Medication of the Elderly Effect on Response to Physical Therapy
Although medications may save many lives each year, they can also cause many problems. All health professionals should be aware of the potential ad verse effects of drug therapy and how they relate to their particular area of expertise. Certain drug ef fects may greatly influence a patient's ability to comply or cooperate with his prescribed physical therapy. This is particularly true of elderly persons. Approximately 10 percent of the population of the United States is in the age group of 65 or over. 1 This group, however, takes about 25 percent of the outpatient prescription medications dispensed. 2 From my observations and experience with elderly patients, it is also obvious that elderly persons consume a large amount of nonprescription (overthe-counter) medications.
PHYSIOLOGICAL RESPONSES Certain functional differences seen in elderly per sons may alter their responses to medications. As a person ages, the active and passive absorption through his intestinal mucosa is impaired. Some difficulty may therefore be experienced in achieving therapeutic drug levels in some elderly patients because many medications enter the bloodstream via these mechanisms. 3,4 Tissue perfusion and drug distribution in elderly persons may change resulting from an increase in body fat or a decrease in cardiac output causing a variability of tissue drug levels and drug response as compared to younger persons. 5 Excretion of medications via the kidneys decreases with an age-related decline in renal function. 5 The metabolism of medications by the liver may also diminish with age. 6 Since most medications are eliminated from the body by either the kidneys or the liver, or both, a slower elimination may result in high drug levels in body tissues. With many drugs, higher than recommended drug tissue levels may cause drug toxicity. Patients who are being treated for multiple dis ease states may be taking a large number of mediDr. Simonson is an Assistant Professor of Pharmaceutical Sci ence, Oregon State University, School of Pharmacy, Corvallis, OR 97330, and is a staff pharmacist with Corvallis Pharmacy Service, Inc.
178
cations and may therefore be subjected to a greater risk of experiencing a drug toxicity. 7 Patients 60 to 70 years old have almost twice the likelihood of experiencing an adverse drug reaction than do adults 30 to 40 years old. 8 Medications may interact with one another result ing in an altered therapeutic effect or in toxicity. The incidence of drug interactions increases with the number of medications that a patient takes. 7 These interactions may occur via various mecha nisms and may range from being clinically insignifi cant to being fatal. 9
COMPLIANCE AND MOTIVATION The inability or unwillingness of elderly patients to properly comply with their prescribed medication regimen is another area of concern. It has been said that "the failure of an elderly person to respond to an effective drug is nearly always due to the failure of the patient to take the drug rather than to absorb it." 10 Some studies performed to measure the degree of patient compliance have shown a remarkable (greater than 50 percent) incidence of improper compliance to outpatient prescription regimens. 11 This is not entirely a reflection of patient willingness but may result from an improper or incomplete understanding of instruction. For example, if a prescription reads "Take one capsule by mouth 4 times a day," Does this mean spaced evenly every 6 hours? Or should all of the doses be taken during the daylight hours? What about before meals? Or after? With a large glass of water? Or with milk? Why do elderly persons take medications? For a number of reasons. As a pharmacist, I can see that a large part of our society is strongly drug-oriented in that their first reaction is to take a "pill" when they have a complaint. This I believe to be largely due to the pressures exerted on health professionals by advertisers and distributors and also to pressures exerted on patients directly through advertising on television, radio, and in household magazines. Others believe that unnecessary prescriptions are the result of "the patient's expectation of a 'magic cure' and the physician's reluctance to admit his own limited ability to modify many conditions." 8
PHYSICAL THERAPY
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WILLIAM SIMONSON, Pharm D
SIDE EFFECTS
RECOMMENDATIONS The following recommendations will allow physi cal therapists to have a greater input into the therapy and management of their elderly patients. 1. If the patient has questions about the medica tions he is taking, encourage him to ask his pharmacist or physician or perhaps even assist the patient in contacting the appropriate person. 2. If you notice that the patient is having problems with home storage of medications or medication compliance, call the pharmacist or physician to inform him of this situation. 3. If the elderly patient has difficulty opening the child-resistant containers in which most medica tions are packaged, contact the patient's phar Volume 58 / Number 2, February 1978
