Ulrike Sommeregger

Polypharmacy and pain treatment

SummaryPain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug–drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.ZusammenfassungSchmerzen betreffen besonders ältere und chronisch kranke Bevölkerungsgruppen. Häufig findet sich die Schmerztherapie als Ergänzung zu einer bereits bestehenden Polypharmazie. Neben unerwünschten Arzneimittelwirkungen sind es vor allem Interaktionen, welche es zu beachten gibt. Die Gruppe der nichtsteriodalen Antirheumatika (NSAR) hat das größte Gefahrenpotential. Im Vordergrund stehen gastrointestinale, kardiovaskuläre und renale Effekte sowie Wirkungen auf das Gerinnungssystem. Paracetamol hat neben der bekannten (in hohen Dosen) toxischen Wirkung auf die Leber, ähnliche Interaktionen wie die NSAR, allerdings in einem geringeren Ausmaß. Metamizol ist nach der aktuellen Studienlage besser als sein Ruf, das Interaktionspotential ist als gering anzusehen. Im Bezug auf Tramadol sowie auch einige stark wirksame Opioide (insbesondere Pethidin) sind vor allen das Serotonin-Syndrom und die ZNS dämpfende Wirkung zu nennen. Auf Grund des erheblichen Gefahrenpotentials bei einer bestehenden Polypharmazie ist es in vielen Fällen ratsam, bei der Auswahl der Analgetika vom WHO-Stufenschema in der Schmerzbehandlung abzusehen.Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.

Management und Therapie des Vorhofflimmerns beim geriatrischen Patienten

Among geriatric patients, atrial fibrillation is the most common cardiac arrhythmia. In patients over 80 years of age, the prevalence rises to approximately 10%. Atrial fibrillation is associated with serious health implications, including a 2-fold increase in mortality risk and a 5-fold increase in stroke risk. In contrast to these facts, the current guidelines on the management of atrial fibrillation of the European Society of Cardiology (ESC) contain only a short paragraph on these patients. Many relevant clinical aspects go without any comment. Thus, the purpose of our paper is to discuss those special needs of geriatric patients and their physicians which are not mentioned in the guidelines of the ESC. In our review, we discuss rhythm versus rate control, oral anticoagulation, outcome, prevention, falls, adherence, polypharmacy, dementia, nursing home patients, frailty, and geriatric assessment in consideration of geriatric patients. An extended search of the literature on Pubmed served as the basis for this review. Individual aspects of each geriatric patient should be considered when managing these complex patients; however, the complexity of each case must not lead to an individualized therapy that is not in accordance with current guidelines and the literature. A large number of papers which help us to answer most of the clinical questions regarding the management of trial fibrillation in geriatric patients have already been published.

Management and therapy of atrial fibrillation in geriatric patients

Among geriatric patients, atrial fibrillation is the most common cardiac arrhythmia. In patients over 80 years of age, the prevalence rises to approximately 10%. Atrial fibrillation is associated with serious health implications, including a 2-fold increase in mortality risk and a 5-fold increase in stroke risk. In contrast to these facts, the current guidelines on the management of atrial fibrillation of the European Society of Cardiology (ESC) contain only a short paragraph on these patients. Many relevant clinical aspects go without any comment. Thus, the purpose of our paper is to discuss those special needs of geriatric patients and their physicians which are not mentioned in the guidelines of the ESC. In our review, we discuss rhythm versus rate control, oral anticoagulation, outcome, prevention, falls, adherence, polypharmacy, dementia, nursing home patients, frailty, and geriatric assessment in consideration of geriatric patients. An extended search of the literature on Pubmed served as the basis for this review. Individual aspects of each geriatric patient should be considered when managing these complex patients; however, the complexity of each case must not lead to an individualized therapy that is not in accordance with current guidelines and the literature. A large number of papers which help us to answer most of the clinical questions regarding the management of trial fibrillation in geriatric patients have already been published.

