Clinicians have a wide variety of choices for treating the symptoms and slowing the progression of rheumatic diseases.
Choice is dependent often on the existence of comorbid
conditions and potential risks of adverse effects or drug interactions. Some agents carry specific risks in the elderly individual and specific care must be taken to avoid negative consequences in these individuals (Table 7.2).
APAP is commonly considered the safest and best toler- ated agent for controlling the pain of OA. Its use may spare the individual from requiring more potentially toxic NSAIDs and may be combined with an opioid analgesic to offer addi- tional symptomatic relief [27]. When short-term use of an NSAID is necessary to optimize therapy, use of a COX-2 selective agent or a nonselective NSAID plus a PPI is recom- mended to reduce the risk of GI toxicity [36]. Both selective and nonselective NSAIDs carry significant risk of negatively impacting cardiovascular and renal function and may increase symptoms of CHF and renal insufficiency, and raise blood pressure in the elderly individual. Although some authors suggest use of a nonselective NSAID over a COX-2 selective agent in the elderly individuals due to concerns of ischemic heart disease or stroke [29, 33], concerns of increased risk of ischemic disease and thrombotic risk are present for both selective and nonselective NSAIDs. A careful medication history is necessary for all patients due to the accessibility and wide-spread availability of both APAP and NSAIDs as single active agent nonprescription products under trade, generic, and store brand labels. Many combination products sold as multi-symptom cough and cold remedies, arthritis pain formulas, and insomnia products also contain APAP or a nonprescription NSAID.
Therapeutic options such as the DMARDs and biologic/
immune-modifying therapies can provide benefit to the elderly individual, but with perceived high risk of significant adverse events. Prescribers may regard the existence of multiple disease states and lowered physiologic reserve seen in the elderly population as significant risks and may alter prescribing accordingly, using less potentially toxic medica- tions and single, rather than multiple therapies. A recent utilization study, conducted by Tutuncu et al., suggests that individuals with elderly-onset RA (EORA) receive less aggressive treatment with DMARDs and biologic/immune response modifier therapies than those with young onset RA (YORA) despite similar length and severity of disease symp- toms. In this study population, individuals with EORA were slightly more likely to receive methotrexate at lower doses as is recommended in this population, but were significantly less likely to be treated with multiple DMARD treatments or biological agents [54].
Economic and health-care systems may present barriers to achieving therapeutic goals in the elderly patient with rheumatic disease [25]. The lack of Medicare reimbursement or formulary selection pressures within Medicare D plans, and the coverage gap or “donut hole” experienced by indi- viduals with moderately expensive medication regiments may impact adherence to ongoing therapy. Variations in
69 7 Pharmacotherapy Considerations Unique to the Older Patient
insurance plan policies relative to provision and coverage of certain injectable therapies may require significant efforts such as prior authorization and documentation of failure to less costly therapies prior to initiation of these advanced modalities. Often, delays from mail-order pharmacies that are required or economically favored within some managed- care programs will cause inadequate symptomatic relief, and the lack of access to pharmacies in some inner city or rural areas may interfere with the timely initiation of therapy.
Ultimately, when selecting a course of therapy of any medication for an elderly patient, the clinician must individ- ualize the regimen. The elderly population is a heterogeneous group with expected changes in pharmacokinetic and pharmacodynamic parameters that are compounded by the accumulation of lifelong influences of lifestyle, genetic predisposition to pathologic changes, and insults to specific
organ systems. Care must be taken when initiating any new therapy, and any benefit from the new medication must be weighed against the potential risks that may be significant in this group with reduced physiologic reserve. The philosophy of “start low and go slow” should be the basis for any thera- peutic intervention.