CONCLUSIONS Elderly persons often face a myriad of drugassociated problems. The medications with which a patient is treated and the patient's therapy are the ultimate responsibility of the physician, but through our awareness and observations we can all take a greater part in the patient's treatment. Many adverse drug reactions could be avoided or eliminated if medications were treated with more respect. It is possible that the patient's entire state of well-being could be significantly improved as the result of your astute observations and comments which could be instrumental in detecting a patient's adverse reactions to medication. REFERENCES 1. Ostfeld AM, Gibson DC: Epidemiology of Aging. Bethesda, MD, US Department of Health, Education, and Welfare, #(NIH) 75-711, 1973 2. Silverman M, Lee PR: Pills, Profits and Politics. Berkeley, University of California Press, 1974, p 19 3. Koup JR, Tobias DE: Suspected digoxin malabsorption. Drug Intell Clin Pharm 8:645, 1974 4. Bender DA: Effects of age on intestinal absorption: Implica tions for drug absorption in the elderly. J Am Geriatr Soc 16:1331-1339, 1968 5. Holloway DA: Drug problems in the geriatric patient. Drug Intell Clin Pharm 8:633, 1974 6. Weg R: Drug interaction with the changing physiology of the aged: Practice and potential. In Davis RH (ed): Drugs and the Elderly. Los Angeles, Ethel Percy Andrus Gerontology Center, 1973, pp 71-91 7. Smith JW, Seidl LG, Cluff LE: Studies on the epidemiology of adverse drug reactions. Ann Int Med 65:629-640, 1966 8. Melmon KL: Preventable drug reactions: Causes and cures. New Engl J Med 284:1361-1368, 1971 9. Evaluation of Drug Interactions, ed 2. Washington, DC, American Pharmaceutical Association, 1976, pp 307-326 10. Hall MRP: Drug therapy in the elderly. Brit Med J 3:582584,1973 11. Hussar DA: Patient noncompliance. J Am Pharm Assoc NS15:183-190, 1975 12. Sanders JF: Evaluation of oxazepam and placebo in emotion ally disturbed aged patients. Geriatrics 20:739-746, 1965 13. de Lange WE, Doorenbos H: Corticotrophin and cortico steroids. In Dukes MNG (ed): Side Effects of Drugs, vol 8, Excerpta Medica, Amsterdam Oxford, 1975, pp 824-826 14. Loeliger EA: Drugs affecting blood clotting and fibrinolysis. In Dukes MNG (ed): Side Effects of Drugs, vol 8, Excerpta Medica, Amsterdam Oxford, 1975, p 768 15. Stenfert Kroese WF: Cytostatic drugs. In Dukes MNG (ed): Side Effects of Drugs, vol 8, Excerpta Medica, Amsterdam Oxford, 1975, p 965 16. Caird FI, Dall JLC: The cardiovascular system. In Brocklehurst JC (ed): Textbook of Geriatric Medicine and Gerontol ogy. Edinburgh and London, Churchill Livingstone, 1973, p 137
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As physical therapists, you may observe certain problems which have been brought about because of patients' use or misuse of their medications. Immobility may result from an overuse of sedatives or tranquilizers. Not only would this impair re sponse to various forms of physical therapy, but the immobilized patient may be predisposed to osteo porosis, contractures, and pressure sores in as little as 24 hours. 12 Osteoporosis may also be a problem with medications that alter calcium metabolism, such as prednisone and related corticosteroids, 13 long-term heparin therapy, 14 and methotrexate. 15 Orthostatic hypotension, or a lowered blood pres sure when the patient changes from a supine to an erect position, may be distressing to him and may greatly decrease his ability or willingness to ambu late. Orthostatic hypotension may be a significant side effect of certain antidepressants, sleeping med ications, antihypertensives, and other medications. 16 Because many drugs in these classes of medications have similar counterparts to which the patient may not react unfavorably, this problem may be alle viated if the physician is willing to substitute a similar but equally effective medication. Drowsiness may be a result of a number of medications either as a predicted effect, such as a sleeping medication, or as a side effect, such as an analgesic. In some instances, when a patient's drug-induced drowsiness interferes with physical therapy, a simple change in the schedule of medication administration or of physical therapy may circumvent that problem. For example, if a patient is groggy in the morning for a few hours as a result of the sleeping medication taken the night before, it would be wise to avoid all physical therapy with that patient until this side effect has worn off.
macist, who can arrange, with the consent of the patient, to have the medications dispensed in standard, easy-to-open containers. 4. Be observant and don't hesitate to question the patient's physician, pharmacist, or nurse if the patient has recently developed a new symptom or problem.
