The relationship between comprehensive functional assessment and optimal pharmacotherapy in the older patient

Factors Associated with Functional Disability Among Lebanese Elderly Living in Rural Areas: Role of Polypharmacy, Alcohol Consumption, and Nutrition-based on the Aging and Malnutrition in Elderly Lebanese (AMEL) Study

The objective is to describe disability risk factors in Lebanese elderly living in rural settings, focusing on the role of polypharmacy, alcohol consumption, and nutrition. The Aging and Malnutrition in Elderly Lebanese study, a cross-sectional population-based one (April 2011–April 2012), included 1200 individuals aged ≥65 years from 24 Lebanese rural districts. The results showed that 288 (24%) were disabled and 287 (23.9%) exposed to polypharmacy. More disabled participants were found among patients exposed to polypharmacy (40.8%) than those who were not (18.8%). Major classes associated with disability were “Parkinson” and “Alzheimer” medications, with “alcohol consumption” being responsible for a major interaction with medications. Chronic diseases, nutrition, and socioeconomic status also had a large effect on disability. Skin ulcer (ORa = 8.569; CI 5.330–14.823), followed by dementia (ORa = 3.667; CI 1.167–8.912), and anti-gout drugs (ORa = 3.962; CI 1.290–7.622) were found to be significantly associated with increased odds of disability the most. Many factors are associated with disability among elderly, including polypharmacy and the association of medications with alcohol. Counseling of the elderly caregivers is warranted.

Medication use and functional status decline in older adults: a narrative review

BACKGROUND

Functional status is the cornerstone of geriatric care and serves as an indicator of general well-being. A decline in function can increase health care use, worsen quality of life, threaten independence, and increase the risk of mortality. One of several risk factors for decline in functional status is medication use.

OBJECTIVE

Our aim was to critically review published articles that have examined the relationship between medication use and functional status decline in the elderly.

METHODS

The MEDLINE and EMBASE databases were searched for English-language articles published from January 1986 to June 2011. Search terms included aged, humans, drug utilization, polypharmacy, inappropriate prescribing, anticholinergics, psychotropics, antihypertensives, drug burden index, functional status, function change or decline, activities of daily living, gait, mobility limitation, and disability. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to retrieve additional publications. Only articles that used rigorous observational or interventional designs were included. Cross-sectional studies and case series were excluded from this review.

RESULTS

Nineteen studies met the inclusion criteria. Five studies addressed the impact of suboptimal prescribing on function, 3 of which found an increased risk of worse function in community-dwelling subjects receiving polypharmacy. Three of the 4 studies that assessed benzodiazepine use and functional status decline found a statistically significant association. One cohort study identified no relationship between antidepressant use and functional status, whereas a randomized trial found that amitriptyline, but not desipramine or paroxetine, impaired certain measures of gait. Two studies found that increasing anticholinergic burden was associated with worse functional status. In a study of hospitalized rehabilitation patients, users of hypnotics/anxiolytics (eg, phenobarbital, zolpidem) had lower relative Functional Independence Measure motor gains than nonusers. Use of multiple central nervous system (CNS) drugs (using different definitions) was linked to greater declines in self-reported mobility and Short Physical Performance Battery (SPPB) scores in 2 community-based studies. Another study of nursing home patients did not report a significant decrease in SPPB scores in those taking multiple CNS drugs. Finally, 2 studies found mixed effects between antihypertensive use and functional status in the elderly.

CONCLUSIONS

Benzodiazepines and anticholinergics have been consistently associated with impairments in functional status in the elderly. The relationships between suboptimal prescribing, antidepressants, and antihypertensives and functional status decline were mixed. Further research using established measures and methods is needed to better describe the impact of medication use on functional status in older adults.

A Pharmacist Approach to Wellness Maintenance in the Community Elderly

Wellness prevention in the elderly has similar goals as prevention in nonelderly adults, which is to improve lifestyles and habits to prevent disease (primary prevention) or the progression of disease (secondary prevention). Pharmacists who interact with the community elderly have a great opportunity of helping to keep our elderly healthy and preventing lifelong chronic problems that can contribute to a decrease in function of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This article focuses on the key prevention interventions that a pharmacist can target in helping to promote health maintenance.

Special problems in the elderly

With aging, the heart, kidneys, liver, lungs, and brain lose mass. While not inherently impaired, the reserve capacity of the older individual to compensate for stress, metabolic derangement, and drug metabolism is increasingly limited. Functional disability occurs faster and takes longer to remediate, necessitating early preventive interventions.

Distinguishing between the fit and frail elderly, and optimising pharmacotherapy

Frail older patients are at risk for adverse consequences from medications or other external stresses. No single marker, such as age or physical disability, or laboratory test can identify this group of patients. As a result, screening questionnaires have been developed and successfully used by nurses to help identify frail older patients upon admission to a hospital. A very short, 7-item screen with questions concerning cognitive ability, physical mobility, nutrition, number of medications used and hospitalisation within the previous month, was able to identify those patients who were more likely to be discharged to a nursing home, die, or incur a large hospitalisation cost for the institution. While the number of medications used was not an independent predictor of the outcome measures studied (e.g. discharge to a nursing home), data from the literature show that the number of medications prescribed is related to iatrogenic complications in older patients, and specific impairments in mobility and cognition. The proper choice and prescribed dose of a medication is extremely important in frail older patients who, for instance, are at increased risk from hip fracture with some benzodiazepines, and who have markedly diminished clearance of some drugs. A systematic approach is suggested for the prescription of medications in frail older persons which will help achieve optimal pharmacotherapy by using a limited number of medications, thoughtfully selecting medications which will not impair function, and prescribing an appropriate dose based on pharmacodynamic and pharmacokinetic changes that occur with age.