In addition to the well-known complications associated with systemic

corticosteroid use (see Chapter 44, Rheumatoid Arthritis), these agents can acutely

cause confusion, agitation, and hyperglycemia.

J.C. is currently maintained on low doses of an inhaled corticosteroid (fluticasone)

in combination with a short-acting β2

-agonist (albuterol), and this is an appropriate

regimen for a patient with mild-persistent asthma. Following resolution of her viral

infection, J.C.’s asthma control should be re-evaluated within the next 3 months for a

step-up or down in therapy. Because J.C. is postmenopausal, she is at risk for

osteoporosis; calcium and vitamin D supplementation should be initiated (see

Chapter 110, Osteoporosis).

Appropriate use of MDIs is difficult for most patients, but may be particularly

problematic in the elderly population because of decreased hand strength or arthritis,

difficulty timing actuation to inhalation, or impaired mental function. The use of

spacer or holding chamber devices can minimize the coordination necessary for

proper use of an MDI and may reduce the incidence of systemic and local (cough,

hoarseness, thrush) side effects associated with inhaled corticosteroids. J.C. should

be discharged with a spacer device to use with her albuterol and fluticasone MDIs.

Even though J.C. previously used an MDI, she should be asked to demonstrate her

MDI technique and reinstructed, if necessary, to ensure she is using the inhaler and

spacer correctly. If J.C. is unable to correctly use her MDIs with a spacer, use of

nebulized solutions, breath-activated inhalers, or dry-powdered delivery devices

should be considered.

Infectious Diseases in the Elderly

Infections are among the most common problems in the elderly and are a significant

cause of morbidity and mortality. Infections are also one of the most frequent reasons

for hospitalization of older ambulatory persons.

90 Antibiotic therapy for an infection

in the elderly may be delayed because they may present with atypical signs and

symptoms. The older population is also more likely to have polymicrobial infections

than younger people, and changes in renal function should be taken into account when

selecting, dosing, and monitoring antibiotic therapy.

PNEUMONIA

CASE 107-5, QUESTION 3: J.C. was admitted to the hospital and given intravenous methylprednisolone for

4 days. She was then discharged home with a new prescription for prednisone 40 mg daily for 7 days. Three

days after J.C. is discharged from the hospital, she presents again to the ED. This time, she is accompanied by

a neighbor who noted that J.C. suddenly became forgetful and confused, and continues to have difficulty

breathing. Her neighbor reports that J.C. has been staying in bed for the past 2 days and has not eaten much.

J.C. has a low-grade fever, and chest examination reveals faint breath sounds with light crackling rales over her

right lung base. A chest radiograph confirms the diagnosis of pneumonia. How is J.C.’s clinical presentation

consistent with community-acquired pneumonia in the elderly?

Community-acquired pneumonia is one of the most prevalent causes of

hospitalization and death due to infection in adults in the United States.

91

In a large

population-based study of community-acquired pneumonia, adults aged 65 to 79

years were found to have an incidence of pneumonia requiring hospitalization that

was 9 times as high as those aged 18 to 49, and 25 times as high in those aged 85 and

older.

Risk factors for CAP in all adults include age greater than 65, COPD, smoking,

alcoholism, aspiration, and chronic medical conditions such as heart, renal, and liver

disease.

92,93 Streptococcus pneumoniae is the most common cause of CAP in the

elderly.

91

Respiratory symptoms and fever are often subtle or absent in older patients with

pneumonia

93

; instead, like J.C., they may present only with altered mental status

(delirium, acute confusion, memory problems) or a decline in functional status.

Delirium or acute confusion is a common presentation in elderly patients who may

have new-onset lower respiratory infection.

CASE 107-5, QUESTION 4: How should J.C. be treated for her respiratory infection?