Although medications may save many lives each year, they can also cause many problems. All health professionals should be aware of the potential ad verse effects of drug therapy and how they relate to their particular area of expertise. Certain drug ef fects may greatly influence a patient's ability to comply or cooperate with his prescribed physical therapy. This is particularly true of elderly persons. Approximately 10 percent of the population of the United States is in the age group of 65 or over. 1 This group, however, takes about 25 percent of the outpatient prescription medications dispensed. 2 From my observations and experience with elderly patients, it is also obvious that elderly persons consume a large amount of nonprescription (overthe-counter) medications.
PHYSIOLOGICAL RESPONSES Certain functional differences seen in elderly per sons may alter their responses to medications. As a person ages, the active and passive absorption through his intestinal mucosa is impaired. Some difficulty may therefore be experienced in achieving therapeutic drug levels in some elderly patients because many medications enter the bloodstream via these mechanisms. 3,4 Tissue perfusion and drug distribution in elderly persons may change resulting from an increase in body fat or a decrease in cardiac output causing a variability of tissue drug levels and drug response as compared to younger persons. 5 Excretion of medications via the kidneys decreases with an age-related decline in renal function. 5 The metabolism of medications by the liver may also diminish with age. 6 Since most medications are eliminated from the body by either the kidneys or the liver, or both, a slower elimination may result in high drug levels in body tissues. With many drugs, higher than recommended drug tissue levels may cause drug toxicity. Patients who are being treated for multiple dis ease states may be taking a large number of mediDr. Simonson is an Assistant Professor of Pharmaceutical Sci ence, Oregon State University, School of Pharmacy, Corvallis, OR 97330, and is a staff pharmacist with Corvallis Pharmacy Service, Inc.
178
cations and may therefore be subjected to a greater risk of experiencing a drug toxicity. 7 Patients 60 to 70 years old have almost twice the likelihood of experiencing an adverse drug reaction than do adults 30 to 40 years old. 8 Medications may interact with one another result ing in an altered therapeutic effect or in toxicity. The incidence of drug interactions increases with the number of medications that a patient takes. 7 These interactions may occur via various mecha nisms and may range from being clinically insignifi cant to being fatal. 9
COMPLIANCE AND MOTIVATION The inability or unwillingness of elderly patients to properly comply with their prescribed medication regimen is another area of concern. It has been said that "the failure of an elderly person to respond to an effective drug is nearly always due to the failure of the patient to take the drug rather than to absorb it." 10 Some studies performed to measure the degree of patient compliance have shown a remarkable (greater than 50 percent) incidence of improper compliance to outpatient prescription regimens. 11 This is not entirely a reflection of patient willingness but may result from an improper or incomplete understanding of instruction. For example, if a prescription reads "Take one capsule by mouth 4 times a day," Does this mean spaced evenly every 6 hours? Or should all of the doses be taken during the daylight hours? What about before meals? Or after? With a large glass of water? Or with milk? Why do elderly persons take medications? For a number of reasons. As a pharmacist, I can see that a large part of our society is strongly drug-oriented in that their first reaction is to take a "pill" when they have a complaint. This I believe to be largely due to the pressures exerted on health professionals by advertisers and distributors and also to pressures exerted on patients directly through advertising on television, radio, and in household magazines. Others believe that unnecessary prescriptions are the result of "the patient's expectation of a 'magic cure' and the physician's reluctance to admit his own limited ability to modify many conditions." 8
PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/58/2/178/4559691 by Washington University in St. Louis user on 28 February 2019
WILLIAM SIMONSON, Pharm D
SIDE EFFECTS
RECOMMENDATIONS The following recommendations will allow physi cal therapists to have a greater input into the therapy and management of their elderly patients. 1. If the patient has questions about the medica tions he is taking, encourage him to ask his pharmacist or physician or perhaps even assist the patient in contacting the appropriate person. 2. If you notice that the patient is having problems with home storage of medications or medication compliance, call the pharmacist or physician to inform him of this situation. 3. If the elderly patient has difficulty opening the child-resistant containers in which most medica tions are packaged, contact the patient's phar Volume 58 / Number 2, February 1978
