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10 - Endocrine Disorders |
287
receives. Anticipate that constipation will improve with correction of hypothyroidism and
physical activity, rendering a long-term bowel regimen unnecessary. An evaluation of
constipation would be recommended if symptoms do not resolve.
Rationale:
The reference interval for TSH may increase with age. However, older adults do not always
exhibit classic symptoms of hypothyroidism, so follow-up will be necessary to determine
whether ST’s complaints are due to hypothyroidism rather than poor diet and low energy
expenditure. Her T4 is within normal range, suggesting subclinical hypothyroidism if thyroid
disorder is present. Exercise may improve strength, emotional health, constipation, and pain
and discomfort due to chronic illnesses.
Case Summary:
Subclinical hypothyroidism may be more difficult to diagnose in the elderly. If treatment is
needed, levothyroxine is the best first-line choice and should be started at low dosages.
Obesity may worsen the symptoms of hypothyroidism, and individuals with a BMI of
30–<35 kg/m
2
should be encouraged to pursue weight loss through changes in diet and
physical activity.
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288
| Fundamentals of Geriatric Pharmacotherapy
C S
Endocrine diseases such as diabetes mellitus,
hypothyroidism, and obesity are common among
older adults. Although they can be safely and
effectively treated with standard approaches
such as drug therapy, attention must be focused
on establishing appropriate goals for the indi-
vidual patient that take into consideration factors
such as life expectancy and level of frailty,
comorbid conditions, and concomitant drug
therapy. The old aphorism of “start low and go
slow” remains particularly applicable to the
management of endocrine disorders in older
adults.
S-A Q
1. What are the advantages and disadvan-
tages of the available drug therapy to
manage diabetes mellitus in older adults?
2. What are common risk factors, presenting
symptoms, and management approaches
for hypoglycemia due to drug therapy in
older adults with diabetes?
3. What are common risk factors, presenting
symptoms, and management approaches
for HHNS?
4. Describe the available pharmacologic
and nonpharmacologic interventions used
for weight loss and determine which have
evidence of benefit in older adults.
5.
Compare and contrast hypothyroidism,
subclinical hypothyroidism, and ESS in
terms of underlying etiology, presentation,
laboratory tests, and management.
6.
What are the advantages and disadvan-
tages of the three primary treatments of
hyperthyroidism in older adults?
7. How do the available oral medications for
hypothyroidism differ?
8.
What are the primary risks with the use of
PDE-5 inhibitors and testosterone products
in older men?
9. What are the primary types of female sexual
dysfunction and the potential treatments?
R
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Clinical Pearls
• Older adults taking antipsychotic medications should be closely monitored for signs and
symptoms of hyperglycemia. The risk of developing new-onset diabetes from antipsychotic
medications appears to be inversely related to age. However, glucose dysregulation
may be problematic among older users of antipsychotics with pre-existing diabetes.
• Assessment of blood glucose can be difficult for an individual with cognitive impairment
who resists fingerstick testing. If monitoring activities routinely turn into a battle resulting in
acute agitation, caregivers may find themselves facing tough choices regarding whether
to monitor less frequently, reduce or withdraw drug therapy, turn to psychoactive drug
therapy, or employ alternate testing methods such as urine dipstick. The risk- benefit
and the rationale for the strategy employed should be carefully documented.
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10 - Endocrine Disorders |
289
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11
G
D
N
LISA C. HUTCHISON and REBECCA B. SLEEPER
L O
1. Compare the prevalence of gastrointestinal (GI) disorders among different subgroups of elderly patients and
young adults.
2.
Assess the applicability of general adult treatment guidelines and management strategies for GI disorders to
different age strata of elderly patients.
3.
Recommend treatment goals and appropriate drug therapy for GI disorders in elderly patients.
4. Recommend treatment goals and strategies for maintaining optimal oral health and nutrition in elderly patients.
K T D
ASPIRATION: The drawing of food or liquid into the lungs with the respiratory current.
DYSGEUSIA: Altered taste sensation.
FECAL IMPACTION: A large lump of dry, hard stool that remains stuck in the rectum.
LAXATIVE ABUSE: Overuse of laxatives because of an eating disorder or in an attempt to have one or more
soft bowel movements every day.
MEGACOLON: Abnormal dilation of the colon with diminished or absent peristalsis.
OROPHARYNGEAL DYSPHAGIA: Difficulty initiating or coordinating swallowing.
SARCOPENIA: Loss of muscle mass and strength associated with aging but not associated with a specific
inflammatory disease.
XEROSTOMIA: Dry mouth.
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| Fundamentals of Geriatric Pharmacotherapy
I
G
astrointestinal (GI) disorders are a common
cause of discomfort and distress throughout
the lifespan and significantly affect appetite,
enjoyment of food, and nutrition. GI symptoms
influence, and are influenced by, activity level,
and as such are closely related to functional level
and quality of life. Aging is associated with physi-
ologic changes throughout the GI tract, resulting
in increased incidence of dysphagia, gastro-
esophageal reflux disease (GERD), nausea,
vomiting, diverticulitis, constipation, diarrhea,
and malnutrition.
There are three primary challenges for
the pharmacist caring for an individual with GI
complaints. The first is to avoid or minimize GI
symptoms caused or exacerbated by medica-
tions. The second is to optimally employ drug
therapy as the intervention for various GI condi-
tions. This can present a particular challenge, as
there are consequences associated with the long-
term use of most medications indicated to treat
GI symptoms. Therefore, the clinician’s charge is
often less about selecting the right medication
to treat the symptoms than about the monitoring
and ongoing evaluation of drug therapy utility.
