Drug Aging
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Review Comparative Study
Postoperative patient-controlled analgesia in the elderly: risks and benefits of epidural versus intravenous administration.
Postoperative patient-controlled analgesia provided by the intravenous route using morphine (PCA) or by the epidural route using an opioid in combination with a local anaesthetic (patient-controlled epidural analgesia; PCEA) is not yet routinely used in the elderly. However, this modality theoretically provides adequate control of postoperative pain in such patients. Firstly, an assessment of the level of pain is particularly difficult in the elderly, and patient-controlled techniques that enable the self-administration of analgesic could resolve this problem. ⋯ PCA and PCEA are particularly useful for elderly patients undergoing major thoraco-abdominal surgery. However, there is a need for further research in elderly patients. In the future, improvements in the management of postoperative pain in the elderly will lead to a greater expansion of self-controlled techniques.
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The physiological changes that occur with increasing age can have significant effects on the pharmacokinetics of neuromuscular-blocking drugs. Changes in cardiac output can affect drug distribution and therefore the speed of onset of neuromuscular block. A decrease in muscle mass and increase in body fat with age can also affect their distribution. ⋯ Onset of block with these two drugs may be prolonged in the elderly, but their clinical duration of action does not alter significantly with age, making them particularly suitable for use in this patient group. Although atracurium besilate may cause histamine release, there is little evidence of it producing haemodynamic changes in the elderly. Its (1R,1R')-isomer, cisatracurium besilate, has very little direct or indirect cardiovascular effect and is, therefore, the most suitable nondepolarising agent to use in elderly patients.
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Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is the most common of the prostatitis syndromes. It is characterised by pelvic pain, with or without voiding symptoms. CP/CPPS accounts for 2 million office visits in the US alone. ⋯ The adverse effects of these medications are a concern in older men with CP/CPPS. Other therapies available include minimally invasive procedures such as microwave thermotherapy and transurethral needle ablation, and now neuromodulation devices. Although much progress has been made, particularly in the last 7 years, considerable work still remains to be done to determine the aetiology and pathogenesis of CP/CPPS, and to develop mechanism based therapy that is shown to be effective in controlled trials.
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Chronic obstructive pulmonary disease (COPD) is a common disability, largely encountered in the elderly population, in whom it causes significant morbidity and mortality. The general perception of health professionals is that COPD is often a self-inflicted disorder affecting the more socio-economically disadvantaged segment of the population with significant comorbidity. COPD is the least funded in terms of research in relation to illness burden compared with other chronic diseases. ⋯ Therefore, pulmonary function including spirometry should be used to make the diagnosis of COPD but not as a monitor of efficacy of treatment. Assessment of severity of COPD and improvement with treatment modalities is best done with dynamic exercise testing such as 6-minute walk tests and incremental shuttle walk tests or with the administration of disease-specific physical disability and quality-of-life questionnaires. Most COPD research does not specifically target the older COPD patients and these patients may merit special consideration for their optimum assessment and management.
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Persons over the age of 65 years are the fastest growing segment of the US population. In the next 30 years this segment will represent more than 20% of the population. Fifty percent of all cancers occur in this age group and therefore the total cancer burden is expected to rise. ⋯ In this article specific diseases are discussed (breast, colon, ovarian and non-small lung cancers) with recommendations for drug selection in adjuvant chemotherapy and the treatment of metastatic disease. Future studies will need to incorporate these various factors to properly evaluate chemotherapy in older patients. Research and educational initiatives targeted to this population will need to be a priority.