that such training can often restore speech and swallowing function in patients of different ages. Therefore, the rehabilitation of the masticatory-speech apparatus of elderly patients can indeed be improved with restorative training, but not as quickly as one would like. Practice has shown that tangible rehabilitation success comes not earlier than after 3 to 6 weeks of regular training [32–36].

In parallel, neurologists have investigated the possibility of accelerating the process of rehabilitation of the masticatory-speech apparatus of elderly and senile patients with the help of medications. However, there was no convincing evidence of a significant increase in the effectiveness of the restorative teaching method. These results suggest that it is the method of restorative teaching that can be considered today as the basis of medical technology for the rehabilitation of the masticatoryspeech apparatus in elderly patients who have suffered a stroke. Such "logopedic" rehabilitation can be based on regular (daily) theoretical and practical lessons with patients lasting 10–40 minutes each. Rehabilitation measures developed and tested in clinical practice include medication support, therapeutic gymnastics, speech therapy classes, massage, neuropsychological correction, and psychotherapeutic care. It is important to note that the success of these measures was achieved without the use of special "geriatric" medications.

In this case, it is implied that medical support for rehabilitation measures is reduced to the common course pharmacotherapy of the main and/or concomitant diseases, which may not refer only to neurological diseases. In turn, it is implied that pharmacotherapy of each disease should be carried out in accordance with the medical standard.

Stroke is one of the main diseases in elderly patients with rehabilitation measures aimed at restoring the function of the masticatory-speech apparatus. Since the cause of stroke may be craniocerebral trauma, hypertensive crisis, or cerebral vascular thrombosis, it is implied that medication support for speech rehabilitation of the masticatory-speech apparatus should be adjusted in full compliance with the available medication standards for craniocerebral trauma, hypertension, or hypercoagulation syndrome (or thromboembolic disease). In turn, comorbidities in patients of age and longevity can often be diabetes mellitus, chronic bronchitis, bronchial asthma, coronavirus infection, and some other diseases [37, 38]. Therefore, it is self-evident that in such cases, the medical support of the ongoing rehabilitation of the masticatoryspeech apparatus should be adjusted (supplemented with drugs) in accordance with

*Perspective Chapter: Clinical Standard of a Geriatric Patient as a Virtual Target for Correction… DOI: http://dx.doi.org/10.5772/intechopen.110671*

the standard of course pharmacotherapy of the relevant diseases and their complications (such as diabetic foot, airway obstruction, pulmonary emphysema, bilateral atypical pneumonia).

Consequently, the aging of the elderly person is most often manifested and/or accompanied by certain geriatric syndromes, which are mainly of a psychoneurological nature. Regardless of this, older people may often have concomitant diseases of various organs and systems of somatic nature. Therefore, medication support for stroke rehabilitation in the elderly cannot be standard and absolutely the same for all patients. In addition, it cannot be a monotherapy (therapy with a single drug). Proper medication support for stroke rehabilitation for each elderly patient must always be an original combination pharmacotherapy regimen in which the drugs must be carefully selected to take into account all the geriatric syndromes and illnesses of each individual patient.

## **4. Peculiarities of choice and prescription of drugs for the elderly in rehabilitation after stroke: Prevention of polypragmasy and its consequences**

One of the unresolved geriatric problems in neurology remains the lack of "geriatric" medications and rehabilitation therapeutic and preventive measures designed exclusively for the elderly people and long-livers who have had a stroke. The lack of clinical standards for average patients of appropriate age groups (65–70, 70–90, and over 90 years old), geriatric medications, and geriatric regimens for course pharmacotherapy (drug support) of their rehabilitation after a stroke does not contribute to solving problems of geriatric neurology, especially in the treatment of hypertension and stroke.

Despite the unresolved geriatric problems, it is currently neurologists who are involved in the rehabilitation of elderly patients after stroke, as patients have traditionally sought medical care from neurologists for 160 years for this pathology. In this situation, doctors are forced to choose and prescribe medications for elderly and senile neurological patients on their own, doing so at their own risk. The fact is that neurologists have no right to refuse treatment to the elderly and long-term residents. Moreover, until today, all doctors are obliged to treat young, mature, and elderly patients equally, namely, in strict compliance with the medical standard, using traditional medications for this purpose.

However, when treating elderly people and long-livers (as opposed to young and mature patients), physicians need to combine medications more often, because elderly patients are more likely to have comorbidities. Because of this, physicians often have to use additional pharmacotherapy regimens. In particular, rehabilitation of elderly people after a stroke is often carried out against the background of geriatric syndromes of neuropsychiatric nature and diseases of various organs and systems of somatic nature. Moreover, aging of elderly patients reduces their reactivity, disease resistance, sensitivity to drugs, and the ability to inactivate the administered drugs [39, 40].

