• Response to P-adrenoceptor agonists and antagonists appears to be blunted in old age partly, it is believed, through reduction in the number of receptors.

• Baroreceptor sensitivity is reduced leading to the potential for orthostatic hypotension with drugs that reduce blood pressure.

These pharmacokinetic and pharmacodynamic differences, together with broader issues particular to the elderly find expression in the choice and use of drugs for this age group, as follows:

Rules of prescribing for the elderly35

1. Think about the necessity for drugs. Is the diagnosis correct and complete? Is the drug really necessary? Is there a better alternative?

2. Do not prescribe drugs that are not useful. Think carefully before giving an old person a drug that may have major side-effects, and consider alternatives.

3. Think about the dose. Is it appropriate to possible alterations in the patient's physiological state? Is it appropriate to the patient's renal and hepatic function at the time?

4. Think about drug formulation. Is a tablet the most appropriate form of drug or would an injection, a suppository or a syrup be better? Is the drug suitably packaged for the elderly patient, bearing in mind any disabilities?

5. Assume any new symptoms may be due to drug side-effects, or more rarely, to drug withdrawal. Rarely (if ever) treat a side-effect of one drug with another.

6. Take a careful drug history. Bear in mind the possibility of interaction with substances the patient may be taking without your knowledge, such as herbal or other nonprescribed remedies, old drugs taken from the medicine cabinet or drugs obtained from friends.

7. Use fixed combinations of drugs only when they are logical and well studied and they either aid compliance or improve tolerance or

35 By permission from Caird F I (ed) 1985 Drugs for the elderly. WHO (Europe) Copenhagen.

efficacy. Few fixed combinations meet this standard.

8. When adding a new drug to the therapeutic regimen, see whether another can be withdrawn.

9. Attempt to check whether the patient's compliance is adequate, e.g. by counting remaining tablets. Has the patient (or relatives) been properly instructed?

10. Remember that stopping a drug is as important as starting it.

The old (80+ years) are particulary intolerant of neuroleptics (given for confusion) and of diuretics (given for ankle swelling that is postural and not due to heart failure) which cause adverse electrolyte changes. Both classes of drug may result in admission to hospital of semicomatose 'senior citizens' who deserve better treatment from their juniors.

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