Skip to main content
SpringerLink
Log in

Arzneimitteltherapie im Alter

Wo liegen die Probleme? Was soll man tun, was muss man lassen?

Drug therapy in the elderly

What are the problems? What are the dos and don’ts?

  • Arzneimitteltherapie
  • Published:
Der Internist Aims and scope Submit manuscript

Zusammenfassung

Der Arzneimittelgebrauch steigt im höheren Lebensalter parallel zur Krankheitslast (Multimorbidität) deutlich an. Ältere Menschen haben häufigere und schwerere unerwünschte Arzneimittelwirkungen als jüngere. Unabdingbar für eine sichere Medikation ist die Beachtung von physiologischen Veränderungen im Alter und ihrer Bedeutung für Pharmakokinetik und Pharmakodynamik sowie eine kritische Indikationsstellung mit klar definierten, am individuellen Gesamtkonzept orientierten Zielen. Wichtig ist die Durchführung von geriatrischen Assessments, die u. a. die Aktivitäten des täglichen Lebens, den Grad der Selbständigkeit in der Versorgung, den kognitiven Status, die soziale Situation, den Hilfebedarf sowie den Ernährungszustand erfassen. Das kalendarische Alter eines Patienten ist dagegen ein eher untergeordnetes Maß für medikamentöse Therapieentscheidungen. Praktische Hilfen (Dispensiersysteme, Hilfe bei visuellen, taktilen oder kognitiven Einschränkungen etc.) können Adhärenz und Sicherheit und damit den Therapieerfolg verbessern. Erkennen und Vermeiden von unerwünschten Arzneimittelwirkungen könnte die bedeutendste Einzelmaßnahme bei den potenziell reversiblen Leiden des Alters sein. Listen mit im Alter ungeeigneten Arzneimitteln sind wegen ihrer kategorischen Empfehlungen nur bedingt zielführend. Wünschenswert wäre eine stärkere Beachtung patientenseitiger Faktoren, um risikoträchtige Medikationen zu vermeiden.

Abstract

With increasing age a clear increase in drug use exists in parallel with the age-related burden of disease. Elderly subjects have more frequent and more severe adverse drug reactions. Often polypharmacy causes a cascade which leads to the prescription of additional drugs to treat adverse drug reactions. To ensure safe medications, consideration of physiological changes and their relevance for pharmacodynamics and pharmacokinetics is necessary, as are critical prescription decisions with clearly defined individual therapeutic targets. Geriatric assessments should be performed more often. They comprise assessments of activities of daily living, the degree of autonomy and self-sufficiency, cognitive and nutritional status. Chronological age is only a minor criterion for prescription decisions. Practical help (dispensing devices, help when visual, tactile or cognitive impairments are present) will be able to improve adherence and thus safety and efficacy of drugs. Recognizing and preventing adverse drug reactions is probably the single most reversible affliction of geriatric medicine. Lists with potentially inappropriate medications (PIM) in the elderly are rather unsuitable due to their categorical character. Better consideration of patient-related factors and defining “potentially inappropriate patients (PIP)” seems preferable for preventing the prescription of risk-entailing medications.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3

Literatur

  1. Agency for Healthcare Research and Quality (2005) National Healthcare Quality Report. http://www.ahrq.gov/qual/nhqr05/nhqr05.htm

  2. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001) Guideline for the prevention of falls in older persons. J Am Geriatr Soc 49: 664–672

    Article  Google Scholar 

  3. Avorn J, Gurwitz JH, Bohn RL et al. (1995) Increased incidence of levodopa therapy following metoclopramide use. JAMA 274: 1780–1782

    Article  CAS  PubMed  Google Scholar 

  4. Avorn J, Shrank WH (2008) Adverse drug reactions in elderly people: A substantial cause of preventable illness. BMJ 336: 956–957

    Article  PubMed  Google Scholar 

  5. Barry PJ, Gallagher P, Ryan C, O’Mahony D (2007) START (screening tool to alert doctors to the right treatment) – an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 36: 632–638

    Article  CAS  PubMed  Google Scholar 

  6. Beers MH (1997) Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med 157: 1531–1536

    Article  CAS  PubMed  Google Scholar 

  7. Beers MH, Ouslander JG, Rollingher I et al. (1991) Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 151: 1825–1832

