**8. Polypharmacy in the elderly**

Polypharmacy is a common problem in the elderly. Particularly in those who have multiple comorbidities. Their therapy should be guided by the estimated life expectancy and

Pulmonary Embolism in the Elderly – Significance and Particularities 49

required also by the elderly and their usage grows also in internal medicine, geriatrics and other non-psychiatric medical branches. One third of the undesired drug effect is

These undesired effects are often wrongly diagnosed which leads to prescription and administration of further drugs – it is a so called prescriptive cascade. Correct medication (both with prescription drugs and commercially available medicaments) is based on the right indication appropriate dosage and forms adapted to intellectual potential and somatic skills of a patient, elimination of predictable undesired effects and drug interactions and minimisation of their impacts on patient, consideration of optimum period of drug administration and consistent monitoring of permanent administration connected with continuous evaluation of compliance (Katzung, 2003). Non-compliance occurs in 25 – 50 per

• Which drug is the most convenient one regarding multi-morbidity and predictable drug

Multiple pathology, or concurrence of diseases, is common among older persons. An early Scottish study of community-dwelling persons over age 65 reported 3.5 major problems per person; for those being admitted to hospitals, 6 disorders were documented per patient. Multiple pathology (Crome & Lally, 2011) poses multiple risks to older patients and their physicians. The first hazard is that active medical problems frequently interact to the

Late detection of treatable problems whose neglecting and interaction have led to functional decline is common in older patients and can be one of the few discouraging features of geriatric care. Preventive dental and medical care could have avoided the sepsis, worsening of diabetes, fall, hip fracture, postoperative heart attack, stroke, and loss of independent

The interaction between old age and illness causes specific changes of diseases in senium

• Multi-morbidity – parallel occurrence of more illnesses in one person with or without

• Mutual causality of social and health situation – each of the changes of the health state

3. distant signs – to the forefront of clinical picture there are symptoms, which belong to the difficulties of other organ than the basic one ( "the innocent organ complains, not

4. tendency to chronicity – even in the diseases which are in younger and middle age

1. microsymptomathology – minimal symptoms of diseases (the iceberg phenomenon) 2. mono- or oligosyptomatology – sporadic symptoms from those, which occur usually in

• Among the specialities of clinical picture of illnesses in old age we can list:

predictable and mere reduction of a dosage can eliminate two thirds of them.

cent of older patients taking drugs regularly. When prescribing a drug the physician should ask:

• Is a drug indication definite and undoubtful?

detriment of the patient -*disease-disease interactions*.

(Beers et al., 2006; Pathy et al., 2006; Ratnaike, 2002).

in old age influences their social status and vice versa

acute, moreover in old age there is higher risk of death

Particularities of illness in old age include:

causality relationship

middle or young age

the sick one")

**10. Multimorbidity in old age and its relations** 

interactions?

living.

• What is the optimum dosage?

the patients' values and goals. Interventions that are likely to help the elderly, who are well, may differ from those that will benefit the ones who are frail. Estimating life expectancy can help a health care provider to focus on those issues to be most likely beneficial in the given patient.

There are several reasons for the greater incidence of iatrogenic drug reactions in the elderly population, the most important of which is the high number of medications that are taken by the elderly, especially those with multiple comorbidities (Blackburn & Dulmus, 2007; Duthie et al., 2007). Older individuals often have varying responses to a given serum drug level. Thus, they are more sensitive to some drugs (eg. opioids) and less sensitive to others (eg. beta-blockers).

Following aspects should be considered in the old-age pharmacotherapy (Katzung, 2003):


Multi-morbidity of advanced age often leads a physician in clinical practice to **polypharmacotherapy** (Nikolaus, 2000; Soriano et al., 2007), which is many times inevitable but still is sometimes hazardous because with increasing age an occurrence of undesired drug effects grows. The elderly are generally more vulnerable and the therapeutic range gets narrower. Compliance decreases inter-individual variability of an effect increases the same way as the risk of drug interactions. Basic requirement for phamacotherapy in advanced age is that it should be simple, purposeful and effective. Polypharmacy can be often risky and ineffective, many times it can be even damaging – **iatrogenia** as a syndrome. In geriatric medicine generally symptomatic treatment overweights the causal one. Its undesired effects can substantially alter the clinical picture of diseases.

The consumption of drugs in the elderly treated within the institutional care is three times higher when compared to the same number of individuals from general population and female patients need twice as many drugs as the male ones.

Distribution of drugs depends on the body composition as mentioned, bonds to plasmatic proteins and blood flow trough tissues. Poorly nourished or frail elderly persons may have a low serum albumin. A cardiac output in advanced age decreases, peripheral vessel resistance grows, liver gets smaller and blood flow trough liver and kidneys decreases. Bigger part of the cardiac output in comparison to the younger ones flows through the brains, heart and skeleton muscles. This also plays a role in the drug distribution.

