The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme

Kannayiram Alagiakrishnan, FRCP(C), Associate Professor, Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, AB.
Cheryl A. Wiens, PharmD, Associate Professor, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB.

Numerous medications are capable of causing psychiatric side effects. Drug abuse or misuse, polypharmacy, or physiological changes due to aging may lead to these adverse effects. Drug-induced effects on mental health is a topic of considerable clinical importance and yet it is poorly recognized by health care professionals. This article is a review of psychiatric side effects of prescription and over-the-counter medications, problem recognition, and what can be done to manage and prevent these adverse events. Prevention of drug-induced psychiatric side effects can be aided by avoiding, where possible, medications that can cause these effects; evaluating renal and hepatic function on a regular basis; avoiding agents that can cross the blood-brain barrier; and conducting brief cognitive and behavioural assessments at baseline with follow up on a periodical basis.
Key words: psychiatric side effect, renal insufficiency, nonpsychiatric medications, adverse drug reactions, cognitive impairment.

Richard Holland, BA, BM BCh, DA, DPH, MFPH, PhD, Senior Lecturer in Public Health Medicine, School of Medicine Health Policy & Practice, University of East Anglia, Norwich, UK.
David Wright, BPharm, PhD, Senior Lecturer in Pharmacy Practice, School of Chemistry and Pharmacy, University of East Anglia, Norwich, UK.

Older people consume a disproportionate quantity of drugs compared to younger people. Furthermore, the volume and cost of these drugs is increasing markedly. In theory, drugs are prescribed to reduce both morbidity and mortality but can also cause harm, particularly amongst older people. Medication review has been advocated as a technique to reduce such problems, whilst at the same time ensuring patients gain maximum benefit from their drugs. Whilst medication review seems a logical solution to inappropriate prescribing in general and adverse reactions in particular, evidence that specific interventions are effective at reducing morbidity or mortality is lacking.
Key words: medication review, adverse drug reactions, medication appropriateness, pharmacists, background.

A. Mark Clarfield, MD,FRCPC, Chief of Geriatrics, Soroka Hospital, Beer-sheva, Israel; Sidonie Hecht Professor of Geriatrics, Ben-Gurion University of the Negev, Beer-sheva, Israel; Staff Geriatrician of the Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC.

Recent research has shown that close to 10% of the older population have at least one potentially inappropriate prescription, placing them at risk of acute hospitalization due to overdose or harmful drug interactions. The problem of polypharmacy in the aged is growing. Primary care physicians are obliged to take responsibility for coordinating the patient’s care and must be aware of various aspects of medication use such as cumulative drug exposure, chronic comorbidities, changing pharmacokinetics, and prescribing habits of consultants.

Key words: polypharmacy, older adult, adverse drug reaction, compliance.

G.A.E. Wong, MBChB, MRCP(UK), and N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions are a common problem affecting ambulatory and hospitalized patients. Older patients may be predisposed to adverse drug reactions due to inappropriate medication prescription, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathologies, and use of drugs with a narrow therapeutic margin. In this second of two articles, the management of cutaneous adverse drug reactions
is reviewed.

Key words: adverse drug reaction, skin, cutaneous, rash, drug eruption, treatment, management.

G.A.E. Wong, MBChB, MRCP (UK); N.H. Shear, MD, FRCP(C), Divisions of Dermatology and Clinical Pharmacology, Sunnybrook & Women’s College Health Sciences Centre, University of Toronto, Toronto, ON.

Cutaneous adverse drug reactions (ADR) are a common problem affecting ambulatory and hospitalized patients. Older patients may be more predisposed to ADR due to inappropriate prescribing of medications, age-associated changes in pharmacokinetics and pharmacodynamics, altered homeostatic mechanisms, multiple medical pathology and use of drugs with a narrow therapeutic margin. In this first of two articles, a practical approach to the assessment and diagnosis of patients with suspected drug-induced rashes will be described. A subsequent article will discuss the management of patients with cutaneous ADR.
Key words: adverse drug reaction, skin, rash, cutaneous, diagnosis, assessment.

Lilia Malkin, BSc

Adverse drug reactions (ADRs) account for a significant proportion of morbidity and mortality in the geriatric population. According to the 1993 Canadian Medical Association (CMA) Policy Summary, over 20 percent of acute care hospital admissions of Canadian seniors may result directly from ADRs. Other studies have reported the incidence of ADR-related admissions ranging from 8 to 35 percent.

The World Health Organization (WHO) defines an adverse drug reaction as "a noxious, unintended effect of a drug that occurs in doses normally used in humans for the diagnosis, prophylaxis, or treatment of disease." ADRs can be divided into two categories: predictable (Type A) and unpredictable (Type B). Predictable reactions make up the vast majority of ADRs at 80 percent. Type A reactions are frequently dose-dependent and related to the augmented pharmacologic action of the medication: toxicity, side effects, indirect effects, and drug interactions. Unpredictable ADRs are less common, and include intolerance, allergy or hypersensitivity, idiosyncrasy, and psycho-genic reactions. Recognition of the pertinent risk factors for both predictable and unpredictable ADRs has direct application to ADR prediction, prevention, and management in the geriatric population.

ADR Prediction: Risk Factors

Older Canadians have a four- to seven-fold higher risk of suffering an ADR compared to younger individuals. According to Dr.