Box 1. Common Causes of Constipation in Older Adults • Opioids. • Anticholinergics. • Calcium channel blockers. • Bile acid resins. • Iron supplements. • Calcium or aluminum-based antacids.
• Hypothyroidism. • Chronic kidney disease. • Parkinson’s disease. • Neurologic/musculoskeletal disorders. • Impaired mobility.
Note. Adapted from Rao & Go, 2010. Gastric acid–reducing agents
The introduction of histamine-2 receptor antagonists (H2RAs) in the late 1970s favorably changed the management and outcome of patients with ulcers, gastroesophageal reflux, and dyspepsia. Cimetidine and, later, ranitidine and famotidine, were among the most frequently prescribed medications for much of the past 40 years (National Library of Medicine, 2018). However, these medications occasionally predisposed older patients to CNS side effects, especially if concomitant renal dysfunction was present. Proton pump inhibitors (PPIs), introduced in the 1990s, reduce gastric acid secretion at the point of the H+/ K+ ATPase pump, which is “downstream” of the histamine-2, gastrin, and acetylcholine receptors located on gastric parietal cells. Based on the PPIs’ mechanism of action, they eventually Cardiovascular therapies Optimal management of hypertension in elderly patients re - mains an important goal to avoid secondary complications, in- cluding stroke and renal dysfunction. A variety of pharmacologic drug classes and available selections within each drug class exist. Therefore, medication selection and dosing decisions should be based on comorbidities, compelling indications, safety/tolerabili- ty, and cost. A full discussion of the management of hypertension is beyond the scope of this document; however, side effects from some antihypertensive drug classes may be more prominent and/ or troublesome in older patients (Watson, 2022): ● Alpha-1 adrenergic blockers: Orthostatic hypotension. ● Angiotensin converting enzyme inhibitors (ACEIs): Hyperkalemia, cough. ● Angiotensin-2 receptor blockers (ARBs): Hyperkalemia. Analgesics The risks of opioid use in older adults, especially CNS and respiratory depression, are well established and represented in the AGS Beers and STOPP criteria. When clinically indicated for severe acute or chronic pain that is uncontrolled by other therapies, treatment with the lowest effective dose and for the shortest practical duration is advised. Prolonged use of opioids Psychotropics, antidepressants, and anxiolytics Mental health conditions established earlier in life are unlikely to abate or resolve as patients age. Additionally, new mental health concerns, including depressive disorders, anxiety, dementia, and its sequelae, may arise in the older patient (Kok & Reynolds, 2017). However, while great advances continue to be made in developing safer and more effective pharmacologic treatments for these conditions, the consistently reliable effectiveness of a given agent is not assured, and the risks of systemic side effects remain a concern when CNS-active medications are employed in older adults. Several examples deserve attention: Anticoagulants The use of anticoagulants in older adults represents another tenuous challenge in balancing primary or secondary thrombotic disease management with the risk of bleeding (Djulbegovic & Lee, 2018). Patients with atrial fibrillation, deep vein thrombosis, pulmonary embolism, other hypercoagulable states, and/or risk for such thrombotic events may require temporary or lifelong anticoagulation therapy to avoid a future thrombotic event. Evidence supports the effectiveness of a variety of agents
demonstrated superior efficacy to the H2RAs for conditions including gastric ulcers, Helicobacter pylori infections, heartburn, and other gastrointestinal pathologies. Unfortunately, chronic and/or prolonged use of PPIs has become associated with risks of developing hypomagnesemia, Clostridium difficile diarrhea, aspiration pneumonia, and bone loss. Additional caution is warranted when PPIs are combined with other chronic medications whose absorption may be altered (increased or decreased) due to gastric pH elevation, which already trends higher in older patients (Kurin & Fass, 2019). Despite some PPIs being readily available as nonprescription medications, the need for critical decision making and cautious duration of use of these medications cannot be understated. ● Beta blockers: Bradycardia, fatigue, masked hypoglycemia symptoms. ● Calcium channel blockers (CCBs): Constipation with verapamil or diltiazem; lightheadedness and edema with amlodipine, nifedipine, or felodipine. ● Clonidine and other centrally acting antihypertensives: CNS effects, bradycardia, and orthostatic hypotension. ● Thiazide diuretics: Hypokalemia, hyponatremia, hyperglycemia, gout exacerbation. ● Loop diuretics: Hypokalemia. Since no medication is devoid of adverse effect risks, clinicians must evaluate the potential benefits (effectiveness, tolerability, safety, convenience, cost) of an available treatment option with the risk and/or severity of adverse effects in each patient. should also be accompanied by regular intake of a stimulant laxative (e.g., senna) to avoid constipation complications. Chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) has been associated with exacerbated hypertension, impaired renal function, and gastrointestinal bleeding (Ali et al., 2018). ● Haloperidol, risperidone, phenothiazines such as perphenazine, and aripiprazole—among other antipsychotics—have demonstrated medium to high risk for patients developing tardive dyskinesia based on their impact on dopamine neurotransmission. ● Anticholinergic side effects of various antidepressants, as well as the combination of CNS depression and fall risk associated with benzodiazepines, sedatives, and anxiolytics, have also been discussed previously. for these conditions, including vitamin K antagonists (e.g., warfarin), low-molecular-weight heparins (e.g., enoxaparin, dalteparin), factor Xa inhibitors (e.g., apixaban, rivaroxaban), and direct thrombin inhibitors (e.g., dabigatran). Warfarin has been a mainstay of chronic anticoagulation therapy for decades; however, inter- and intraindividual dose response variations have warranted intensive management. With a narrow therapeutic window currently defined as an international normalized ratio
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