#### **9. Problems and complications of polypharmacy**

Occurrence of **undesired drug effects** is generally 3 – 5 times higher in advanced age when compared to preceding age categories (Beers et al. , 2006). Higher consumption of drugs brings along higher risks (including deep venose thrombosis - DVT and PE). Side effects occur in 2 per cent of the elderly using less than 3 drugs at a time during a year. This percentage grows up to 17 in those who use 10 drugs. Combination of more drugs is preferred recently more and more frequently to mono-therapy. Except for expected and beneficial effect of synergism it can bring also adverse side effects. Number of new drugs especially in psychiatry and neurology grows dramatically during last decades. The most frequently prescribed drugs today are anxiolytics and antidepressants. They are often required also by the elderly and their usage grows also in internal medicine, geriatrics and other non-psychiatric medical branches. One third of the undesired drug effect is predictable and mere reduction of a dosage can eliminate two thirds of them.

These undesired effects are often wrongly diagnosed which leads to prescription and administration of further drugs – it is a so called prescriptive cascade. Correct medication (both with prescription drugs and commercially available medicaments) is based on the right indication appropriate dosage and forms adapted to intellectual potential and somatic skills of a patient, elimination of predictable undesired effects and drug interactions and minimisation of their impacts on patient, consideration of optimum period of drug administration and consistent monitoring of permanent administration connected with continuous evaluation of compliance (Katzung, 2003). Non-compliance occurs in 25 – 50 per cent of older patients taking drugs regularly.

When prescribing a drug the physician should ask:


48 Pulmonary Embolism

the patients' values and goals. Interventions that are likely to help the elderly, who are well, may differ from those that will benefit the ones who are frail. Estimating life expectancy can help a health care provider to focus on those issues to be most likely

There are several reasons for the greater incidence of iatrogenic drug reactions in the elderly population, the most important of which is the high number of medications that are taken by the elderly, especially those with multiple comorbidities (Blackburn & Dulmus, 2007; Duthie et al., 2007). Older individuals often have varying responses to a given serum drug level. Thus, they are more sensitive to some drugs (eg. opioids) and less sensitive to others

Following aspects should be considered in the old-age pharmacotherapy (Katzung, 2003): 1. Responses to drugs are different from preceeding age categories which is a consequence

Multi-morbidity of advanced age often leads a physician in clinical practice to **polypharmacotherapy** (Nikolaus, 2000; Soriano et al., 2007), which is many times inevitable but still is sometimes hazardous because with increasing age an occurrence of undesired drug effects grows. The elderly are generally more vulnerable and the therapeutic range gets narrower. Compliance decreases inter-individual variability of an effect increases the same way as the risk of drug interactions. Basic requirement for phamacotherapy in advanced age is that it should be simple, purposeful and effective. Polypharmacy can be often risky and ineffective, many times it can be even damaging – **iatrogenia** as a syndrome. In geriatric medicine generally symptomatic treatment overweights the causal one. Its

The consumption of drugs in the elderly treated within the institutional care is three times higher when compared to the same number of individuals from general population and

Distribution of drugs depends on the body composition as mentioned, bonds to plasmatic proteins and blood flow trough tissues. Poorly nourished or frail elderly persons may have a low serum albumin. A cardiac output in advanced age decreases, peripheral vessel resistance grows, liver gets smaller and blood flow trough liver and kidneys decreases. Bigger part of the cardiac output in comparison to the younger ones flows through the

Occurrence of **undesired drug effects** is generally 3 – 5 times higher in advanced age when compared to preceding age categories (Beers et al. , 2006). Higher consumption of drugs brings along higher risks (including deep venose thrombosis - DVT and PE). Side effects occur in 2 per cent of the elderly using less than 3 drugs at a time during a year. This percentage grows up to 17 in those who use 10 drugs. Combination of more drugs is preferred recently more and more frequently to mono-therapy. Except for expected and beneficial effect of synergism it can bring also adverse side effects. Number of new drugs especially in psychiatry and neurology grows dramatically during last decades. The most frequently prescribed drugs today are anxiolytics and antidepressants. They are often

brains, heart and skeleton muscles. This also plays a role in the drug distribution.

of changed pharmaco-dynamics and pharmaco-kinetics. 2. Increased occurrence of undesired effects of drugs in general

undesired effects can substantially alter the clinical picture of diseases.

female patients need twice as many drugs as the male ones.

**9. Problems and complications of polypharmacy**

3. Increased non-compliance in the elderly 4. Increased occurrence of drug interactions

beneficial in the given patient.

(eg. beta-blockers).

• Is a drug indication definite and undoubtful?
