Skip to main content

Any Symptom in an Older Adult is a Medication Side Effect Until Proven Otherwise

Mike Steinman recently published a paper in JAMA about sensible medication managment in older adults.  I've had the opportunity to see him speak about this issue on a couple of occassions.  I wanted to share a few take home "GeriPal" pearls, leading with the title of the post:
  • Any symptom in an older adult is a medication side effect until proven otherwise
  • Review medication lists and sort by indication.  Most older adults are on at least one unnecessary medication, or one where the harms outweigh the benifits in light of the patient's goals, social and clinical circumstances, and life expectancy.
  • If you taper it up, taper it down
  • When starting a medication, start low, and go slow
  • Warfarin, hypoglycemic agents, and digoxin account for one-third of all adverse drug event related emergency department visits by older adults.  Doesn't mean don't prescribe them, just prescribe thoughtfully and monitor for adverse side effects.
  • Most adverse drug events are due to a failure of monitoring, not prescribing innapropriate medications
by: Alex Smith

Comments

Pratima said…
Great post, Alex! Thanks so much for the article as well! Have been researching this issue for my comprehensive paper (interventions to reduce polypharmacy in older adults -- lit. review) and found this very useful. I believe this is such an important issue, and needs a lot more research than has been done so far, although the answers seem pretty simple, obvious and easy to do!

Thank you!

Pratima
October 27, 2010 at 10:53 AM
Kate said…
Hi ALex, wonderful post -
I do want to also share something that I've been struggling with as I teach on the inpatient wards and in the clinic - there is also a pervasive syndrome of undertreatment - as in, "I can't give them an anti-depressant, they're OLD" -- or "We shouldn't, start warfaring, because they're OLD and they MIGHT FALL". So, although I absolutely agree that caution is needed, we may need to remind our learners that caution doesn't mean absolute avoidance...
Great post!
Kate.
November 1, 2010 at 9:02 AM
Helen Chen said…
Thanks, Alex! Just wanted to add an important clause to the "start low and go slow" aphorism. I can't remember who said this, but while it is essential to start low and go slow, it's also important to GO. As Kate mentioned many MDs are relucant to start meds for elders and many others never get to effective therapeutic levels because they are afraid to dose escalate. It's always bad to induce an ADE, but I think it's really sad when and ADE occurs in relation to an underprescribed medication that never had a chance to be effective for the original indication.
November 4, 2010 at 10:10 AM
Alex Smith said…
Pratima, Kate, and Helen, appreciate the comments and feedback. I like the revised pearl:
-start low and go slow, but GO! Advanced age does not mean "do not treat."
November 4, 2010 at 10:37 AM
Lindy said…
Terrific post, and so true. I would echo the previous comments--we use the saying "Start low, go slow, but GET SOMEWHERE." So often our older adults are started on a low dose of medication, but then that is never titrated to a therapeutic dose.

Thank you!
Lindy Swain, PharmD
www.pharmacyadvocates.com
November 9, 2010 at 9:24 PM
adult day care centers said…
With the increasing demand and interest for community care alternatives, senior day care centers are becoming the top choice of care. This institution doesn't only cure, they can also provide the elders with essential healthcare and social support that they need.
March 1, 2011 at 2:05 AM
Post a Comment

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …
7 comments
Read more

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…
5 comments
Read more

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …
9 comments
Read more