In these circumstances, to improve the effectiveness of pharmacotherapy and rehabilitation of geriatric patients, physicians are often forced to increase single, daily, and course doses of drugs, use new drugs and new drug combinations, expand the list of combined drugs and prescribe longer courses of pharmacotherapy. All this increases the risk of polypragmasy, side effects, drug complications, and poisoning; that is, it reduces the safety of drug therapy [39, 41, 42].

Many factors make this problem difficult to solve. First, an increase in the age of patients reduces their sensitivity to drugs (reduces the strength of the effect of drugs on the human body). This is caused, on the one hand, by a decrease in the reactivity of the organism as it ages, and on the other hand, by the development of addiction to drugs. At the same time, the decrease in the reactivity of the organism is universal and applies equally to many influences, including many drugs (also almost equally). Addiction to drugs is strictly individual in nature because it develops only in those patients who have previously used drugs for long courses. Moreover, in the case where drugs were used rarely, not regularly, and in short courses in adulthood, the use of drugs in old age may show no or very weak habituation to them, which may not be essential for the choice and prescription of drugs in the treatment of stroke in old age. In the other case, when drugs have been used frequently, regularly, and in long courses in adulthood, the use of drugs in old age may manifest itself by the presence of a strong habituation to them, which may deprive the action of these drugs or their analogues in the doses taken, but maintain their pharmacological activity when the single and/or daily doses are increased. It may be quite different when a person has been taking drugs at a young and/or mature age on a regular basis and for several months or years. The thing is that in this case, a person may develop drug addiction (drug disease) which is characterized by perversion of the effects of drug and development of withdrawal syndrome when the drug is withdrawn. The fact that the patient has drug dependence is confirmed by the development of withdrawal syndrome in the field of drug use cessation [28]. The presence of a patient's drug dependence requires a neurologist to consult a narcologist.

Second, as a rule, an increase in the age of patients is accompanied by a decrease in the intensity of their metabolism and inactivation of biologically active substances, including drugs. Therefore, with increasing age, the half-life of drugs (drug elimination half-life) usually increases in the elderly, the value of which is commonly indicated by the symbol T1/2. By the way, in some elderly patients and in long-livers, the intensity of drug neutralization may be decreased not only because of the reduced intensity of general metabolism, but also because of the probable inhibition of the functional activity of the liver and kidneys. Therefore, to preserve the safety of course pharmacotherapy (to prevent chronic poisoning, i.e., to prevent overdose) in elderly patients, it is advisable to prescribe medications less frequently than indicated in the instructions for use of drugs, as these "instructions" currently apply only to patients of young and mature age. In addition, elderly patients are highly likely to have underlying or overt cardiovascular, liver, and kidney diseases. These diseases may be additional factors in slowing down the metabolism, inactivation, and/or excretion of drugs (and their metabolites) from the body [43, 44]. Therefore, the presence of hepatic, renal, and/or cardiovascular insufficiency in some patients contributes to an additional prolongation of the period of many drugs in the body, increasing the probability of their accumulation and overdose development during a long-course pharmacotherapy carried out with standard single doses and time intervals between their injections during drug rehabilitation of older patients who have had a stroke.

Third, the prescription of several drugs from different pharmacological groups to elderly patients simultaneously in the presence of geriatric syndromes of neuropsychiatric nature and diseases of various organs and systems of somatic nature predetermines the creation of an incredible multitude of combinations of different drugs with each other. The fact is that an average statistical patient today receives in different countries of the world during an average statistical course of pharmacotherapy 7–14 drugs. Moreover, more than half of them are prescribed simultaneously with

*Perspective Chapter: Clinical Standard of a Geriatric Patient as a Virtual Target for Correction… DOI: http://dx.doi.org/10.5772/intechopen.110671*

each other [14]. At the same time, some of them are a ready combination of several drugs. At the same time, the characteristics of the pharmacodynamics and pharmacokinetics of the drugs in their combinations remain a mystery to most physicians in almost all specialties. Nevertheless, this unique information can be found by any physician if he opens the "white" book of pharmacology.

