Elderly patients diuretics

P-blocker therapy was ineffective in preventing coronary heart disease, cardiovascular mortality, and all-cause mortality when compared to diuretics for elderly patients (60 years of age or greater) treated for primary hypertension. Clearly, the effects of P-blockers on blood pressure are complex and difficult to ascribe to one or two mechanisms. Rather, the varied effects of negative chronotropic and inotropic properties along with reduced renin levels (Fig. 2-3) appear to result in an overall reduction in cardiac output and/or reduction in peripheral resistance. 

Patients at increased risk of NSAID-induced gastrointestinal adverse effects (e.g., dyspepsia, peptic ulcer formation, and bleeding) include the elderly, those with peptic ulcer disease, coagulopathy, and patients receiving high doses of concurrent corticosteroids. Nephrotoxicity is more common in the elderly, patients with creatinine clearance values less than 50 mL/minute, and those with volume depletion or on diuretic therapy. NSAIDs should be used with caution in patients with reduced cardiac output due to sodium retention and in patients receiving antihypertensives, warfarin, and lithium. 

Lithium is commonly used for bipolar affective disorders. Lithium however has a narrow therapeutic index and high risk for toxicity (Groleau 1994). The use of loop diuretics or ACE-inhibitors significantly increases the risk of hospitalisation for lithium toxicity in the elderly (Juurlink et al. 2004). Treatment of elderly patients with lithium should be thoroughly monitored. 

Elderly patients must be started on the lowest possible dose of diuretics as they tend to be more susceptible to their side-effects, such as postural hypotension. 

Management necessitates correction of the underlying cause. In unusually severe cases, with haemoglobin levels as low as 20 or 30 g/1 and particularly in elderly patients where heart failure is present, a single unit of packed red cells can be given over 6 hours with a loop-acting diuretic such as 10 mg of oral or intravenous furosemide. Haemoglobin levels will correct at the rate of 20 g/1 every 3 weeks provided replacement is adequate. It should be noted that for stores to be reconstituted 3 and sometimes 6 months of oral treatment are needed. 

The use of corticosteroids is often suggested for elderly patients with chronic tophaceous gout, since gout in the older individual often displays symptoms similar to those of rheumatoid arthritis. Patients can be given short-term administration of corticosteroids, especially for acute flare-ups. The concomitant use of alcohol, nonsteroidal antiinflammatory drugs, and most diuretics should be avoided. 

Although appropriate studies on the relationship of age to the effects of potassium-sparing diuretics have not been performed in the geriatric population, the elderly may be at an increased risk of developing hyperkalemia. In addition, elderly patients are more likely to have age-related renal function impairments, which may require caution in patients receiving potassium-sparing diuretics. 

Therapeutic uses Thiazide diuretics decrease blood pressure in both the supine and standing positions postural hypotension is rarely observed, except in elderly, volume-depleted patients. These agents counteract the sodium and water retention observed with other agents used in the treatment of hypertension (for example, hydralazine). Thiazides are therefore useful in combination therapy with a variety of other antihypertensive agents including (3-blockers and ACE inhibitors. Thiazide diuretics are particularly useful in the treatment of black or elderly patients, and in those with chronic renal disease. Thiazide diuretics are not effective in patients with inadequate kidney function (creatinine clearance less than 50 mls/min). Loop diuretics may be required in these patients. 

The GP then added in indometacin, which compromised renal perfusion. The combination therapy of an NSAID, an ACE inhibitor and a diuretic in an elderly patient who because of his age already has reduced renal function, induced a state of acute renal failure. 

Q5 Yes. Thiazide diuretic drugs are one of the treatments of choice for hypertension in elderly patients. Bendroflumethiazide, 2.5 mg daily, is commonly prescribed for hypertension in the United Kingdom. Although the thiazides have been in use for many years, their mechanism of action is not completely understood. They reduce renal reabsorption of sodium and water and so initially decrease blood volume they also dilate blood vessels and BP falls. However, blood volume may return to normal while the vasodilation and antihypertensive action remains. 

The risk of hospital admission related to lithium toxicity has been estimated in a case-control study of 10 615 elderly patients over 9 years (512). Lithium toxicity occurred at least once in 413 of the patients who were taking lithium. Factors that increase the likelihood of hospital admission included starting treatment with a loop diuretic or ACE inhibitors during the month before hospitalization. Although furosemide has been suggested as the diuretic of choice for patients taking lithium, the authors suggested that furosemide may cause lithium... 

More recently, it has been shown that hypokalemia and other dose-related adverse metabolic effects of thiazide diuretics increase the risk of sudden death and negate the cardiovascular benefit of blood pressure lowering when high doses these drugs are prescribed (21). Hence, another explanation for the apparent inability of antihypertensive therapy to lower mortality in patients with coronary heart disease is that high thiazide doses were used in many of the trials that were analyzed. As pointed out by Temple (2), this explanation is supported by the results of a trial of antihypertensive therapy in elderly patients with isolated systolic hypertension (22). In this study, only low doses of a thiazide diuretic were prescribed and a 4-mm Hg average decrease in diastolic blood pressure was associated with a 36% reduction in the... 

Calcium homeostasis. Renal caldum loss is increased by the loop diuretics in the short term this is not a serious disadvantage and indeed frusemide may be used in the management of hypercalcaemia after rehydration has been achieved. In the long term h3rpocalcaemia may be harmful especially in elderly patients who tend in any case to be in negative calcium balance. Thiazides, by contrast, decrease renal excertion of calcium and this property may influence the choice of diuretic in a potentially calcium deficient or osteoporotic individual, for thiazide use is associated with reduced risk of hip fracture in the elderly. The h5rpocalciuric effect of the thiazides has also been used effectively in patients with idiopathic hypercalduria, the commonest metabolic cause of renal stones. 

Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Strieker BH, Bakker A. NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics. Arch Intern Med 1998 158(10) 1108-12. 

It has been argued that potassium-sparing diuretics present a real risk of renal insufficiency when they are used in elderly people (15). In large-scale studies in elderly hypertensive patients there is indeed some slight increase in the incidence of renal insufficiency when combinations including potassium-sparing diuretics are used. Although the overall incidence of nephrotoxicity is quite low, elderly patients and those with prior renal dysfunction are at particular risk. Special care is necessary in these circumstances. 

Although dizziness is a fairly frequent complaint at the beginning of diuretic treatment (1), postural hjrpotension is rarely reported. Ischemic complaints (mesenteric infarction and transient cerebral ischemic attacks) have been observed in elderly patients, but it is not clear whether these resulted from diminished organ perfusion or from an effect of the drug itself. The former is more likely, since similar problems have arisen with any form of antihypertensive treatment in old people who have to some degree become dependent on their hypertension to ensure a blood supply through sclerotic vessels. 

Symptomatic reversible hypercalcemia was seen in two elderly patients taking apparently safe amounts of vitamin D and thiazide diuretics. Their unusual susceptibility to this effect resulted from an interaction with calcium carbonate which had been taken simultaneously. In the presence of other predisposing factors, hypercalcemia can develop in patients taking calcium carbonate 5-10 g/day (72,73). 

Thiazide diuretics or -blockers have been compared with either ACE inhibitors or CCBs in elderly patients with either systolic or diastolic hypertension or both. In a Swedish trial, no significant differences were seen between conventional drugs and either ACE inhibitors or CCBs. However, there were significantly fewer myocardial infarctions and cases of heart failure in the ACE inhibitor group compared with the CCB group. These data suggest that overall treatment may be more important than specific antihypertensive agents in this population. 

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