Elderly

Faxative abuse in elderly patients results in abdominal pain, as well as fluid and electrolyte imbalance. The chronic misuse of analogs containing large amounts of caffeine may produce rebound headache. Antihistamines may cause sedation and drowsiness, and it is advised that patients do not drive after taking antihistamines. People who are involved in performing skilled jobs should restrict their use of antihistamines and sedatives.99,100 

The intelligent use of drugs with elderly patients can increase their life span. Drug noncompliance by the elderly may result from forgetfulness, confusion, or even deliberate intent if prescribed with large number of drugs to be taken at different time intervals. Some errors in drug intake are caused by physical disabilities such as arthritis, tremors, blurred vision, or deafness. 

The toxicity of aminoglycosides in the kidney and other organs is concentration-dependent. Antibiotics such as kanamycin and gentamycin have their half-lives doubled in elderly patients. The elderly commonly suffer from osteoarthritis and (less commonly) rheumatoid arthritis. NSAIDs must be carefully used in geriatric patients, as they cause GI toxicity. For example, aspirin causes GI irritation 

The quantity of drags that can be excreted by the kidneys is influenced by the pH of the urine, which normally is between 4.5 and 8.0. Acidic urine (4.5) elimi- 

Kidney disease decreases the glomerular filtration rate (GFR) and thereby reduces the quantity of dmgs that can be eliminated by the kidneys. This can result in dmg toxicity. A similar effect can be caused by a decrease in bloodflow to the kidneys. 

Kidney function is tested by the creatinine clearance test. A decrease in GFR causes an increase in creatinine in semm and a decrease in creatinine in urine. The results of the creatinine clearance test vary with age and whenever there is decreased muscle mass. 

In some situations, it is important to reduce the excretion of a drug to prolong the dmg s therapeutic effect, such as with penicillin. Giving the patient another dmg, such as Probenecid, blocks excretion of penicillin. 

Dmgs can be excreted artificially through the use of dialysis, which is a common treatment in certain dmg overdoses. Drags that are excreted by the kidneys can be eliminated using hemodialysis. These drags include stimulants, depressants, and some non-narcotic analgesics. 

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Z. Elder and G. R. Stephenson, 1987 British Crop Protection Conference—Weeds, Vol. 3, Brit. Crop Protect. Conf, Croydon, U.K., 1987, p. 1105. 

K. R. ErvaU and R. Murray, Lvaluation of Commercially Nvailahk Laser Frotective Lyewear, HEW Publication (PDA) 79-8086, U.S. Dept, of Health, Education, and Welfare, Bureau of Radiological Health, RockviUe, Md., 1979 R. L. Elder, Science 182, 1080 (1973). 

Aniracetam (6), launched in 1993 in both Japan and Italy for the treatment of cognition disorders, is in Phase II trials in the United States as of this writing. In clinical studies it has been shown to cause some improvement in elderly patients with mild to moderate mental deterioration (63), and in geriatric patients with cerebral insufficiency (64). In a multicenter double-blind placebo-controUed trial involving 109 patients with probable AD, positive effects were observed in 36% of patients after six months of treatment (65), a result repeated in a separate study of 115 patients (66). A review of the biological and pharmacokinetic properties, and clinical results of aniracetam treatment in cognitively impaired individuals is available (49). 

Geriatric factors a variety of factors, both pharmacokinetic and pharmacodynamic, that contribute to variable dmg responses in the elderly. These responses are not seen for every class of dmg. Thus, the depressant effects of the glycosides also appear to increase with aging (116,117). 

X Bq of Pu has been released, mostiy from bum-up of the nuclear powered sateUite SNAP-9a and that 3.7 X 10 Bqof + ° Pu was released by the Chernobyl accident (167,168). Many studies have been done to determine the cumulative fallout on sods, plants, bodies of water, animals, and humans. For example, the cumulative Pu fallout ia forest and grasslands and ia the Hver of elderly humans ia Bavaria, Germany are approximately... 

One component of the age-ielated decline in immune function is decreased production of the lymphokine that promotes the growth of T-ceUs, interleukin 2 (IL-2). Administration of recombinant-derived IL-2, both in vitro and in vivo, appears to restore certain immune functions in aged mice. Recovery of T-regulatory effects on B-ceU differentiation has been reported in human cells from elderly patients treated with IL-1 and/or IL-2 (42). Similar effects have been observed in the presence of the pentapeptide thymopentin [69558-55-0] (Arg Lys Asp Val Tyr), a weU-known IL-2 inducer. Recombinant IL-2 adrninistered to aged mice for three weeks has been shown to correct the T-ceU functional deficiency associated with antigen-specific immunoglobulin production by certain lymphoid tissue (43). 

Egyptian papyms bonded with a starchy adhesive has been dated to 3500—4000 BC. Pliny the Elder (23—74 ad) described Egyptian use of wheat starch modified by boiling in vinegar to produce a smooth surface for papyms documents. 