Polypharmazie und Schmerztherapie

SummaryPain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug–drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.ZusammenfassungSchmerzen betreffen besonders ältere und chronisch kranke Bevölkerungsgruppen. Häufig findet sich die Schmerztherapie als Ergänzung zu einer bereits bestehenden Polypharmazie. Neben unerwünschten Arzneimittelwirkungen sind es vor allem Interaktionen, welche es zu beachten gibt. Die Gruppe der nichtsteriodalen Antirheumatika (NSAR) hat das größte Gefahrenpotential. Im Vordergrund stehen gastrointestinale, kardiovaskuläre und renale Effekte sowie Wirkungen auf das Gerinnungssystem. Paracetamol hat neben der bekannten (in hohen Dosen) toxischen Wirkung auf die Leber, ähnliche Interaktionen wie die NSAR, allerdings in einem geringeren Ausmaß. Metamizol ist nach der aktuellen Studienlage besser als sein Ruf, das Interaktionspotential ist als gering anzusehen. Im Bezug auf Tramadol sowie auch einige stark wirksame Opioide (insbesondere Pethidin) sind vor allen das Serotonin-Syndrom und die ZNS dämpfende Wirkung zu nennen. Auf Grund des erheblichen Gefahrenpotentials bei einer bestehenden Polypharmazie ist es in vielen Fällen ratsam, bei der Auswahl der Analgetika vom WHO-Stufenschema in der Schmerzbehandlung abzusehen.Pain is a frequent symptom in clinical practice. Elderly and chronically ill patients are particularly affected. On account of the high prevalence of polypharmacy among these patients, pharmacological pain therapy becomes a challenge for physicians. Drug side effects and drug-drug interactions have to be taken into account so as to minimize the health risk for these patients. Especially the group of NSAID has a high risk of adverse drug reactions and drug interactions. The gastrointestinal, the cardiovascular, the renal and the coagulation system are particularly affected. Except for the toxic effect on the liver (in a high dose) Paracetamol (acetaminophen) has similar risks, to a minor degree, though. According to current data Metamizol is actually better than its reputation. The risk of potential drug interactions seems to be low. Beside the risk of sedation in combination with other drugs, Tramadol and other opioids such as Pethidin may induce the Serotonin syndrome. In order to avoid dangerous drug interactions and adverse side effects in the case of polypharmacy, it is recommended to prefer individual choices instead of sticking to the pain management as proposed by the WHO.

Polypharmazie in der Kardiologie – ein beachtliches Problem bei Synkopen, QT-Zeit-Verlängerung, Bradykardie und Tachykardie

SummaryQuality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.ZusammenfassungSpektakuläre Innovationen prägen das Fachgebiet der Kardiologie im letzten Dezennium. Das Management des akuten Koronarsyndroms mit invasiven und medikamentösen Methoden, die Behandlung der Herzinsuffizienz und die Klappenersatzoperationen wurden zum Wohle der betroffenen Patienten verbessert. Gleichzeitig sind Kardiologen und alle betreuenden Ärzte mit einem Wandel der Patientencharakteristik konfrontiert. Begleiterkrankungen, Multimorbidität und die damit einhergehende Problematik der Polypharmazie erfordern klare Konzepte. Diagnostische und therapeutische Ansätze der geriatrischen Medizin bieten Ansätze zur Optimierung des therapeutischen Vorgehens in dieser Situation.Quality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.

Medikamenten-induzierte Delirien älterer Menschen

Drugs have been widely associated with the development of delirium in the elderly and represent the most common reversible cause of this condition. This is of importance since successful treatment depends on identifying the reversible contributing factors. Medications with anticholinergic properties, tranquilizers, analgesics and narcotics are common causes of drug-induced delirium. This article provides practical approach to prevent and recognise this condition, reviews the underlying neurotransmitter imbalances and reconsiders age-related changes of pharmacological effects, which may contribute to the development of delirium.SummaryDrugs have been widely associated with the development of delirium in the elderly and represent the most common reversible cause of this condition. This is of importance since successful treatment depends on identifying the reversible contributing factors. Medications with anticholinergic properties, tranquilizers, analgesics and narcotics are common causes of drug-induced delirium. This article provides practical approach to prevent and recognise this condition, reviews the underlying neurotransmitter imbalances and reconsiders age-related changes of pharmacological effects, which may contribute to the development of delirium.ZusammenfassungMedikamente sind häufige Auslöser von Delirien älterer Menschen und stellen dabei die häufigste reversible Ursache dar – dies ist von besonderer Bedeutung, da die Identifikation auslösender Faktoren die Grundlage einer erfolgreichen Therapie darstellt. Anticholinerg wirksame Medikamente, Tranquilizer, Schmerzmittel und Narkotika sind geläufige Auslöser von Delirien. Dieser Artikel bietet eine klinisch orientierte Übersicht über Prävention und Diagnose pharmakogener Delirien. Neben altersassoziierten Veränderungen der Pharmakologie werden die zu Grunde liegenden pathophysiologischen Mechanismen vor dem Hintergrund der involvierten Neurotransmitter dargestellt.

