Medication use in rest and nursing homes in Belgium. - KCE

102 Medication use in Nursing Homes KCE reports 47
Osteoporosis is caused by the cumulative effect of bone resorption in excess of bone
formation. Multiple treatments are available and more are being developed.
Calcium and Vitamin D: less than one third of elderly residents take in the recommended
amounts of calcium and vitamin D. Patients with malabsorptive problems, renal disease
or liver disease may have further problems. Calcium and Vitamin D supplementation
have been shown to reduce the risk of hip fracture in older adults. Calcium should be
given with meals for optimal absorption and adults should take in at least 1000 mg/day
(ideally 1500 mg/day in postmenopausal women or those with osteoporosis). Vitamin D
(25 and 1.25 D3) can be checked, but if the serum calcium level is normal most would
recommend empiric treatment with additional vitamin D of at least 400 IU. In frail older
patients with limited diets and sun exposure, the required amounts are most likely
much higher, at least 600-800 IU daily.
Bisphosphonates: these drugs act to decrease bone resorption. Multiple studies have
demonstrated a significant benefit in the reduction of hip and vertebral fractures. It is
important to remember that those at highest risk for fracture (the older patients and
those with existing vertebral fractures) were the patients who derived the most benefit
from treatment. Contraindications include renal failure and significant oesophageal
erosions/disease.
Diabetes and no aspirin 195
Patients with type 2 diabetes mellitus have a markedly increased risk of cardiovascular
morbidity and mortality. Guidelines of both the American and Canadian Diabetes
Associations recommend the use of aspirin as antiplatelet therapy for all adults with
type 2 diabetes. Aspirin is a safe, inexpensive, and readily available therapy that is
effective for preventing cardiovascular disease, and patients with type 2 diabetes are
particularly likely to benefit from such preventive therapy.
However, we found significant underuse of aspirin therapy among our study population.
Low dose aspirin should be included and better promoted as a factor in high-quality,
evidence-based diabetes management.
PROBLEMS IDENTIFIED WITH THE BEERS CRITERIA OF POTENTIALLY
INAPPROPRIATE MEDICATION
Digoxin 196
The incidence of digoxin toxicity increases with age, largely because the two most
common conditions that benefit from use of digoxin, congestive heart failure and atrial
fibrillation, are markedly more prevalent in old age. Current reviews conclude that the
drug still has beneficial effects in patients who remain symptomatic with appropriate
treatment with diuretics and angiotensin-converting enzyme inhibitors. 197 Whether the
elderly are more sensitive to the effects of digoxin because of age per se is unclear.
However, several other factors render the elderly more susceptible to digoxin toxicity.
These include an age-related decline in renal function and a decrease in volume of
digoxin distribution. There is also an increase in the number of comorbid conditions,
including cardiovascular and chronic obstructive pulmonary disease, which heightens
susceptibility to digoxin toxicity. Moreover, treatment of these diseases with such
interactive medications as quinidine and calcium channel blockers may increase the
serum level of digoxin. Similarly, such electrolyte imbalances as hypokalemia and
hypomagnesemia occur more frequently in the elderly as a result of diuretic therapy.
Oxybutinin 198
Oxybutynin is a tertiary amine with anticholinergic and spasmolytic effects on the
bladder smooth muscle. It was developed specifically for overactive bladder and to
suppress involuntary bladder contractions. Oxybutynin works by a direct antispasmodic
action on smooth muscle and inhibits the muscarinic action of acetylcholine on smooth
muscle. It is selective for muscarinic receptors on the detrusor and is more potent and
more direct than atropine. Despite an improved anticholinergic side effect profile, side
effects are still frequently dose limiting, or cannot be tolerated in the elderly.
Anticholinergic effects are important causes of acute and chronic confusional states.
Nevertheless, polypharmacy with anticholinergic compounds is common, especially in