Influenza. Although current influenza vaccine (subunit spHt vaccine) has been in use yearly for the elderly, it is not recommended for the general population or infants. Improvements to increase or prolong the immunogenicity, reduce the side-effects (due to egg production procedure), and provide mass protection are stiU being pursued. One approach is to use a five, attenuated vims though cold adaptation. A vaccine has been used in Russia and demonstrated to be safe and efficacious for infants (82). Clinical trials for a similar vaccine are being carried out in the United States (83). 

The adrenal glands and pituitary glands have the highest tissue concentration of ascorbic acid. The brain, Hver, and spleen, however, represent the largest contribution to the body pool. Plasma and leukocyte ascorbic acid levels decrease with increasing age (152). Elderly people require higher ascorbic acid intakes than children to reach the same plasma and tissue concentration (153). 

The most recent RDA has included a vitamin C recommendation of 100 mg/day for cigarette smokers. An increasing number of investigators have concluded that the current RDA for vitamin C may not be adequate for elderly individuals. Plasma vitamin C level is generally accepted as an indicator of vitamin C status. 

Neurological symptoms result from demyelination of the spinal cord and are potentially irreversible. The symptoms and signs characteristic of a vitamin B 2 deficiency include paresthesis of the hands and feet, decreased deep-tendon reflexes, unsteadiness, and potential psychiatric problems such as moodiness, hallucinations, delusions, and psychosis. Neuropsychiatric disorders sometimes develop independently of the anemia, particularly in elderly patients. Visual loss may develop as a result of optic atrophy. 

Vitamin Deficiency. Vitamin deficiency is uncommon in normal adults. However, when it does occur, it can be serious, particularly in pregnant women. Some vitamin deficiency can occur because of a large reduction of fat intake, which decreases absorption. Strict vegetarians also risk reduced vitamin intake. Premature infants and elderly people who are exposed to minimal sunlight and consume Htde vitamin also have a reduced capacity to metabolize and can develop vitamin deficiency. 

Generally, nephrotoxicity is not a problem. Some cephalosporins, especially those with the 3-methylthiotetrazole side chain, such as moxalactam (48), show a tendency to promote bleeding. This appears to be due to a reduction in the synthesis of prothrombin and can be a problem especially in elderly patients, patients with renal insufficiency, or patients suffering from malnutrition (219). The same side chain seems to promote a disulfiramlike reaction in patients consuming alcohol following a cephalosporin dose (80,219). 

In some of his work, Pliny the Elder (24—79 Ad) wrote of the heating of wine with flames. In the tenth century, the Persian philosopher Avicenna (980—1037 ad) described a distillation stUl. Magister Salemus wrote about "aqua ardens" around 1150 AD. The German alchemist and philosopher, Albertus Magnus (1200—1280 ad), studied wine distillation, made improvements, and wrote a manuscript on the production of aqua ardens. 

Patients having high plasma renin activity (PRA) (>8 ng/(mLh)) respond best to an ACE inhibitor or a -adrenoceptor blocker those having low PRA (<1 ng/(mLh)) usually elderly and black, respond best to a calcium channel blocker or a diuretic (184). -Adrenoceptor blockers should not be used in patients who have diabetes, asthma, bradycardia, or peripheral vascular diseases. The thiazide-type diuretics (qv) should be used with caution in patients having diabetes. Likewise, -adrenoceptor blockers should not be combined with verapamil or diltiazem because these dmgs slow the atrioventricular nodal conduction in the heart. Calcium channel blockers are preferred in patients having coronary insufficiency diseases because of the cardioprotective effects of these dmgs. 

Better antihypertensive effect of P-adrenoceptor blockers is found in patients having high PRA and most are not efficacious in patients having low PRA or in elderly patients. P-Adrenoceptor blockers usually lower arterial blood pressure about 10 mm Hg (1.3 kPa). Side effects include lethargy, dyspnea, nausea, dizziness, headache, impotency, cold hands and feet, vivid dreams and nightmares, bronchospasm, bradycardia, and sleep disturbances. 

Calcium channel blockers normalize the blood pressure in about 80% of hypertensive patients older than 60 years of age, 50% of those between 40 and 60 years of age, and only 20% of patients under 40 years of age. Thus calcium channel blockers are best for patients who are elderly and have low PRA and mosdy ineffective in patients who have high PRA. This responsiveness profile is very similar to that of the diuretics. 

Nifedipine (Table 3) is a potent vasodilator that selectively dilates resistance vessels and has fewer effects on venous vessels. It does not cause reflex tachycardia during chronic therapy. Nifedipine is one of the first-line choices for black or elderly patients and patients having concomitant angina pectoris, diabetes, or peripheral vascular diseases. Nifedipine, sublingually, is also suitable for the treatment of hypertensive emergencies. Nifedipine does not impair sexual function or worsen blood Hpid profile. The side effects are flushing, headache, and dizziness. 

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