Drug Aging
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It is likely that the trend towards ever more aggressive surgery in elderly and possibly frail patients will continue, with the lifting of traditional age limits. Recent evidence has show that surgical trauma induces processes of nervous system sensitisation that contributes to and enhances postoperative pain and leads to chronic pain. This knowledge provides a rational basis for pro-active, pre-operative and post-operative analgesic strategies which can reduce the neuronal barrage associated with tissue damage. ⋯ Complete pain control cannot be achieved with a single agent or technique without significant serious adverse effects, a problem which is compounded in the elderly patient due to a combination of slower drug metabolism, decreased organ function and physiological changes in cardiovascular and respiratory reserves. A balanced analgesic regimen that includes an effective afferent block (regional analgesia) is more appropriate. By preventing postoperative pain and its associated neuroendocrine sequelae, major surgical procedures in traditionally unsuitable patients can be seriously considered.
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Phantom limb and stump pain is a common sequela of amputation. In geriatric patients with an amputated limb and multiple other illnesses, drug therapy may be problematic and invasive techniques may be risky. Interactions between pathophysiological mechanisms in the peripheral and central nervous systems may be responsible for the initiation and maintenance of chronic phantom limb and stump pain. ⋯ Pharmacological treatment should be combined with transcutaneous electrical nerve stimulation, sympathetic blockade and psychotherapy. In addition, new therapeutic strategies are now being tested; examples include capsaicin, new anticonvulsants and N-methyl-D-aspartate antagonists. Patients with severe pain should be referred to a pain specialist to ensure optimal and timely interventional pain management.
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Midodrine is a prodrug which undergoes enzymatic hydrolysis to the selective alpha 1-adrenoceptor agonist desglymidodrine after oral administration. Oral midodrine significantly increases 1-minute standing systolic blood pressure compared with placebo. The drug also improves standing time and energy level and clinical symptoms of orthostatic hypotension including dizziness, light-headedness and syncope. ⋯ The risk of supine hypertension, which is associated with midodrine therapy in up to 25% of patients, can be reduced by taking the final daily dose at least 4 hours before bedtime. Thus, oral midodrine is an effective therapeutic option for the management of various forms of orthostatic hypotension. This well-tolerated agent is likely to be useful in conjunction with standard nonpharmacological care.
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Review Comparative Study
Diagnosis and treatment of psychotic symptoms in elderly patients.
The diagnosis and treatment of psychotic symptoms in elderly patients requires more than extrapolation from studies of similar symptoms in the adult population. In comparison with early-onset psychosis, late-onset psychosis is characterised by differences in both its risk factors and typical signs and symptoms. Diagnosis may include psychotic disorders, mood disorders, delusional disorder, dementia or delirium. ⋯ In addition, the newer atypical antipsychotics such as clozapine have shown early promise. It is important to consider the higher incidence of adverse effects and tardive dyskinesia in the elderly when choosing a drug and its dosage. Consideration of psychosocial factors completes the appropriate management of psychotic symptoms in older patients.
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Herpes zoster is a common disease primarily affecting the elderly. Although some individuals experience no symptoms beyond the duration of the acute infection, many develop chronic pain [postherpetic neuralgia (PHN)], which is the commonest complication of herpes zoster infection and remains notoriously difficult to treat once established. It may persist until death and has major implications for quality of life and use of healthcare resources. ⋯ In the future, vaccines may have an important place in reducing the incidence of chickenpox in the population or, through the vaccination of middle-aged individuals, in boosting immunity to varicella zoster virus, thus preventing or modifying the replication of the virus from its latent phase that results in herpes zoster. Developments in the understanding of the pathophysiology of PHN indicate possible directions for improved drug management of established PHN, although no evidence yet exists for efficacy of the drugs concerned. Such agents include new generation anticonvulsants and N-methyl-D-aspartate antagonists.