Polypharmazie und Stürze im Alter

Falls and their consequences are a major problem in geriatric medicine. Main causes are the combination of age-related physiological changes with multimorbidity and subsequent polypharmacy. Elderly patients are more susceptible to adverse drug effects and have less compensatory capacity than younger adults. Therefore careful monitoring of side effects is indicated and prescribing for elderly patients calls for alertness in order to identify symptoms as possible adverse drug effects.SummaryFalls and their consequences are a major problem in geriatric medicine. Main causes are the combination of age-related physiological changes with multimorbidity and subsequent polypharmacy. Elderly patients are more susceptible to adverse drug effects and have less compensatory capacity than younger adults. Therefore careful monitoring of side effects is indicated and prescribing for elderly patients calls for alertness in order to identify symptoms as possible adverse drug effects.ZusammenfassungStürze und ihre Folgen gehören zu den Hauptproblemen der Geriatrie. Neben altersphysiologischen Veränderungen spielt Multimorbidität und die sich daraus ergebende Polypharmazie dabei eine wesentliche Rolle. Ältere Menschen zeigen eine erhöhte Empfindlichkeit für Nebenwirkungen und eine verminderte Kompensationsfähigkeit in der Aufrechterhaltung der Homöostase. Deshalb ist eine erhöhte Aufmerksamkeit für mögliche unerwünschte Nebenwirkungen oder Interaktionen und eine verstärkte begleitende Kontrolle notwendiger Dauermedikation notwendig.

[Drug-related delirium in elderly patients].

Drugs have been widely associated with the development of delirium in the elderly and represent the most common reversible cause of this condition. This is of importance since successful treatment depends on identifying the reversible contributing factors. Medications with anticholinergic properties, tranquilizers, analgesics and narcotics are common causes of drug-induced delirium. This article provides practical approach to prevent and recognise this condition, reviews the underlying neurotransmitter imbalances and reconsiders age-related changes of pharmacological effects, which may contribute to the development of delirium.SummaryDrugs have been widely associated with the development of delirium in the elderly and represent the most common reversible cause of this condition. This is of importance since successful treatment depends on identifying the reversible contributing factors. Medications with anticholinergic properties, tranquilizers, analgesics and narcotics are common causes of drug-induced delirium. This article provides practical approach to prevent and recognise this condition, reviews the underlying neurotransmitter imbalances and reconsiders age-related changes of pharmacological effects, which may contribute to the development of delirium.ZusammenfassungMedikamente sind häufige Auslöser von Delirien älterer Menschen und stellen dabei die häufigste reversible Ursache dar – dies ist von besonderer Bedeutung, da die Identifikation auslösender Faktoren die Grundlage einer erfolgreichen Therapie darstellt. Anticholinerg wirksame Medikamente, Tranquilizer, Schmerzmittel und Narkotika sind geläufige Auslöser von Delirien. Dieser Artikel bietet eine klinisch orientierte Übersicht über Prävention und Diagnose pharmakogener Delirien. Neben altersassoziierten Veränderungen der Pharmakologie werden die zu Grunde liegenden pathophysiologischen Mechanismen vor dem Hintergrund der involvierten Neurotransmitter dargestellt.

DEL-FINE: a new tool for assessing the delirogenic properties of drugs of relevance for European pharmacotherapy

