Advertisement

Drugs & Aging

, Volume 1, Issue 1, pp 67–89 | Cite as

Poisoning in the Elderly

Epidemiological, Clinical and Management Considerations
  • Wendy Klein-Schwartz
  • Gary M. Oderda
Adverse Effects

Summary

Poisoning is a significant problem in the elderly. The majority of poisonings in older people are unintentional and may result from dementia and confusion, improper use of the product, improper storage or mistaken identities. Depression is also common in the elderly and suicide attempts are more likely to be successful in this age group. The elderly patient’s recuperative abilities may be inadequate as a result of numerous factors including impaired hepatic or renal function as well as chronic disease processes.

General management of poisoning in the elderly parallels management of younger adults, but it is especially important to ascertain underlying medical conditions and concurrent medications. In most poisonings, activated charcoal and cathartic are sufficient. Haemodialysis or haemoperfusion may be required at lower plasma drug concentrations in elderly patients. While the specific indications for antidotes are the same for all age groups, dosage alterations and precautions may need to be considered in the elderly.

Drugs most often implicated in poisonings in the elderly include psychotherapeutic drugs, cardiovascular drugs, analgesics and anti-inflammatory drugs, oral hypoglycaemics and theophylline.

Cardiovascular and neurological toxicities occur with overdoses of neuroleptic drugs and, more frequently and severely, with cyclic antidepressants. Patients with pre-existing cardiovascular disease are at particular risk of worsening ischaemic heart disease and congestive heart failure. Benzodiazepines only appear to produce significant toxicity during long term administration or in combination with other CNS depressants.

Digoxin can cause both chronic and acute intoxication, most seriously cardiac toxicity including severe ventricular arrhythmias, second or third degree heart block or severe refractory hyperkalaemia. Immune Fab antibody is indicated for the management of digoxin toxicity, although patients dependent on the inotropic effect of digoxin may develop heart failure after digoxin Fab antibody administration. Nitrates can cause toxicity including headache, vomiting, hypotension and tachycardia from excessive sublingual, transdermal or intravenous doses. Conduction disturbances and hypotension occur with overdoses of antihypertensive drugs; these effects are mild with angiotensin converting enzyme (ACE) inhibitors, occasionally severe with β- blockers and of significant concern with calcium channel antagonists.

The elderly commonly use aspirin and other salicylates, are more likely to develop chronic intoxications to these agents, and are more susceptible to severe complications such as pulmonary oedema. Salicylate poisoning, recognition of which is often delayed, should be considered in elderly patients with neurological abnormalities or breathing difficulties, especially in the setting of acid-base abnormalities. The clinical effects of NSAID overdose are mild and usually involve the central nervous system and gastrointestinal tract.

Elderly patients are also more likely to develop hypoglycaemia when taking sulphonylurea agents even with therapeutic doses. Seizures and arrhythmias occur at lower serum theophylline concentrations in the elderly.

Poison prevention efforts aimed at unintentional exposures are primarily focused on preventing toxic exposures from occurring and minimising the consequences of injury should a toxic exposure occur. Several potential poison prevention strategies are outlined below.