CONCLUSIONS Elderly persons often face a myriad of drugassociated problems. The medications with which a patient is treated and the patient's therapy are the ultimate responsibility of the physician, but through our awareness and observations we can all take a greater part in the patient's treatment. Many adverse drug reactions could be avoided or eliminated if medications were treated with more respect. It is possible that the patient's entire state of well-being could be significantly improved as the result of your astute observations and comments which could be instrumental in detecting a patient's adverse reactions to medication. REFERENCES 1. Ostfeld AM, Gibson DC: Epidemiology of Aging. Bethesda, MD, US Department of Health, Education, and Welfare, #(NIH) 75-711, 1973 2. Silverman M, Lee PR: Pills, Profits and Politics. Berkeley, University of California Press, 1974, p 19 3. Koup JR, Tobias DE: Suspected digoxin malabsorption. Drug Intell Clin Pharm 8:645, 1974 4. Bender DA: Effects of age on intestinal absorption: Implica tions for drug absorption in the elderly. J Am Geriatr Soc 16:1331-1339, 1968 5. Holloway DA: Drug problems in the geriatric patient. Drug Intell Clin Pharm 8:633, 1974 6. Weg R: Drug interaction with the changing physiology of the aged: Practice and potential. In Davis RH (ed): Drugs and the Elderly. Los Angeles, Ethel Percy Andrus Gerontology Center, 1973, pp 71-91 7. Smith JW, Seidl LG, Cluff LE: Studies on the epidemiology of adverse drug reactions. Ann Int Med 65:629-640, 1966 8. Melmon KL: Preventable drug reactions: Causes and cures. New Engl J Med 284:1361-1368, 1971 9. Evaluation of Drug Interactions, ed 2. Washington, DC, American Pharmaceutical Association, 1976, pp 307-326 10. Hall MRP: Drug therapy in the elderly. Brit Med J 3:582584,1973 11. Hussar DA: Patient noncompliance. J Am Pharm Assoc NS15:183-190, 1975 12. Sanders JF: Evaluation of oxazepam and placebo in emotion ally disturbed aged patients. Geriatrics 20:739-746, 1965 13. de Lange WE, Doorenbos H: Corticotrophin and cortico steroids. In Dukes MNG (ed): Side Effects of Drugs, vol 8, Excerpta Medica, Amsterdam Oxford, 1975, pp 824-826 14. Loeliger EA: Drugs affecting blood clotting and fibrinolysis. In Dukes MNG (ed): Side Effects of Drugs, vol 8, Excerpta Medica, Amsterdam Oxford, 1975, p 768 15. Stenfert Kroese WF: Cytostatic drugs. In Dukes MNG (ed): Side Effects of Drugs, vol 8, Excerpta Medica, Amsterdam Oxford, 1975, p 965 16. Caird FI, Dall JLC: The cardiovascular system. In Brocklehurst JC (ed): Textbook of Geriatric Medicine and Gerontol ogy. Edinburgh and London, Churchill Livingstone, 1973, p 137
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Downloaded from https://academic.oup.com/ptj/article-abstract/58/2/178/4559691 by Washington University in St. Louis user on 28 February 2019
As physical therapists, you may observe certain problems which have been brought about because of patients' use or misuse of their medications. Immobility may result from an overuse of sedatives or tranquilizers. Not only would this impair re sponse to various forms of physical therapy, but the immobilized patient may be predisposed to osteo porosis, contractures, and pressure sores in as little as 24 hours. 12 Osteoporosis may also be a problem with medications that alter calcium metabolism, such as prednisone and related corticosteroids, 13 long-term heparin therapy, 14 and methotrexate. 15 Orthostatic hypotension, or a lowered blood pres sure when the patient changes from a supine to an erect position, may be distressing to him and may greatly decrease his ability or willingness to ambu late. Orthostatic hypotension may be a significant side effect of certain antidepressants, sleeping med ications, antihypertensives, and other medications. 16 Because many drugs in these classes of medications have similar counterparts to which the patient may not react unfavorably, this problem may be alle viated if the physician is willing to substitute a similar but equally effective medication. Drowsiness may be a result of a number of medications either as a predicted effect, such as a sleeping medication, or as a side effect, such as an analgesic. In some instances, when a patient's drug-induced drowsiness interferes with physical therapy, a simple change in the schedule of medication administration or of physical therapy may circumvent that problem. For example, if a patient is groggy in the morning for a few hours as a result of the sleeping medication taken the night before, it would be wise to avoid all physical therapy with that patient until this side effect has worn off.
macist, who can arrange, with the consent of the patient, to have the medications dispensed in standard, easy-to-open containers. 4. Be observant and don't hesitate to question the patient's physician, pharmacist, or nurse if the patient has recently developed a new symptom or problem.