    Article  CAS  PubMed  Google Scholar 

  8. Berthold HK (2003) Problemfelder der Arzneimitteltherapie, 2. Aufl. In: Berthold HK (Hrsg) Klinikleitfaden Arzneimitteltherapie. Urban & Fischer, München Jena, S 125–200

  9. Berthold HK (2004) Die Bedeutung von Alter, Körperzusammensetzung und Nierenfunktion für eine optimierte Arzneitherapie. In: 28. Interdisziplinäres Forum der Bundesärztekammer „Fortschritt und Fortbildung in der Medizin“. Bundesärztekammer, Köln

  10. Boyd CM, Darer J, Boult C et al. (2005) Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 294: 716–724

    Article  CAS  PubMed  Google Scholar 

  11. Budnitz DS, Shehab N, Kegler SR, Richards CL (2007) Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med 147: 755–765

    PubMed  Google Scholar 

  12. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40: 373–383

    Article  CAS  PubMed  Google Scholar 

  13. Chrischilles EA, Segar ET, Wallace RB (1992) Self-reported adverse drug reactions and related resource use. A study of community-dwelling persons 65 years of age and older. Ann Intern Med 117: 634–640

    CAS  PubMed  Google Scholar 

  14. Cockcroft DW, Gault MH (1976) Prediction of creatinine clearance from serum creatinine. Nephron 16: 31–41

    Article  CAS  PubMed  Google Scholar 

  15. Ferri CP, Prince M, Brayne C et al. (2005) Global prevalence of dementia: a Delphi consensus study. Lancet 366: 2112–2117

    Article  PubMed  Google Scholar 

  16. Fialova D, Topinkova E, Gambassi G et al. (2005) Potentially inappropriate medication use among elderly home care patients in Europe. JAMA 293: 1348–1358

    Article  CAS  PubMed  Google Scholar 

  17. Fick DM, Cooper JW, Wade WE et al. (2003) Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 163: 2716–2724

    Article  PubMed  Google Scholar 

  18. Fortin M, Soubhi H, Hudon C et al. (2007) Multimorbidity’s many challenges. BMJ 334: 1016–1017

    Article  PubMed  Google Scholar 

  19. Gallagher P, O’Mahony D (2008) STOPP (Screening Tool of Older Persons‘ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers‘ criteria. Age Ageing 37: 673–679

    Article  PubMed  Google Scholar 

  20. Gallagher P, Ryan C, Byrne S et al. (2008) STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 46: 72–83

    CAS  PubMed  Google Scholar 

  21. Gurwitz JH, Field TS, Harrold LR et al. (2003) Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 289: 1107–1116

    Article  PubMed  Google Scholar 

  22. Handler SM, Hanlon JT, Perera S et al. (2008) Consensus list of signals to detect potential adverse drug reactions in nursing homes. J Am Geriatr Soc 56: 808–815

    Article  PubMed  Google Scholar 

  23. Holmes HM (2009) Rational prescribing for patients with a reduced life expectancy. Clin Pharmacol Ther 85: 103–107

    Article  CAS  PubMed  Google Scholar 

  24. Jano E, Aparasu RR (2007) Healthcare outcomes associated with beers‘ criteria: a systematic review. Ann Pharmacother 41: 438–447

    Article  PubMed  Google Scholar 

  25. Knight EL, Avorn J (2001) Quality indicators for appropriate medication use in vulnerable elders. Ann Intern Med 135: 703–710

    CAS  PubMed  Google Scholar 

  26. Laroche ML, Charmes JP, Merle L (2007) Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol 63: 725–731

    Article  PubMed  Google Scholar 

  27. Lechevallier-Michel N, Gautier-Bertrand M, Alperovitch A et al. (2005) Frequency and risk factors of potentially inappropriate medication use in a community-dwelling elderly population: results from the 3C Study. Eur J Clin Pharmacol 60: 813–819

    Article  PubMed  Google Scholar 

  28. Leipzig RM, Cumming RG, Tinetti ME (1999) Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 47: 30–39

    CAS  PubMed  Google Scholar 

  29. Levey AS, Bosch JP, Lewis JB et al. (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Modification of Diet in Renal Disease Study Group. Ann Intern Med 130: 461–470