Keywords

Digoxin Theophylline Activate Charcoal Ipecac Psychotherapeutic Drug 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Adams DH, Michael J, Bacon PA, et al. Nonsteroidal antiinflammatory drugs and renal failure. Lancet 1: 57–60, 1986PubMedCrossRefGoogle Scholar
  2. Agura ED, Wexler LF, Witzburg RA. Massive propranolol overdose: successful treatment with high-dose isoproterenol and glucagon. American Journal of Medicine 80: 755–757, 1986CrossRefGoogle Scholar
  3. Anderson RJ, Potts DE, Gabow PA, Rumack BH, Schrier RW. Unrecognized adult salicylate intoxication. Annals of Internal Medicine 85: 745–748, 1976PubMedGoogle Scholar
  4. Anthony T, Jastremski M, Elliot W, et al. Charcoal hemoperfusion for the treatment of a combined diltiazem and metoprolol overdose. Annals of Emergency Medicine 15: 1344–1348, 1986PubMedCrossRefGoogle Scholar
  5. Asplund K, Wiholm BE, Lithner F. Glibenclamide-associated hypoglycaemia: a report on 57 cases. Diabetologia 24: 412–417, 1983PubMedCrossRefGoogle Scholar
  6. Auerbach PS, Osterloh J, Braun O, Hu P, Beehr EC, et al. Efficacy of gastric emptying: gastric lavage versus emesis induced with ipecac. Annals of Emergency Medicine 15: 692–698, 1986PubMedCrossRefGoogle Scholar
  7. Augenstein WL, Kulig KW, Rumack BH. Captopril overdose resulting in hypotension. Journal of the American Medical Association 259: 3302–3305, 1988PubMedCrossRefGoogle Scholar
  8. Barry D, Meyskens FL, Becker CE. Phenothiazine poisoning: a review of 48 cases. California Medicine 118: 1–5, 1973PubMedGoogle Scholar
  9. Boehnert MT, Lovejoy FH. Value of the QRS duration versus the serum drug level in predicting seizures and ventricular arrhythmias after an acute overdose of tricyclic antidepressant. New England Journal of Medicine 313: 474–479, 1985PubMedCrossRefGoogle Scholar
  10. Boldy DAR, Smart V, Vale JA. Multiple doses of charcoal in digoxin poisoning. Lancet 1: 1076–1077, 1985CrossRefGoogle Scholar
  11. Bresnahan JF, Vlietstra EE. Digitalis glycosides. Mayo Clinic Proceedings 54: 675–684, 1979PubMedGoogle Scholar
  12. Brogden RN, Goa KL. Flumazenil: a preliminary review of its benzodiazepine antagonist properties, intrinsic activity and therapeutic use. Drugs 35: 448–467, 1988PubMedCrossRefGoogle Scholar
  13. Buenger JW, Mauro VF. Organic nitrate-induced methemoglobinemia. DICP, Annals of Pharmacotherapy 23: 283–288, 1989Google Scholar
  14. Buiumsohn A, Eisenberg ES, Jacob H, Rosen N, et al. Seizures and intraventricular conduction defect in propranolol poisoning: a report of two cases. Annals of Internal Medicine 91: 860–862, 1979PubMedGoogle Scholar
  15. Callaham M, Kassel D. Epidemiology of fatal tricyclic antidepressant ingestion: implications for management. Annals of Emergency Medicine 14: 1–9, 1985PubMedCrossRefGoogle Scholar
  16. Coates JR, Robbins JJ. Severe hypoglycemic shock due to chlorpropamide. Journal of the American Medical Association 170: 941–943, 1959PubMedCrossRefGoogle Scholar
  17. Cole PL, Smith TW. Use of digoxin-specific Fab fragments in the treatment of digitalis intoxication. Drug Intelligence and Clinical Pharmacy 20: 267–270, 1986PubMedGoogle Scholar
  18. Corre KA, Niemann JT, Bessen HA. Extended therapy for acute dystonic reactions. Annals of Emergency Medicine 13: 194–197, 1984PubMedCrossRefGoogle Scholar
  19. Cosnett JE. Tolbutamide overdosage and irreversible cerebral damage: a case report. South African Medical Journal 35: 43–44, 1961PubMedGoogle Scholar
  20. Crane GE. Cardiac toxicity and psychotropic drugs. Diseases of the Nervous System 31: 534–539, 1970PubMedGoogle Scholar
  21. Critchely JAJH, Ungar A. The management of acute poisoning due to β-adrenoceptor antagonists. Medical Toxicology 4: 32–45, 1989Google Scholar
  22. Curtis RA, Barone J, Giacona N. Efficacy of ipecac and activated charcoal/cathartic: prevention of salicylate absorption in a simulated overdose. Archives of Internal Medicine 144: 48–52, 1984PubMedCrossRefGoogle Scholar