In many cases, management of pneumonia in the elderly requires hospitalization

because they are at greater risk for mortality and complications. Early empiric

antibacterial therapy is particularly important for older patients with pneumonia (see

Chapter 67, Respiratory Tract Infections). J.C. should be hospitalized again and

treated aggressively for pneumonia with broad-spectrum IV antibiotics. The

Infectious Diseases Society of America/American Thoracic Society Consensus

Guidelines on the Management of Community-Acquired Pneumonia in Adults

recommends treatment of most hospitalized nonintensive care unit (ICU) patients with

a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) or β-lactam

plus macrolide, and for ICU patients the recommendation is for a β-lactam plus either

azithromycin or a respiratory fluroquinolone.

93

PREVENTION

CASE 107-5, QUESTION 5: After 7 days of hospitalization, J.C. is discharged home with an oral antibiotic

to finish the 14-day course of therapy. What preventative measures are available to J.C. after she is

discharged?

Once patients are stable and ready to be discharged home, they should be switched

to oral antibiotics to complete their therapy at home.

Both influenza and pneumococcal vaccinations are beneficial and recommended in

the prevention of community acquired-pneumonia.

93–95

The CDC now recommends pneumococcal conjugate vaccine (PCV13) for all

adults aged 65 and older who have not previously received it, followed by the

pneumococcal polysaccharide vaccine (PPSV23) 12 months later.

96

If the PPSV23

has already been received, the dose of PCV13 should be given at least 1 year after

(see Chapter 64, Vaccinations).

J.C.’s immunization status should be confirmed, and as a preventative measure,

J.C. should be offered both influenza and pneumococcal vaccines after she is

discharged from the hospital.

URINARY TRACT INFECTION

CASE 107-6

QUESTION 1: A.H. is a 72-year-old Hispanic woman who is currently wheelchair-bound because of pain in

her right hip. Her granddaughter brings A.H. to the geriatric clinic because she has recently developed urinary

incontinence. Her granddaughter reports that A.H. has been feeling weak for the past 2 days and fell while

getting out of the wheelchair. A urinalysis indicates the presence of a urinary tract infection (UTI).

Are A.H.’s symptoms typical of urinary tract infections?

Urinary tract infections are common in older patients, and clinical symptoms often

vary from patient to patient.

97,98

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p. 2228

Common signs and symptoms may include dysuria, hematuria, urinary frequency,

urinary incontinence, pyuria and fever.

98 Bacteriuria is estimated to be asymptomatic

in more than 15% of women over age 70 who live in the community, and even greater

in men and women who reside in long-term care.

99 Asymptomatic bacteriuria may not

always require antibiotic treatment.

97

Impaired voiding with residual urine in older

women and obstructive uropathy from prostatic disease in older men predispose them

to bacteriuria.

100 The severity of UTI in the older population ranges from mild cystitis

to life-threatening urosepsis; both are more difficult to treat because of resistant

organisms and age-related decreases in host defenses. The majority of UTIs in the

older population do not present typically; instead, there are often nonspecific

manifestations such as decline in functional status, cognitive impairment, weakness,

falls, and urinary incontinence.

101

A.H.’s presentation (weakness, urinary incontinence, and a recent fall) is

consistent with this pattern. As with most UTIs, those in the elderly are caused

primarily by Escherichia coli. However, other species of bacteria such as Klebsiella

species, Proteus species, and Enterococcus species are also frequently involved (see

Chapter 71, Urinary Tract Infections).

CASE 107-6, QUESTION 2: A.H. is prescribed a 7-day course of ciprofloxacin 250 mg PO twice daily. Is

this drug therapy appropriate?

Oral antibiotics, such as nitrofurantoin and sulfamethoxazole-trimethoprim, are

appropriate for most patients with symptomatic UTI, reserving fluoroquinolones as

alternatives.

102 An important consideration of antibiotic therapy for older adults with

UTI is impaired renal function.

103 Nitrofurantoin should not be used in those patients

with significantly impaired renal function due to the potential risk of peripheral

neuropathy and pulmonary toxicity.

