Drug Aging
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The present review focuses on subarachnoid haemorrhage (SAH) secondary to the rupture of an intracranial aneurysm, a condition with a high case fatality rate. Additionally, many of the surviving patients are left with significant disabilities. Risk factors for aneurysmal SAH include both genetic and acquired conditions. ⋯ Unlike other acute neurological disorders such as brain injury, in which patient outcome is closely related to the extent of the injury occurring at the time of the trauma, patients with aneurysmal SAH are at risk of subsequent deterioration from 'avoidable' complications such as rebleed, vasospasm, hydrocephalus, and several other non-neurological general medical complications. Thus, the critical care management of the patient with SAH is of utmost importance in order to maximise the chances of satisfactory recovery. Although surgical clipping of the ruptured aneurysm remains the gold standard therapy, with the continuing refinement of endovascular techniques, a new, 'less invasive' option is now available, especially for patients considered poor surgical candidates.
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The incidence of community-acquired pneumonia (CAP), an infectious disease, sharply increases among the elderly and the main risk factor for CAP in this age group is chronic comorbidity. The use of the term CAP in the elderly population should be reserved for pneumonia acquired outside of the nursing home setting, since nursing home-acquired pneumonia differs from CAP in terms of its aetiology and clinical manifestations. The main aetiology for CAP is Streptococcus pneumoniae, but atypical pathogens also play an important role as causative agents. ⋯ In addition to antibiotic therapy, it is critically important to identify and treat the physiological disturbances that accompany CAP as well as decompensation of chronic comorbid conditions. As soon as the patient's condition permits, oral antibiotic therapy should replace intravenous therapy and early discharge from the hospital should be considered. Since influenza and pneumococcus immunisation can reduce morbidity and mortality from CAP, it is important to implement regular immunisation programmes in the primary care setting.
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Complete estrogen blockade has long been sought as a more effective means of controlling breast cancer compared with single agent endocrine therapy. This approach may be accomplished through the use of agents which reduce estrogen production combined with agents that prevent the activity of estrogen at the cellular level. For prostate cancer, another hormonally responsive malignancy, this approach has not been successful at improving survival compared with that achieved with single agent therapy. ⋯ Addition of LHRH agonist therapy in premenopausal patients with estrogen receptor-positive tumour who had maintained the ovarian function following chemotherapy [cyclophosphamide, doxorubicin (adriamycin), fluorouracil, and tamoxifen], also led to a reduction in the risk of recurrence. These studies have identified a sub-population of patients who may benefit from the addition of combination endocrine therapy. Overall, the issue is quite complex and the data from many ongoing trials are still awaited with anticipation to further delineate the role of complete estrogen deprivation in this disease.
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Long term prescription of diuretics for heart failure is very prevalent among elderly patients, although the rationale for such a treatment strategy is often unclear, as diuretics are not indicated if volume overload is absent. The concept of diastolic heart failure in the elderly might particularly change the role of diuretic therapy, since diuretics may have additional adverse effects in these patients. This paper reviews the effects of diuretic therapy in elderly patients with heart failure, emphasising the differences between patients with normal and decreased left ventricular systolic function. ⋯ Indeed, preliminary studies demonstrate that diuretics may provoke or aggravate hypotension on standing and after meals in these patients. Therefore, it is suggested that elderly patients with heart failure with intact left ventricular systolic function should not receive long term diuretic therapy, unless proven necessary to treat or prevent congestive heart failure. This implies that physicians should carefully evaluate the opportunities for diuretic dose tapering or withdrawal in all of these patients, and that a cautiously guided intermittent diuretic treatment modality may be critical in the care for older patients with heart failure with intact left ventricular systolic function.
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Elderly people are more likely than younger patients to develop cognitive impairment as a result of taking medications. This reflects age- and disease-associated changes in brain neurochemistry and drug handling. Delirium (acute confusional state) is the cognitive disturbance most clearly associated with drug toxicity, but dementia has also been reported. ⋯ Drug-induced confusion can be prevented by avoiding polypharmacy and adhering to the saying 'start low and go slow'. Special care is needed when prescribing for people with cognitive impairment. Early diagnosis of drug-induced confusion, and withdrawal of the offending agent or agents is essential.