  23. Davenport J. Cardiovascular effects of antidepressants: avoiding cardiotoxicity in the elderly. Postgraduate Medicine 84: 105–115, 1988PubMedGoogle Scholar
  24. Done AK. Aspirin overdosage incidence, diagnosis and management. Pediatrics 62 (Suppl.): 890–897, 1978PubMedGoogle Scholar
  25. Downs M. To the Editor. Journal of Emergency Medicine 7: 533, 1989PubMedCrossRefGoogle Scholar
  26. Elkayam V, Frishman W. Cardiovascular effects of phenothiazines. American Heart Journal 100: 397–401, 1980PubMedCrossRefGoogle Scholar
  27. Ellenhorn MJ, Barceloux DG. Nitrates, nitrites, and methemoglobinemia. In Medical toxicology: diagnosis and treatment of human poisoning, pp. 844–852, Elsevier, New York, 1988Google Scholar
  28. Everitt DE, Avorn J. Drug prescribing for the elderly. Archives of Internal Medicine 146: 2393 1986PubMedCrossRefGoogle Scholar
  29. Foulke GE, Alberton TE, Walby WF. Tricyclic antidepressant overdose: emergency department findings as predictors of clinical course. American Journal of Emergency Medicine 4: 496–500, 1986PubMedCrossRefGoogle Scholar
  30. Garrelts JC, Watson WA, Holloway KD, Sweet DE. Magnesium toxicity secondary to catharsis during management of theophylline poisoning. American Journal of Emergency Medicine 7: 34–37, 1989PubMedCrossRefGoogle Scholar
  31. Goldberg MJ, Spector R, Park GD, Johnson GF, Roberts P. The effect of sorbitol and activated charcoal on serum theophylline concentrations after slow-release theophylline. Clinical Pharmacology and Therapeutics 41: 108–111, 1987PubMedCrossRefGoogle Scholar
  32. Greenblatt DJ, Allen MD, Noel BJ, Shader RI. Acute overdosage with benzodiazepine derivatives. Clinical Pharmacology and Therapeutics 21: 497–514, 1977PubMedGoogle Scholar
  33. Greer HD, Ward HP, Corbin KB. Chronic salicylate intoxication in adults. Journal of the American Medical Association 193: 85–88, 1965CrossRefGoogle Scholar
  34. Haddon W, Baker SP. Injury control. In Clard D (Ed.) Preventive and community medicine, pp. 109–140, Little, Brown and Company, Boston, 1981Google Scholar
  35. Heath A, Knudsen K. Role of extracorporeal drug removal in acute theophylline poisoning. Medical Toxicology 2: 294–308, 1987PubMedGoogle Scholar
  36. Heffner JE, Sahn SA. Salicylate-induced pulmonary edema, clinical features and diagnosis. Annals of Internal Medicine 95: 405–409, 1981PubMedGoogle Scholar
  37. Herrington DM, Insley BM, Weinman GG. Nifedipine overdose. American Journal of Medicine 81: 344–346, 1986PubMedCrossRefGoogle Scholar
  38. Hoffman JR, McElroy CR. Bicarbonate therapy for dysrhythmia and hypotension in tricyclic antidepressant overdose. Western Journal of Medicine 134: 60–64, 1981PubMedGoogle Scholar
  39. Hormaechea E, Carlson RW, Rogove H, Uphold J, Henning RJ, et al. Hypovolemia, pulmonary edema and protein changes in severe salicylate poisoning. American Journal of Medicine 66: 1046–1050, 1979PubMedCrossRefGoogle Scholar
  40. Hurwitz MD, Kallenbach JM, Pincus PS. Massive propranolol overdose. American Journal of Medicine 81: 1118 1986PubMedCrossRefGoogle Scholar
  41. Jusko WJ, Gardner MJ, Mangoine A, Schentag JJ, Koup JR, et al. Factors affecting theophylline clearances: age, tobacco, marijuana, cirrhosis, congestive heart failure, obesity, oral contraceptives, benzodiazepines, barbiturates and ethanol. Journal of Pharmaceutical Sciences 68: 1358–1366, 1979PubMedCrossRefGoogle Scholar
  42. Kingston ME. Hyperventilation in tricyclic antidepressant poisoning. Critical Care Medicine 7: 550–551, 1979PubMedCrossRefGoogle Scholar
  43. Klein-Schwartz W, Gorman RL, Orderda GM, Wedin GP, Saggar D. Ipecac use in the elderly: the unanswered question. Annals of Emergency Medicine 13: 1152–1154, 1984PubMedCrossRefGoogle Scholar
  44. Klein-Schwartz W, Oderda GM, Booze L. Poisoning in the eldcrly. Journal of the American Geriatrics Society 31: 195–199, 1983PubMedGoogle Scholar
  45. Kounis NG. Asystole after verapamil and digoxin. British Journal of Clinical Practice 34: 57–58, 1980PubMedGoogle Scholar