    CAS  PubMed  Google Scholar 

  30. Lindeman RD, Tobin J, Shock NW (1985) Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 33: 278–285

    CAS  PubMed  Google Scholar 

  31. McLeod PJ, Huang AR, Tamblyn RM, Gayton DC (1997) Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 156: 385–391

    CAS  PubMed  Google Scholar 

  32. Qato DM, Alexander GC, Conti RM et al. (2008) Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA 300: 2867–2878

    Article  CAS  PubMed  Google Scholar 

  33. Ray WA, Griffin MR, Schaffner W et al. (1987) Psychotropic drug use and the risk of hip fracture. N Engl J Med 316: 363–369

    CAS  PubMed  Google Scholar 

  34. Robbins AS, Rubenstein LZ, Josephson KR et al. (1989) Predictors of falls among elderly people. Results of two population-based studies. Arch Intern Med 149: 1628–1633

    Article  CAS  PubMed  Google Scholar 

  35. Rochon PA, Gurwitz JH (1997) Optimising drug treatment for elderly people: the prescribing cascade. BMJ 315: 1096–1099

    CAS  PubMed  Google Scholar 

  36. Saxena S, Lawley D (2009) Delirium in the elderly: a clinical review. Postgrad Med J 85: 405–413

    Article  CAS  PubMed  Google Scholar 

  37. Schiff GD, Galanter WL (2009) Promoting more conservative prescribing. JAMA 301: 865–867

    Article  CAS  PubMed  Google Scholar 

  38. Schwabe U (2008) Arzneiverordnungen für ältere Patienten. In: Schwabe U, Paffrath D (Hrsg) Arzneiverordnungs-Report 2008. Springer, Berlin Heidelberg New York, S 923–960

  39. Sorock GS, Shimkin EE (1988) Benzodiazepine sedatives and the risk of falling in a community-dwelling elderly cohort. Arch Intern Med 148: 2441–2444

    Article  CAS  PubMed  Google Scholar 

  40. Spinewine A, Schmader KE, Barber N et al. (2007) Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 370: 173–184

    Article  PubMed  Google Scholar 

  41. Steinhagen-Thiessen E, Borchelt M (1999) Morbidity, medication, and functional limitations in very old age. In: Baltes PB, Mayer KU (eds) The Berlin Aging Study: Aging from 70 to 100. Cambridge University Press, Cambridge, pp 131–166

  42. Steinman MA, Rosenthal GE, Landefeld CS et al. (2009) Agreement between drugs-to-avoid criteria and expert assessments of problematic prescribing. Arch Intern Med 169: 1326–1332

    Article  PubMed  Google Scholar 

  43. Tinetti ME, Baker DI, King M et al. (2008) Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med 359: 252–261

    Article  CAS  PubMed  Google Scholar 

  44. Tinetti ME, Speechley M, Ginter SF (1988) Risk factors for falls among elderly persons living in the community. N Engl J Med 319: 1701–1707

    Article  CAS  PubMed  Google Scholar 

  45. Todd C, Skelton D (2004) What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe http://www.euro.who.int/document/E82552.pdf

  46. Van Spall HG, Toren A, Kiss A, Fowler RA (2007) Eligibility criteria of randomized controlled trials published in high-impact general medical journals: a systematic sampling review. JAMA 297: 1233–1240

    Article  Google Scholar 

  47. Zhan C, Sangl J, Bierman AS et al. (2001) Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 286: 2823–2829

    Article  CAS  PubMed  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor gibt an, dass kein Interessenkonflikt besteht.

Author information

Authors and Affiliations

  1. Geriatrie, Charité Universitätsmedizin Berlin und Evangelisches Geriatriezentrum Berlin gGmbH, Reinickendorfer Straße 61, 13347, Berlin, Deutschland

    H.K. Berthold & E. Steinhagen-Thiessen

Authors
  1. H.K. Berthold
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. Steinhagen-Thiessen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to H.K. Berthold.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Berthold, H., Steinhagen-Thiessen, E. Arzneimitteltherapie im Alter. Internist 50, 1415–1424 (2009). https://doi.org/10.1007/s00108-009-2518-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00108-009-2518-4

Schlüsselwörter

Keywords

Search

Navigation