Arthur Bookman, MD, FRCPC, Division of Rheumatology, Toronto Western Hospital/University Health Network, Toronto, ON.

Rheumatoid arthritis (RA) in older adults has a lower female-to-male ratio, and presents as either a rheumatoid factor positive typical case of RA, or an acute seronegative syndrome consisting of myalgia, fever, weight loss, and fatigue. Differentiating among systemic lupus erythematosus, polymyalgia rheumatica, and rheumatoid arthritis may initially be very difficult in older patients. Rheumatoid arthritis beginning in younger people can lead to earlier death, accelerated atherosclerosis, complicated polypharmaceutical management, debilitating deformity, osteoporosis, and more frequent infection as these patients enter their geriatric years.
Key words: rheumatoid arthritis, geriatrics, polypharmacy, chronic disease, inflammatory arthritis.

Jenny Rogers, MD, Psychiatry Department, Postgraduate Education, University of British Columbia, Vancouver, BC.
Bonnie S. Wiese, MD, Psychiatry Department, Postgraduate Education, University of British Columbia, Vancouver, BC.
Kiran Rabheru, MD, CCFP, FRCP, Clinical Associate professor, Psychiatry Department, University of British Columbia, Vancouver, BC.

Alcohol, recreational drugs, over-the-counter, and prescription medications may cause a range of cognitive impairments from confusion to delirium, and may even mimic dementia. Moderate to high alcohol consumption is one of the often overlooked risk factors for development of dementia and cognitive impairment among older adults. Substances such as opioids, benzodiazepines, and anticholinergics pose a particular risk of cognitive impaiment and the risk increases when these are combined with multiple medications, as polypharmacy is common in patients over 65. A substance-induced dementia may have a better prognosis compared to other types of dementia, as once the instigating factor is gone, the cognition often improves.
Key words: Alcohol related dementia, geriatric substance abuse and dependence, polypharmacy, anticholinergic adverse effects, cognitive impairment.

Tessa L. Lewis, MD, General Practitioner, Carreg Wen Surgery, Church Road, Blaenavon, Torfaen, UK.

The NO TEARS structure can aid efficient medication review within a 10-minute consultation. It is a flexible system that can be tailored to the individual practitioner’s consultation style:
Need/indication
Open questions
Tests
Evidence
Adverse effects
Risk reduction
Simplification/switches

Key words: medication review, NO TEARS, primary care, older adults, polypharmacy.

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.

Dr. Clarfield is the Chief of Geriatrics, Soroka Hospital Centre, Professor, Faculty of Medicine, Ben Gurion University of the Negev, Beersheva, Israel, and Professor (Adjunct), Division of Geriatric Medicine, McGill University, and Jewish General Hospital, Montreal, QC.

The other day, I was consulted on a 75-year-old lady who was (supposedly) ingesting 12 different medications: ranging across the daylight hours and in all the colours of the spectrum, exhibiting various shapes and sizes. Some were to be taken before, others after, and the remainder with meals. The total number of tablets that was theoretically being consumed by this lady was 62. Individually, all of these medications could have caused adverse drug reactions (ADR), and many of them are also known to interact in various ways with each other. My patient exhibited a typical "final common pathway" of the results of basic research, drug trials, pharmaceutical marketing, physician prescribing practices and pharmacist dispensing behaviour. Unfortunately for the patient in question, the option of noncompliance was not available since her husband tried his best to help her ingest this immense pharmacological load.

This lady represents an extreme example of the kind of medication problems that elderly patients can face in Canada. Yet, it must also be pointed out that the modern pharmaceutical armamentarium is more extensive and far superior to that available 30 years ago.

Psychotropic Drugs and Polypharmacy are Proven Risk Factors for Falls

Tawfic Nessim Abu-Zahra, MSc

Many risk factors have been shown to contribute to falls suffered by the elderly, including the use of sedatives¹ and the concurrent use of several medications.^2-4 Evidence-based conclusions concerning the relationship between drugs and falls provide limited confirmation due to the studies results' variability, inconsistencies in classification schemes of drugs, and because of the small number of subjects participating in most studies.³ Thus, singling out specific agents and recommending guidelines for prescribing to the elderly is difficult. However, some studies have implicated psychotropic or CNS-active drugs, including sedatives, antidepressants and neuroleptics, as being especially high-risk in terms of leading to falls. Hence, special caution should be taken in prescribing these for the elderly.

Leipzig and colleagues reviewed^3,4 all existing literature dealing with the association between drugs and falling in the elderly. Pooled odds ratios that measure the likelihood that a person taking a drug will also experience a fall were calculated for different classes of drugs.

Barry Goldlist, MD, FRCPC, FACP

The issue of drug use in the elderly is extraordinarily important. All physicians know that medications in older patients are a two edged sword: the elderly have many more diseases that potentially benefit from medications, but they are also prone to more adverse effects from those same medications. The increased burden of disease in the elderly is the major reason for the high drug utilization in the elderly, but in the clinical practice of geriatric medicine, it is almost as common to see potentially beneficial medications withheld, as it is to see unnecessary polypharmacy. Of the many reasons for this, I would like to discuss two physician-related factors, excessive fear of side effects, and a flawed understanding of cost effectiveness.

There is no doubt that the elderly are prone to drug side effects. However, withholding effective treatment because of a fear of side effects is often an example of flawed reasoning. All treatments, regardless of the age of the patient, require that the risks and benefits are evaluated and a judgement regarding the balance is then made. To withhold anticoagulants from an elderly patient with atrial fibrillation because age increases the risk of bleeding is assessing only one side of the equation. The number of strokes prevented by anticoagulation is greater in older patients, and if anything the risk/benefit ratio is more favorable for seniors. Similarly, withholding anticoagulants because a patient has fallen once or twice, means a definite benefit is lost to prevent a theoretical complication of traumatic bleeding. Current evidence does not warrant the common perception that recurrent falls are an absolute contraindication to anticoagulation.

Many new pharmaceuticals are quite expensive, and there is a feeling among some physicians that they are too expensive for the elderly. While pharmacoeconomics is a crucial new discipline, none of the experts in the field would eliminate the elderly from potentially beneficial treatments. Decisions not to use expensive medications when cheaper efficacious therapies are available are an appropriate approach regardless of age. Once again, because of the higher event rates for the elderly, treatments are generally more cost effective in the elderly. The best example of this is the use of thrombolytic therapy in those over 70. The cost per life year saved is much less in the elderly than in younger patients with myocardial infarction.

In summary, we do want to avoid polypharmacy in the elderly, and the prescribing cascade that can result, as more drugs are prescribed to relieve side effects of prior medications. However, it is just as important to ensure that therapies of proven value are not withheld from older patients.