Ciprofloxacin is a reasonable choice for A.H. because E. coli is the most likely

causative agent. Fluoroquinolones carry a black box warning due to an increased risk

of tendonitis and tendon rupture. Along with renal function, monitoring should

include symptoms of tendon inflammation or pain.

Osteoarthritis Pain

Arthritis is the leading cause of functional decline and morbidity in older patients,

with prevalence rates up to 30%.

104,105 This immobility may place older patients at

risk of confinement to their bed or home. Osteoarthritis, also called degenerative

joint disease, is the most common type of joint disease in the older population.

Nonpharmacologic management of osteoarthritis, such as physical and occupational

therapy, has been shown to decrease pain and improve function in patients with

osteoarthritis, both alone or in combination with appropriate analgesics.

106

CASE 107-7

QUESTION 1: C.W., a 71-year-old retired schoolteacher, has been suffering from osteoarthritis of his hands

for 5 years. He is an active older adult who enjoys volunteer work at the local hospital. He presents to the

geriatric clinic with increased arthritis pain, which is uncontrolled by his current pain medication. He also

complains of increased heartburn and gastric reflux symptoms. His past medical history is significant for

diabetes, hypertension, hypercholesterolemia, and GERD. C.W.’s current medications include glipizide 10 mg

daily, verapamil sustained-released 240 mg daily, atorvastatin 10 mg daily, famotidine 20 mg twice daily,

docusate sodium 100 mg twice daily, and ibuprofen 200 mg 4 times a day as needed. What modifications can be

made to his drug regimen to better control his arthritis pain and minimize side effects from his pain medication?

Acetaminophen is the drug of choice for mild-to-moderate arthritis pain (see

Chapter 43, Osteoarthritis). Though pain control may be inferior to NSAIDs, its

reduced gastrointestinal and renal toxicity provides an advantage in older patients

who may be more susceptible to the adverse effects of NSAIDs.

104 Doses greater than

3,000 mg per day should be avoided in the elderly and more conservative dosing

utilized for those with a history of alcohol abuse or hepatic impairment.

104,107

If C.W.

has not tried acetaminophen in the past for his arthritis pain, acetaminophen 1,000 mg

3 times a day should be initiated. Older patients with osteoarthritis pain often find

relief from NSAIDs, which should be used with caution because of their potential GI

complications, renal toxicity, and cardiovascular risks. Though not as common as GI

toxicity, advanced age is a major risk factor for NSAID-associated renal toxicity,

such as sodium and water retention as well as risk for hypertension.

108 Thus,

ibuprofen may be contributing to C.W.’s increased GERD symptoms and to his

hypertension. Nonacetylated salicylates, such as salsalate, can be used if

acetaminophen does not provide adequate pain relief. Compared with NSAIDs,

nonacetylated salicylates have less renal and GI toxicity, but cardiovascular risks are

unknown. The currently available selective COX-2 inhibitor celecoxib is less likely

to cause GI complications than nonselective agents; however, the risk of adverse

renal and cardiovascular events persists.

108 A COX-2 inhibitor or the addition of a

more potent gastroprotective agent such as a proton-pump inhibitor to ibuprofen is

the option for C.W., who may experience reduced GI symptoms with equally

effective pain relief. The topical analgesics often require multiple daily applications,

assessment of skin integrity, and application technique.

104 The use of glucosamine and

chondroitin has been shown to decrease osteoarthritis pain and delay progression of

the disease in some studies; however, their place in therapy is controversial.

109

Glucosamine may increase insulin resistance in diabetic patients, and C.W. should be

counseled to monitor his blood glucose more closely if initiating this agent.

CASE 107-7, QUESTION 2: C.W. reveals that he has tried acetaminophen without much relief of his pain.

He is prescribed celecoxib and tries it for several months, but his pain continues and he is still experiencing GI

distress. What other pain medication options does C.W. have?