In this regard, a doctor who organizes medication support for rehabilitation of elderly stroke patients is likened to a kind of conductor of a drug orchestra, which under the doctor's control can play a certain "tune" in the patient's body. At the same time, the desired "sound" of the drug orchestra occurs only when each musician (in this case, when the effect of each drug is skillfully managed) plays skillfully. However, the mechanism of action of all possible combinations in the organism of an elderly patient is not described [7, 14, 18]. Therefore, a highly qualified physician and his ability to think philosophically are very important because only this can give the physician an understanding of the essence of combination pharmacotherapy. Only a philosopher doctor can manage the pharmacodynamics and pharmacokinetics of drugs when they are combined in the body of a particular elderly patient. The fact is that in a physician-uncontrolled drug combination, *no drugs, even the best ones, will ever 'play' a good tune together and produce nothing but "noise"* [14].

In daily therapeutic practice, most doctors who combine drugs fear side effects, complications, and overdose the most. The fact is that as a student, every doctor remembers Paracelsus' winged dictum "All things are poisons, for there is nothing without poisonous qualities. It is only the dose which makes a thing poisonous. This means that all things are poisons, for there is nothing without poisonous qualities. Only the dose makes a thing poisonous*"* [45]. A wise physician, therefore, when combining remedies, limits his choice to mildly and moderately active agents and their small doses, fearing as fire the remedies related to strongly active agents and poisons.

It has been reported that when it is necessary to use potent drugs for combination pharmacotherapy, in order to avoid complications and overdose, they should be used only in very low doses, namely in doses that are 1/10 to 1/20 of their usual therapeutic dose or even less [7, 14].

Nevertheless, the physician should always remember that the conditions of interaction of each drug with the body of each patient may change at any time of the pharmacotherapy. The most variable interaction factors are the patient's psychoemotional state, the value of temperature, humidity, ambient air, oxygen content in the breathing gas, total and local body temperature of the patient, the value of atmospheric pressure, the degree of illumination of the patient, his waking or sleeping state, and time of day. Moreover, the physician should assume that the conditions of interaction of drugs with the body of an elderly patient who has had a stroke will change the more likely and more significantly the longer the course of the ongoing pharmacotherapy will be.

#### **5. Conclusion**

In recent decades, in most countries of the world, the birth rate has decreased and life expectancy has increased significantly. Long-livers have appeared. In connection with this, the proportion of elderly people in society has increased, which has generally worsened the state of health in society, since the elderly fall ill more often than people of young and mature age. Hardly anyone would dispute the fact that aging leads to progressive "wear and tear" of the body, the fading of physical and mental

activity, the depletion of the reserves of all organs and systems, and reduced resistance to disease. In this regard, older people are more often ill not only with diseases that occur at a young and mature age, but also with diseases caused by the aging (wear and tear) of the body. Therefore, elderly people and long-livers seek medical attention more often, and their diseases are prolonged and often combined with each other. Moreover, as the age of the elderly increases, their resistance to disease weakens. That is why the World Health Organization (WHO) recommends that physicians not only identify the elderly, but also divide them into three groups: patients aged 65–70 years, 70–90 years, and patients over 90 years (long-livers) [46].

These days, the health care system is not fully prepared to provide medical care to the elderly in all of these age groups. The fact is that the medical knowledge accumulated in the past and the established traditions of treating diseases (medical standards and medications) are oriented toward patients of young and mature age and are not oriented toward the elderly and long-term residents. Nevertheless, when treating the elderly, physicians are forced to use the same medical standards and medications as when treating the young and mature, because other medical standards and medications have not yet been developed.

Doctors know that diseases occur differently in older adults than in those who are young and mature, so doctors are prepared to make adjustments to their treatment, which should be the greater, the older the patient's age over 65. Physicians also know that traditional medical standards and medications are intended for use by patients of average age (18–65), average weight (weighing about 70 pounds), average gender, and average health (having sufficient reserves to recover independently from illnesses that occur by chance). This is the object recognized as the average patient today. Therefore, when treating an elderly patient, the doctor compares the anatomico-physiological features of his or her body condition with the corresponding parameters of the virtual (average) patient. If there is no significant difference, the doctor uses the medical standard without adjusting it, and if there is a significant difference, the doctor makes appropriate adjustments to the medical standard using special knowledge, the status of "treating physician," and the patient's legal right to informed consent.

However, not all physicians and not all cases manage to solve geriatric problems equally independently. The greatest difficulties in treating elderly patients arise for neurologists in the treatment of hypertension and stroke. It turns out that not only do neurologists lack appropriate geriatric medical standards and medications, but they also lack precise instructions on how to turn existing medical standards and medications into "geriatric" ones, especially when long-term rehabilitation of patients after a stroke is necessary.