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Table 7.2 Selected rheumatologic agents in the elderly people: typical risks and special concerns [23, 26, 28]
Drug Typical adverse effects Concerns in elderly
Azathioprine Fever and chills, GI irritation and intolerance, bone marrow suppression, and hepatic toxicity
No documented changes in efficacy or tolerability
Celecoxib Lower risk of gastrointestinal irritation and little effect on platelet aggregation compared to typical NSAIDs
Decrease dose with weight <50 kg, increased risk of cardiovascular events (Black Box warning)
Corticosteroids CNS effects: insomnia, nervousness
GI effects: indigestion, increased risk of GI bleeding Derm effects: hirsutism, pigmentation changes,
thinning skin
Endocrine effects: diabetes mellitus, hyperglycemia, Cushing’s syndrome, osteoporosis, pituitary–adrenal axis suppression
Ocular effects: cataracts, glaucoma
Renal effects: sodium/water retention, swelling Musculoskeletal effects: fractures and muscle wasting
Reduced serum albumin increases unbound drug and risk for adverse effects. Adverse effects compound common diseases in the elderly population (cataracts, hypertension, osteoporosis, thin/fragile skin, cognitive deficits and delirium, glaucoma, reduced immune function, latent granulomatous disease)
Cyclosporin Hypertension, increased creatinine, hirsutism, nausea, gingival hypertrophy, and tremor
Renal impairment and hepatic disease are contraindications to use
Antimalarials: chloroquine and hydroxychloroquine
GI irritation, rash, headache, dermal discoloration, and retinal toxicity (uncommon but serious)
Age-related changes in vision may mask ocular toxicity
Leflunomide Hypertension, headache, GI irritation, weight loss, alopecia, rash, bone marrow suppression, and hepatic toxicity
Dose adjustment not typically necessary in the elderly population, but needed if adverse effects develop (alopecia, weight loss, elevated hepatic transaminases, etc.) Methotrexate GI irritation, hepatic toxicity, bone marrow suppression,
pneumonitis
Toxicity linked to decreases in renal function not chronologic age. Pneumonitis incidence not linked with age
Nonsteroidal anti-inflammatory agents
Gastrointestinal effects including gastritis and bleeding, sodium and water retention, increased blood pressure, increased risk of ischemic disease (COX-2 selective)
Reduced nutritional status and hypoproteinemia may cause increased free fraction of these high protein bound agents causing increased effect and adverse effects
Sulfasalazine GI irritation, rash, itching, dizziness, headache, bone marrow suppression, hepatic disease
Sustained-release enteric-coated tablets useful to reduce GI effects common in the elderly population, but may be harder to swallow and should not be broken or crushed
Anticytokine therapies Etanercept
Infliximab Adalimumab Anakinra
Injection site and infusion reactions, increased risk of infections, worsening heart failure
Increased risk of hidden granulomatous disease in the elderly population, cardiovascular disease leading to congestive failure, underlying asthma is linked to higher incidence of pulmonary infections with anakinra therapy
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Y. Nakasato and R.L. Yung (eds.), Geriatric Rheumatology: A Comprehensive Approach, 73 DOI 10.1007/978-1-4419-5792-4_8, © Springer Science+Business Media, LLC 2011
Abstract Currently 20,000 nursing homes provide care for nearly two million persons in USA. Today, 69% of people turning 65 years will need some form of long-term care.
By 2020, 12 million Americans will need long-term health care for short-term rehabilitation, short-term hospice care, or longer term custodial care. These are typically the oldest and sickest geriatric patients and the most vulnerable to geriatric syndromes including polypharmacy, falls, cogni- tive impairment, and frailty (failure to thrive). Pain and functional impairment related to rheumatic disease are quite common in this population. Assessment of these patients is complicated by cognitive impairment and comorbidities.
Pharmacologic management can be challenging, making non-pharmacologic approaches imperative. Interdisciplinary collaboration adds to the therapeutic options and improves function and comfort.
Keywords Activities of daily living • Functional impairment
• Polypharmacy • Frailty • Comorbidity
Introduction
According to the US Bureau of the Census, currently 16,100 certified nursing homes and 39,500 assisted living facilities provide care to slightly over 5% of the population aged 65 years and older. The rate of nursing home use increases with age from 1.4% of the young-old to 24.5% of the oldest old.
Almost 50% of those aged 95 years and older live in nursing homes. Today, 69% of people turning 65 years will need some form of long-term care and by 2020, 12 million Americans will require long-term care [1].
The general public assumes that those providing health care for nursing home residents have been trained to deal with issues specific to this very complicated patient popula- tion but often, this is not the case. Caring for these frail patients with multiple comorbidities and varying goals of care can be challenging, and working within the regulatory confines of the nursing home industry can be frustrating.
Providing quality care to this vulnerable group based on comprehensive geriatric assessment, care goals, and solid scientific evidence is imperative.
The arthritis foundation estimates that one in six Americans has arthritis and that the incidence of osteoarthri- tis increases with age. The prevalence of arthritis in the old- est old is so common that arthritis is often not even listed on the problem list. One study of 629 residents in five nursing homes found an osteoarthritis or rheumatoid arthritis preva- lence of 23% [2]. These residents were more likely to have pain and to require assistance with ADLs and less able to ambulate independently [2]. A more recent cross-sectional sample of 8,138 residents in 1,406 nursing homes in USA found that only 3% of residents had a primary diagnosis of arthritis and only 19% had any arthritis diagnosis at all [3].
This is a far smaller estimate than the 50% prevalence rate estimated for the non-institutionalized population over age 65 years and implies that the underreporting of arthritis in the nursing home population is quite likely.
Comprehensive assessment of the nursing home patient is generally recognized as a multidisciplinary evaluation which identifies the multiple medical and functional problems of the resident. Based on this initial assessment, the need for services is determined and a plan of care is developed [4]. The basic components of this assessment include function, cognition, affect, nutrition, medications, social and functional support, advance directives, and end of life care. Of these basic compo- nents, rheumatologists deal primarily with pain, and functional and medication assessments as the key components in caring for the nursing home patients with arthritis. Issues of pain management, cognition, family and resident care goals, and advance directives are a constant thread that runs through all decisions and treatment options for these patients.
J. Sandberg-Cook (*)
Dartmouth Hitchcock Kendal, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03766, USA
e-mail: [email protected]