For moderate-to-severe chronic pain caused by osteoarthritis, a low-dose opiate

may provide relief from pain with minimal adverse drug effects (see Chapter 55,

Pain Management). Of particular concern in elderly patients are the risks of falls,

delirium, and constipation with opioid medication use. Codeine and tramadol are

“weak” opioids that have ceiling effects, generally do not provide adequate

analgesia, and may carry dangerous side effects in the elderly. Meperidine should

also be avoided in older adults because of its high potential for CNS side effects,

especially in those with reduced renal function. C.W. is a candidate for opioid

therapy. He should be started on the lowest dose of a short-acting formulation on a

scheduled regimen and counseled on the adverse drug reactions. Constipation may be

a particular problem because he is also taking verapamil, which can also cause

significant constipation. The elderly are also at increased risk for constipation as a

result of age-related reduced bowel motility. To prevent opioid-associated

constipation in C.W., prophylactic laxatives and stool softeners should be started at

the initiation of opioid therapy.

LONG-TERM CARE FACILITIES

The LTCF environment is governed in part by the Omnibus Budget Reconciliation

Act (OBRA), as well as by numerous other

5.

6.

7.

1.

2.

3.

4.

p. 2228

p. 2229

laws and regulations, which are contained in the federal Centers for Medicare and

Medicaid Services (CMS) publication, States Operations Manual (SOM).

110 The

federal mandates include monthly review of each resident’s medication regimen to

help ensure each resident’s regimen is free from unnecessary drugs and that their

medication regimen helps to support their mental, physical, and psychosocial wellbeing. Medication regimens are reviewed to determine the following:

Is each drug clearly indicated?

Have therapeutic goals been established for chronic drug therapies?

If indicated, is it being dosed and administered appropriately?

Are any real or potential problems with drug side effects or interactions present?

If antipsychotics are being prescribed, have nonpharmacologic approaches been

used first, has their use been justified, and is the therapy being monitored?

What specific recommendations can be made to optimize the resident’s drug

therapy?

Are the laboratory results and vital signs being monitored appropriately, and are

they available for adequate evaluation of therapy?

The findings of the medication regimen review, including medication

discrepancies, errors, and adverse drug reactions, must be documented and reported

to the patient’s physician who must respond to any recommendations in a timely

manner. The American Society of Consultant Pharmacists publishes detailed

information concerning standards of practice in the LTCF environment.

111

CASE 107-8

QUESTION 1: As a new consultant pharmacist to a 60-bed, skilled nursing facility, several multiple-drug-use

problems become apparent during initial chart reviews. A typical case is D.M., an 82-year-old man who has

resided there for the past month. D.M.’s past medical history is significant for hypertension, depression,

constipation, long-standing mild cognitive impairment that is now worsening, and dizziness. In the nurses’ notes,

it is documented that D.M. had a fall when getting out of bed last week.

At admission, D.M.’s weight was 165 pounds; BP 100/60 mm Hg; pulse 85 beats/minute; and temperature

98.6°F. Subsequent vital signs are not recorded systematically into his medical record. Sporadic documentation

in the nurses’ notes indicates little change from admission values. No laboratory information is available at this

time. D.M. has no known allergies.

Current medications include amlodipine 10 mg daily, diltiazem CD 240 mg daily, hydrochlorothiazide 25 mg

daily, quetiapine 300 mg daily, lorazepam 0.5 mg every 8 hours as needed for anxiety, docusate sodium 100 mg

twice daily, milk of magnesia 30 mL daily, temazepam 15 mg at bedtime, and acetaminophen one to two 325-mg

tablets every 4 to 6 hours as needed for pain. D.M. follows a 2-g sodium diet.

D.M. is ambulatory and takes his meals in the facility’s dining room. He is not in any acute distress, but the

nurses’ notes indicate that D.M. is often confused and complains of dizziness when ambulating. His weight has

decreased 4 pounds since being admitted. What should be expected of this LTCF with respect to medication

monitoring?

