Drugs & aging
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In patients with dementia, undertreatment of pain, irrespective of its aetiology, is widely recognized; the risk for undertreatment increases with the severity of dementia. We argue, however, that central neuropathic pain is by far the most undertreated type of pain in patients with dementia. Central pain is a type of neuropathic pain that is known to occur in stroke patients and is caused by white matter lesions. ⋯ Antidepressants and antiepileptic drugs appear to have a positive effect on central neuropathic pain. In the review, advantages and disadvantages of amitriptyline, carbamazepine, lamotrigine, gabapentin and pregabalin are discussed; a negative effect of these drugs on liver and kidney functions, as well as on cognitive functions in patients who already suffer from cognitive impairment is highlighted. Next to pharmacotherapy, non-pharmacological treatment strategies such as transcutaneous electrical nerve stimulation may be effective as long as afferent pathways transmitting the electrical stimulus are still intact.
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An increasing number of older patients are prescribed proton pump inhibitors (PPIs). However, the extent of inappropriate PPI prescribing in this group is largely unknown. ⋯ Inappropriate PPI prescribing in older patients is frequent and independently associated with co-morbidities and dementia. A targeted in-hospital educational strategy can significantly and safely reduce inappropriate PPI prescribing in the short term.
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In the treatment of chronic malignant and non-malignant pain, opioids are used as strong analgesics. Frail elderly patients often have multiple co-morbidities and use multiple medicines, leading to an increased risk of clinically relevant drug-drug and drug-disease interactions. Age-related changes and increased frailty may lead to a less predictable drug response, increased drug sensitivity, and potential harmful drug effects. ⋯ Nevertheless, tapentadol may prove to be a useful analgesic for the treatment of chronic pain in frail elderly persons because of its possible better gastrointestinal tolerability. In the treatment of chronic pain in the frail elderly, the opioids of first choice are buprenorphine, fentanyl, hydromorphone, morphine and oxycodone. In order to improve the convenience for elderly patients, the controlled-release oral dosage forms and transdermal formulations are preferred.
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On 31 March 2009, the US Centers for Medicare & Medicaid Services (CMS) provided revised guidance for meeting compliance in the evaluation and management of pain in nursing home residents, known as F-Tag 309. ⋯ The implementation of revisions to the surveyors' interpretive guidelines for F-Tag 309 improved recognition and management of pain as well as analgesic use in nursing home residents with documented non-cancer pain. Use of directed language as part of the surveyors' interpretive guidelines may be a viable approach to stimulating improvements in pain documentation and management.
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Cholinesterase inhibitors (ChEIs) are a mainstay treatment for individuals with dementia. ChEIs may worsen airflow obstruction because of their pro-cholinergic properties. ⋯ In a large cohort of elderly individuals with COPD and dementia, new users of ChEIs had a similar risk for adverse pulmonary outcomes as those who were not receiving ChEIs.