  46. Kulig K, Bar-Or D, Cantrill SV, Rumack BH, Rosen P. Management of acutely poisoned patients without gastric emptying. Annals of Emergency Medicine 14: 562–567, 1985PubMedCrossRefGoogle Scholar
  47. Kulig K, Rumack BH, Sullivan JB, Brandt H, Spyker DA, et al. Amoxapine overdose: coma and seizures without cardiotoxic effects. Journal of the American Medical Association 248: 1092–1094, 1982PubMedCrossRefGoogle Scholar
  48. Lalonde RL, Deshpande R, Hamilton PP, McLean WM, Green-way DC. Acceleration of digoxin clearance by activated charcoal. Clinical Pharmacy and Therapeutics 37: 367–371, 1985CrossRefGoogle Scholar
  49. Lamy PP. Prescribing for the elderly. PSG Publishing Inc., Littleton, Massachusetts, 1980Google Scholar
  50. Lau CP. Attempted suicide with enalapril. New England Journal of Medicine 315: 197, 1986PubMedGoogle Scholar
  51. Laufen H, Leitold M. The effect of activated charcoal on the bio-availability of piroxicam in man. International Journal of Clinical Pharmacology, Therapy and Toxicology 24: 48–52, 1986Google Scholar
  52. Litovitz T. Fatal benzodiazepine toxicity? American Journal of Emergency Medicine 5: 472, 1987Google Scholar
  53. Litovitz TL, Schmitz BF, Bailey KM. 1989 Annual report of the American Association of Poison Control Centers National Data Collection System. American Journal of Emergency Medicine, in press, 1990Google Scholar
  54. Litovitz TL, Troutman WG. Amoxapine overdose, seizures and fatalities. Journal of the American Medical Association 250: 1069–1071, 1983PubMedCrossRefGoogle Scholar
  55. Manoguerra AS, Krenzelok EP. Rapid emesis from high-dose ipecac syrup in adults and children intoxicated with antiemetics or other drugs. American Journal of Hospital Pharmacy 351: 1360–1362, 1978Google Scholar
  56. Marrs-Simon PA, Zell-Kanter M, Kendzierski DL, Leikin JB. Cardiotoxic manifestations of mesoridazine overdose. Annals of Emergency Medicine 17: 1074–1078, 1988PubMedCrossRefGoogle Scholar
  57. Marshall JB, Ecklund RE. Methemoglobinemia from overdose of nitroglycerin. Journal of the American Medical Association 244: 330, 1980PubMedCrossRefGoogle Scholar
  58. Martinez R, Smith DW, Frankel LR. Severe metabolic acidosis after acute naproxen sodium ingestion. Annals of Emergency Medicine 18: 129–131, 1989Google Scholar
  59. Maryland Poison Center 1989 Statistical Report. Toxalert 7: 1–4, 1990Google Scholar
  60. McKendry JBR. Fatal hypoglycaemic coma from the use of tolbutamide (Orinase). Canadian Medical Association Journal 76: 572–573, 1957PubMedGoogle Scholar
  61. Montamat SC, Cusack BJ, Vestal RE. Management of drug therapy in the elderly. New England Journal of Medicine 321: 303–309, 1989PubMedCrossRefGoogle Scholar
  62. Neuvonen PJ, Karkkainen S. Effects of charcoal, sodium bicarbonate, and ammonium chloride on chlorpropamide kinetics. Clinical Pharmacology and Therapeutics 33: 386–393, 1983PubMedCrossRefGoogle Scholar
  63. Neuvonen PJ, Vartiainen M, Tokola O. Comparison of activated charcoal and ipecac syrup in prevention of drug absorption. European Journal of Clinical Pharmacology 24: 557–562, 1983PubMedCrossRefGoogle Scholar
  64. Ng RC, Darwish H, Stewart DA. Emergency treatment of petroleum distillate and turpentine ingestions. Canadian Medical Association Journal 111: 537–538, 1974PubMedGoogle Scholar
  65. North DS, Retzinger T, Thompson JD. Seizures and delirium associated with overdosage of maprotiline hydrochloride. Clinical Pharmacy 2: 370–373, 1983PubMedGoogle Scholar
  66. Oderda GM, Klein-Schwartz, W. Poison prevention in the elderly. Drug Intelligence and Clinical Pharmacy 18: 183–185, 1984PubMedGoogle Scholar
  67. Olson KR, Benowitz NL, Woo OF, Pond SM. Theophylline overdose: Acute single ingestion versus chronic repeated overmedication. American Journal of Emergency Medicine 3: 386–394, 1985PubMedCrossRefGoogle Scholar
  68. Pond SM, Olson KR, Osterloh JD, Tong TG. Randomized study of the treatment of phenobarbital overdose with repeated doses of activated charcoal. Journal of the American Medical Association 251: 3104–3108, 1984 Product Information Adv. 1, Whitehall, New York, 1987PubMedCrossRefGoogle Scholar
