Drug Aging
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Aspiration of the oropharyngeal or gastric contents by elderly persons often leads to lower respiratory tract infections, such as aspiration pneumonia or pneumonitis. The existence of dysphagia and aspiration in elderly patients are important factors in the occurrence of aspiration pneumonia, but are not sufficient to cause aspiration pneumonia in the absence of other risk factors. Salivary flow and swallowing can eliminate Gram-negative bacilli from the oropharynx in healthy persons. ⋯ Therefore, dysphagia and a decreased cough reflex may be induced by the impairment of dopamine metabolism in some elderly patients with cerebrovascular disease, suggesting that pharmaceutical agents which modulate dopamine metabolism may be able to improve swallowing and the cough reflex in patients with basal ganglia infarction. The main strategy for controlling aspiration and aspiration-related pulmonary infection in the elderly is to prevent aspiration of pathogenic bacteria along with the oropharyngeal or gastric contents. Because aspiration pneumonia in the elderly is related to certain risk factors, including dysphagia and aspiration, effective preventive measures involve various approaches, such as pharmacological therapy, swallowing training, dietary management, oral hygiene and positioning.
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With age our ability to maintain haemodynamic homeostasis during position changes becomes less effective. This predisposes elderly patients to significant changes in blood pressure upon standing and orthostatic hypotension (OH). The prevalence of OH varies according to the population being studied. ⋯ A detailed patient history, an accurate orthostatic blood pressure measurement and careful evaluation of the autonomic nervous system can provide clinical guidance for management of OH. In hypertensive individuals with no pre-treatment OH, the use of antihypertensive medication can be safe and lead to a low risk of developing OH. In individuals with pre-treatment OH or who develop OH while on antihypertensive medications avoidance of the classes that may exacerbate OH and a judicious use of antihypertensive classes that may improve PBP changes may be safe and adequate treatment.
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Xerostomia is a common symptom in the elderly population. Studies have suggested that the underlying cause of approximately 40% of xerostomia in the elderly is Sjögren's syndrome. Although it is highly prevalent among middle-aged individuals, elderly patients account for up to 20% of Sjögren's syndrome cases. ⋯ The diagnosis of Sjögren's syndrome requires evaluation of both the exocrine and nonexocrine components of the disease. Management of Sjögren's syndrome requires collaboration by the primary-care physician, rheumatologist, ophthalmologist and dentist. This article reviews current understanding of the clinical manifestations, diagnosis and treatment of Sjögren's syndrome with special emphasis on the oral component of the disease.
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Asthma is under-recognised and undertreated in older populations. This is not surprising, given that one-third of older people experience significant breathlessness. The differential diagnosis commonly includes asthma, chronic obstructive pulmonary disease (COPD), heart failure, malignancy, aspiration and infections. ⋯ There is no evidence that addition of anticholinergics improves control of asthma further, although the role of long-acting anticholinergics in the prevention of disease progression is currently being researched. Older patients need to be taught good inhaler technique to improve delivery of medications to lungs, minimise adverse effects and reduce the need for oral corticosteroids. Nurse-led education programmes that include a written asthma self-management plan have the potential to improve outcomes.
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Some degree of hypothyroidism is common in the elderly. It affects 5-20% of women and 3-8% of men. The occurrence varies with genetics with a high prevalence in Caucasians, and the disease is more common in populations with a high iodine intake. ⋯ Patients with subclinical hypothyroidism should be informed about the disease and offered the possibility of replacement. Only some patients treated for subclinical hypothyroidism will feel better after therapy. In elderly patients on replacement therapy, care should include estimation of serum TSH level once or twice a year, with small dosage adjustments of levothyroxine sodium to keep serum TSH level within the normal range.