Multiple medication: problems of the elderly patient

Elderly persons are apt to receive multiple drugs for many diseases. Prescribers should take extra care in persons aged over 65-70 years, and especially the very old. The main problem of the elderly is the unpredictability of their response to drugs. Self-medication with both prescribed and over-the-counter drugs worsens this problem. Drug actions may be altered by impairment of the liver, kidneys and brain, or acute illness, or both. Unwanted (adverse) drug reactions often produce rapid and unduly severe illness in the old. Some antibacterial antibiotics like the sulphonamides are best avoided. Taking many drugs together promotes adverse interactions between the drugs. Drugs with a narrow therapeutic ratio, such as warfarin, digoxin, the aminoglycosides, and many antiarrhythmic drugs, cause clinical problems. Old persons respond more abruptly to drugs like benzodiazepines, opioid analgesics, and antiparkinsonian drugs. Anaesthesia given on top of psychotropic drugs may damage the central nervous system. The elderly brain is more sensitive to induction agents and short-acting intravenous anaesthetics, like alfentanil and midazolam; the elderly liver is more easily damaged by inhalational anaesthetics like halothane. The overall benefit:risk ratio should be judged for every drug in each patient. Wherever possible, drug treatment should be avoided. If drugs are given, safe drugs with broad therapeutic ratios and tissue- or receptor-specific actions are preferable. Drug doses are usually, but not always, reduced. Benefit from a drug should be assessed early. Severe unpredictable adverse reactions need immediate cessation of the drug and prompt patient support. The practitioner should frequently review the patient's continuing need for drugs.