  69. Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton LJ. Psychotropic drug use and the risk of hip fracture. New England Journal of Medicine 316: 363–369, 1987PubMedCrossRefGoogle Scholar
  70. Resnik HLP, Cantor JM. Suicide and aging. Journal of the American Geriatrics Society 18: 152–158, 1970PubMedGoogle Scholar
  71. Rumack BH (Ed.). Poisindex Information System, Micromedex, Calcium Antagonist Management, Vol. 64, 1990aGoogle Scholar
  72. Rumack BH (Ed.). Drugdex Information System, Micromedex, Ibuprofen monograph, Vol. 65, 1990bGoogle Scholar
  73. Sendbuehler JM, Goldstein S. Attempted suicide among the aged. Journal of the American Geriatrics Society 25: 245–248, 1977PubMedGoogle Scholar
  74. Sketris I, Wheeler D, York S. Hypoglycemic coma induced by inadvertent administration of glyburide. Drug Intelligence and Clinical Pharmacy 18: 142–143, 1984PubMedGoogle Scholar
  75. Smith TW, Butler VP, Haber E, Fozzard H, Marcus FI, et al. Treatment of life-threatening digitalis intoxication with digoxin Fab antibody fragments: experience in 26 cases. New England Journal of Medicine 307: 1357–1362, 1982PubMedCrossRefGoogle Scholar
  76. Snover SW, Bocchino V. Massive diltiazem overdose. Annals of Emergency Medicine 15: 1221–1224, 1986PubMedCrossRefGoogle Scholar
  77. Sorensen SC. Adult respiratory-distress syndrome in salicylate intoxication. Lancet 1: 1025 1979PubMedCrossRefGoogle Scholar
  78. Svenson J. Obtundation in the elderly patient: presentation of drug overdose. American Journal of Emergency Medicine 5: 524–526, 1987PubMedCrossRefGoogle Scholar
  79. Tandberg D, Diven BG, McLeod JW. Ipecac-induced emesis versus gastric lavage: a controlled study in normal adults. American Journal of Emergency Medicine 4: 205–209, 1986PubMedGoogle Scholar
  80. Tennenbein M, Cohen S, Sitar DS. Efficacy of ipecac-induced emesis orogastric lavage, and activated charcoal for acute drug overdose. Annals of Emergency Medicine 16: 838–841, 1987CrossRefGoogle Scholar
  81. Thoman ME, Verhulst HL. Ipecac syrup in antiemetic ingestion. Journal of the American Medical Association 196: 433–434, 1966PubMedCrossRefGoogle Scholar
  82. Turhan A, Grateau G, Kamoun P, et al. Intoxication volontaire par le captopril. Presse Médicale 13: 2707 1985Google Scholar
  83. Waeber B, Nussberger J, Bonner HR. Self poisoning with enalapril. British Medical Journal 288: 287–288, 1984PubMedCrossRefGoogle Scholar
  84. Weber WA, Santiago R. Hypermagnesemia: a potential complication during treatment of theophylline intoxication with oral activated charcoal and magnesium-containing cathartics. Chest 95: 56–59, 1989PubMedCrossRefGoogle Scholar
  85. Wedin GP, Oderda GM, Klein-Schwartz W, Gorman RL. Relative toxicity of cyclic antidepressants. Annals of Emergency Medicine 15: 797–804, 1986PubMedCrossRefGoogle Scholar
  86. Weinstein RS. Recognition and management of poisoning with beta-adrenergic blocking agents. Annals of Emergency Medicine 13: 1123–1131, 1984PubMedCrossRefGoogle Scholar
  87. Wenger TL, Butler VP, Haber E, Smith TW. Treatment of 63 severely digitalis-toxic patients with digoxin-specific antibody fragments. Journal of the American College of Cardiology 5: 118A–123A, 1985PubMedCrossRefGoogle Scholar
  88. White RD, Goldsmith RS, Rodriguez R, et al. Plasma ionic calcium levels following injection of chloride, gluconate, and gluceptate salts of calcium. Journal of Thoracic and Cardiovascular Surgery 71: 609–613, 1976PubMedGoogle Scholar
  89. Whitten CF, Chen YC, Gibson GW. Studies in acute iron poisoning: I. Desferrioxamine in the treatment of acute iron poisoning: clinical observations, experimental studies, and theoretical considerations. Pediatrics 38: 102–110, 1966PubMedGoogle Scholar

Copyright information

© Adis International Limited 1991

Authors and Affiliations

  • Wendy Klein-Schwartz
    • 1
  • Gary M. Oderda
    • 1
  1. 1.Maryland Poison CenterUniversity of Maryland School of PharmacyBaltimoreUSA

Personalised recommendations