This article presents a list of potentially delirogenic properties of drugs that are currently of relevance to drug therapy in Europe, which was created through a Delphi process including experts from professions relevant to diagnosis and treatment of delirium. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) defines delirium as a disturbance in attention, awareness and cognition that develops over a short period of time and fluctuates. Possible causes of delirium are manifold: usually delirium is considered to develop in a multifactorial way, caused by inalterable parameters, such as advanced age and pre-existing cognitive impairment and precipitated by modifiable parameters, such as the use of certain drugs or substance withdrawal. Delirium is a serious condition with a pronounced impact on morbidity, mortality and costs to the healthcare system. Circumstances and drugs that might precipitate or worsen delirium should therefore be avoided whenever possible. A list of drugs that might have a detrimental influence on the emergence and duration of delirium has been created using the terms “delirogenity” and “delirogenic” to describe the potential of a drug or withdrawal to cause or worsen delirium. The results are novel and noteworthy, as their focus is on substances relevant to European pharmacotherapy. Furthermore, they represent a methodical consensus from a group of experts of a wide variety of professions relevant to the prevention, diagnosis and treatment of delirium, such as nursing, pharmacy, pharmacology, surgical and internal medicine, neurology, psychiatry, intensive care and medicine, with working, teaching and scientific experience in several European countries practicing both in primary and secondary care.ZusammenfassungIn diesem Beitrag wird eine Aufstellung von Arzneimitteln vorgestellt, die für die aktuelle Pharmakotherapie in Europa relevant sind und die potentiell delirogene Eigenschaften aufweisen. Diese Liste wurde durch einen Delphi-Prozess, unter Mitbeteiligung von Berufen, die für die Delirdiagnose und -behandlung von Relevanz sind, erstellt. Das „Diagnostic and Statistical Manual of Mental Disorders 5“ (DSM 5) definiert ein Delir als eine Störung von Aufmerksamkeit, Bewusstsein und Wahrnehmung, die sich innerhalb kurzer Zeit entwickelt und fluktuiert. Die möglichen Ursachen für eine Delirentwicklung sind zahlreich: Generell geht man von einer multifaktoriellen Genese aus, die einerseits von vorgegebenen Parametern, wie vorgerücktem Alter oder bereits vorbestehenden kognitiven Einschränkungen, und andererseits durch modifizierbare Einflüsse, wie den Einsatz bestimmter Arzneimittel oder Substanzentzug, beeinflusst wird. Das Durchleben eines Delirs ist eine für die Betroffenen einschneidend grausame Erfahrung, die von einer deutlich erhöhten Morbidität, Mortalität und finanziellen Belastungen für das Gesundheitssystem begleitet wird. Begleitumstände und der Einsatz von Substanzen, die ein Delir auslösen oder verschlimmern können sollten daher tunlichst vermieden werden. Eine Liste von Arzneimitteln, die ein Delir auslösen und einen ungünstigen Einfluss auf dessen Dauer haben können, wurde erstellt. Dabei wurden die Termini „Delirogenität“ und „delirogen“ verwendet, um das Potenzial eines Wirkstoffs zu charakterisieren, der selbst oder durch seinen Entzug ein Delir auslösen oder verschlechtern kann. Die Ergebnisse besitzen insofern einen beachtenswerten Neuwert, als dass der Fokus auf Arzneimitteln lag, welche für die medikamentöse Therapie in Europa repräsentativ sind. Zusätzlich sind sie der Konsensus einer Expertengruppe, die ein breites Spektrums an Berufen repräsentiert, die für Prävention, Diagnose und Therapie des Delirs relevant sind, wie z.B. Pflege, Pharmazie, Pharmakologie, chirurgische und konservative Medizin, Psychiatrie, Neurologie und Intensivmedizin. Die Delphi-Gruppe wies Erfahrung in mehreren europäischen Ländern im extra- und intramuralen Bereich, sowie in Lehre und Wissenschaft auf.

Polypharmacy and falls in the Elderly

Falls and their consequences are a major problem in geriatric medicine. Main causes are the combination of age-related physiological changes with multimorbidity and subsequent polypharmacy. Elderly patients are more susceptible to adverse drug effects and have less compensatory capacity than younger adults. Therefore careful monitoring of side effects is indicated and prescribing for elderly patients calls for alertness in order to identify symptoms as possible adverse drug effects.SummaryFalls and their consequences are a major problem in geriatric medicine. Main causes are the combination of age-related physiological changes with multimorbidity and subsequent polypharmacy. Elderly patients are more susceptible to adverse drug effects and have less compensatory capacity than younger adults. Therefore careful monitoring of side effects is indicated and prescribing for elderly patients calls for alertness in order to identify symptoms as possible adverse drug effects.ZusammenfassungStürze und ihre Folgen gehören zu den Hauptproblemen der Geriatrie. Neben altersphysiologischen Veränderungen spielt Multimorbidität und die sich daraus ergebende Polypharmazie dabei eine wesentliche Rolle. Ältere Menschen zeigen eine erhöhte Empfindlichkeit für Nebenwirkungen und eine verminderte Kompensationsfähigkeit in der Aufrechterhaltung der Homöostase. Deshalb ist eine erhöhte Aufmerksamkeit für mögliche unerwünschte Nebenwirkungen oder Interaktionen und eine verstärkte begleitende Kontrolle notwendiger Dauermedikation notwendig.