Under the CMS-mandated regulations, the establishment of goals of

antihypertensive therapy and monitoring for these goals are required. D.M.’s blood

pressure should be measured and documented in his medical record with a signature

and date on a regular basis. D.M.’s dizziness, a symptom of orthostatic hypotension,

may be caused by overtreatment of his hypertension as evidenced by his low

admission blood pressure. Orthostatic hypotension occurs in 10% to 30% of older

adults and is most common when patients first arise, indicating that this may have

been the cause of D.M.’s recent fall.

25 D.M. is being treated with two calciumchannel blockers. Discontinuation of one of them should reduce his dizziness and

help prevent future falls. Because D.M. is being treated with a diuretic, monitoring

should include a chemistry panel for electrolyte abnormalities.

CASE 107-8, QUESTION 2: What changes should be made to D.M.’s medication regimen?

In the admission workup, D.M. was described as having a long-standing history of

mild cognitive impairment, but subsequent nursing notes suggest that his symptoms of

disorientation and confusion worsened quickly after admission. Chronic dementia is

not normally characterized by rapid deterioration of mental acuity (see Chapter 108,

Geriatric Neurocognitive Disorders). This should raise the suspicion that a

reversible factor could be responsible for D.M.’s mental decline. Potentially

inappropriate drug use in older adults living in the community and in long-term care

is well documented.

112–114 The cognitive impairment of chronic degenerative

dementia can be greatly exaggerated by D.M.’s treatment with lorazepam,

temazepam, and quetiapine, especially with higher than recommended dosages.

115

Benzodiazepines may also increase the risk of falls and bone fractures in the geriatric

population.

116 Antipsychotics are some of the most commonly prescribed drugs in

nursing home residents. It is only appropriate to use these agents if the patient’s

behavior is considered to be a danger to themselves or others (including staff),

impairing the patient’s daily functioning, interfering with the staff’s ability to care for

them, or causing distress to the patient (i.e., frightening hallucinations).

110

Antipsychotics may be unnecessarily prescribed for anxiety, insomnia, confusion, or

failure to conform to the institution’s standards for behavior. Antipsychotic use in

older adults with dementia has been shown to be associated with a 1.7-fold

increased risk of all-cause mortality compared with nonusers.

117 Primary reasons for

death were heart failure, sudden cardiac death, or pneumonia. Federal regulations

require that these drugs be used for a specified condition, at the lowest possible

dosage, and for the shortest possible duration. Regulations also mandate tapering of

doses and careful documentation of all clinical assessments that justify the ongoing

need for antipsychotics.

109

In light of the atypical deterioration of D.M.’s cognitive function, the doses of all

psychotropic medications should be gradually tapered down to the lowest effective

dose and/or discontinued if appropriate. It may not be appropriate to make multiple

changes all at once; however, a plan should be developed to target the medications

that are likely responsible for D.M.’s decline in mental status. A baseline assessment

of D.M.’s cognitive function and psychiatric status should be performed by a

geriatrician, psychiatrist, or clinical psychologist to establish the presence or

absence of psychotic behavioral disturbances or depression. If any of these disorders

are present, then each should be managed with appropriate nonpharmacologic

interventions and drug therapy that includes appropriate therapeutic doses and

duration of treatment.

The American Geriatrics Society (AGS) updated the Beers Criteria for Potentially

Inappropriate Medication Use in Older Adults in 2015.

118 This evidence-based

review outlines medications that may lead to adverse events in older adults. Other

helpful tools available include the Screening Tool of Older Persons’ potentially

inappropriate Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right

Treatment (START) criteria.

118 The combined

p. 2229

p. 2230

use of these tools along with clinical judgment is meant to guide clinicians in drug

selection, to help decrease exposure to medications that may increase the risk of

adverse drug events, and to support the safe medication therapy of older adults.

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