Stroke is one of the most difficult diseases to treat in elderly patients. The fact is that in elderly patients, stroke and its consequences are often a consequence not only of hypertension, but also of such comorbidities as thromboembolic disease, coronary heart disease, diabetes mellitus, chronic pneumonia, liver, kidney, as well as neurosurgical intervention and course pharmacotherapy with oral anticoagulants. It has been shown that in stroke patients, the recovery of the lost functions of the nervous system can be accelerated by rehabilitation based on the training (coaching) of patients. For this purpose, special "speech therapy" rehabilitation measures were developed, including medication support, therapeutic gymnastics, massage, speech therapy classes, neuropsychological correction, and psychotherapeutic assistance. At the same time, medication support for the above rehabilitation measures in geriatric neurology was reduced to the common course pharmacotherapy not only for hypertension, but also for other comorbidities. As a result, the recommended drug support turned out to be

#### *Perspective Chapter: Clinical Standard of a Geriatric Patient as a Virtual Target for Correction… DOI: http://dx.doi.org/10.5772/intechopen.110671*

essentially a combined pharmacotherapy of several diseases simultaneously. Moreover, today, this pharmacotherapy can be implemented in patients of all age groups only using the most common drugs, since there are no specially developed "geriatric" drugs.

It turned out that according to the established practice, neurologists are obliged to treat patients of young, mature, and elderly age according to a single medical standard, which relies exclusively on a diagnosis made without regard to the patient's age, and provides treatment of diseases through the use of traditional medications only. Because aging reduces the body's reactivity, resistance to disease, sensitivity to drugs, and ability to inactivate the drugs administered, when treating hypertension and/or stroke in the elderly, the physician in these circumstances is unwittingly in the role of an experimenter. The fact is that in these conditions, it is the neurologist who is forced to independently combine different medications and evaluate their effectiveness, because ready-made combined geriatric medications for the elderly and long-term patients have not yet been developed. The complexity of such a clinical trial is due to the fact that the combination of drugs may include 7–14 drugs from different pharmacological groups, and the combined pharmacotherapy lasts for many weeks and months in a row. In this case, the doctor is afraid not so much of the lack of therapeutic effect of the drugs prescribed by them, as of the damage caused by the drugs, since the combination of drugs is injected into a rather "worn out" organism.

So the lack of medical standards for averaged patients of appropriate age groups (65–70, 70–90, and over 90 years), special appropriate "geriatric" drugs and regimens for course pharmacotherapy of hypertension, stroke, and medical support for rehabilitation of elderly patients after a stroke hinders progress in geriatric neurology, pharmacology and pharmacy.

Can we today complement the only available virtual average patient's etalon reflecting the anatomical-functional state of a young and mature person with virtual patient's etalons reflecting the features of the anatomical-functional state of an average elderly person of the following age groups: 65–70, 70–90, and over 90 years old? Yes, of course, we can, because we have enough information about how the anatomico–functional state distinguishes the elderly from the young and the mature.

What would the development of such a clinical standard for the geriatric patient give us? Recognition of such a standard will ensure the development of a "geriatric" medical standard for diagnosis and treatment of diseases in older adults, "geriatric" medications, and "geriatric" regimens for combination pharmacotherapy of the most likely underlying and comorbidities (hypertension, stroke, diabetes mellitus, thromboembolic disease, coronary heart disease, atherosclerosis, chronic inflammation of the respiratory system, digestion, urinary tract, skin and external mucous membranes, arthrosis and arthritis, malignant neoplasms, etc.), which occur under conditions of reduced reactivity of the body, its resistance to disease, sensitivity to drugs, and the ability to inactivate the injected drugs. That is why the development of a clinical standard for the elderly patient aims at improving the diagnosis of diseases, increasing the efficiency and safety of treatment of the main group of modern patients, and reducing healthcare costs. In addition, it is hoped that the use of such virtual averaged elderly patients will optimize the adjustment of treatment of hypertension and stroke in the elderly, reducing drug complications and polypragmasy.

#### **Conflict of interest**

The author declares no conflict of interest.

*Stroke – Management Pearls*

## **Author details**

Aleksandr Urakov1 \*, Aleksandr Samorodov2 and Varvara Sokolova1

1 Izhevsk State Medical University, Izhevsk, Russia

2 Bashkir State Medical University, Ufa, Russia

\*Address all correspondence to: urakoval@live.ru

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Clinical Standard of a Geriatric Patient as a Virtual Target for Correction… DOI: http://dx.doi.org/10.5772/intechopen.110671*

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## **Chapter 3**