The third challenge, an overarching one, is to
ensure the maintenance of optimal overall nutri-
tional status. This chapter discusses the etiology,
epidemiology, and clinical presentation of various
GI disorders commonly seen in the aging popu-
lation, summarizes standard treatment strate-
gies, and discusses special considerations for
older patients, including special considerations
for specific subgroups of patients.
O H D
A review of the GI system begins with an assess-
ment of oral health. Oral health is associated with
systemic health and nutritional status. A signifi-
cant focus of a discussion of oral health is dental
health and oral hygiene, but other consider-
ations such as dry mouth, taste perversions, and
vulnerability to thrush should not be overlooked.
Advancing age is correlated with decline
in dental status, with the greatest decline
observed in populations aged 75 years or older.
1
Compared with younger cohorts, older adults
have worse oral hygiene, poorer oral functional
capacity, and a higher rate of gingivitis, dental
caries, and tooth loss. Disability is also associ-
ated with poor oral health.
2
One of the most common oral health prob-
lems in older populations is denture stoma-
titis: oral lesions caused by ill-fitting dentures
or poor denture hygiene and maintenance.
3
Besides discomfort, inability to comfortably wear
dentures can result in problems with nutrition
and communication.
Microorganisms found in the oral cavity are
associated with dental caries and also systemic
disease. These include cardiovascular prob-
lems such as infective endocarditis, orthopedic
problems such as prosthetic joint infections, and
respiratory complications such as aspiration
pneumonia.
4-8
The risk of aspiration pneumonia
increases when poor oral health is compounded
by dysphagia.
9
Dry mouth, or xerostomia, is a common
problem reported among older patients.
2,10,11
It
is a symptom that can be caused by a variety
of systemic conditions, with Sjögren’s syndrome
being particularly common, but a significant
cause of dry mouth is medication related.
12,13
In various studies, 17% to 32% of community
individuals reported feeling dry mouth. The
prevalence increased with age and was higher
among women than men, and higher among
individuals receiving medications than those
who were unmedicated.
14,15
When associated
with drug therapy, this is reported as an adverse
effect in 12% to 39% of noninstitutionalized older
persons.
2
Medications most likely to be associ-
ated with dry mouth include those with anticholin-
ergic activity, such as tricyclic antidepressants,
antihistamines, muscle relaxants, and bladder
antispasmodics. In addition, diuretics, cloni-
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11 - Gastrointestinal Disorders and Nutrition |
295
dine, beta blockers, calcium-channel blockers,
inhaled medications, and cytotoxic medications
can be causes.
14-17
KEY POINT:
Drug regimen review may
identify modiable causes of dry mouth.
Although altered taste, or dysgeusia, can
be associated with many conditions, such as
renal failure, psychiatric disorders, hypothy-
roidism, neoplastic conditions, nasal disorders,
dry mouth, gingivitis, and zinc deficiency, the
most common cause of altered taste percep-
tion is drug therapy.
18-24
The incidence varies by
drug, but common medications that can cause
taste perversions include (at therapeutic doses)
inhaled corticosteroids or bronchodilators, nasal
drainage of intranasal and ophthalmic medica-
tions, clarithromycin, lithium, divalproex sodium,
amiodarone, omeprazole, interferon alfa,
tobacco, and some chemotherapy agents.
24-26
Dysgeusia can also be a sign of toxicity from
digitalis, dextromethorphan, amphetamine, and
buspirone.
Similarly, oral thrush is a problem that can be
caused by many conditions, including immune
deficiencies, cancer, thyroid disorders, uncon-
trolled diabetes, poor denture hygiene, and dry
mouth, but a common cause is improper admin-
istration of inhaled corticosteroids.
25-28
The combination of suboptimal oral hygiene,
comorbid medical conditions, and medication
use all contribute to multiple symptoms affecting
the health of teeth, gums, and oral mucosa.
In addition to regular brushing and flossing,
regular dental check-ups are recommended
every 6 months to provide cleaning and to
evaluate the health of the teeth, gums, and oral
mucosa. One of the best resources for general
oral health recommendations for the adult popu-
lation is the American Dental Association’s (ADA)
online Center for Evidence-Based Dentistry.
29
Their clinical recommendations provide guid-
ance in the areas of dental carie prevention,
fluoride supplementation, oral screenings, and
others. For the prevention of infective endocar-
ditis, the ADA refers to the clinical guidelines from
the American Heart Association.
30
Despite the
link between periodontal and systemic disease,
it is controversial whether prospective treatment
with antibiotics at the time of dental procedure
significantly mitigates this risk in all patients,
particularly in the case of joint complications.
7
Therefore, guidelines recommend antibiotic
prophylaxis only for a subset of individuals with
underlying cardiac conditions undergoing dental
procedures that involve manipulation of the
gingival tissue or perforation of the oral mucosa.
30
The guidelines recommend amoxicillin or a first-
or second-generation cephalosporin given as a
single dose 30–60 minutes prior to the proce-
dure, with clindamycin, azithromycin, or clarithro-
mycin as an alternative among individuals with
an allergy to one of the other options.
30
For the treatment of discomfort associated
with dry mouth, the range of pharmacological
options include over-the-counter oral moistur-
izers or salivary substitutes and salivary stimu-
lants such as pilocarpine.
16
However, long-term
management requires ongoing dental care,
treatment of underlying conditions, or removal
of offending medications, if possible.
16,31,32
In the
case of oral thrush, antifungal medications such
as nystatin, either swish-and-spit or swish-and-
swallow, as appropriate, or tablet formulations
such as fluconazole can be prescribed, but if the
cause is a drug or the improper administration of
a drug, drug therapy intervention will be neces-
sary to prevent recurrence. Rinsing the mouth
after administration of inhaled corticosteroids is
recommended.
33
The evaluation of the evidence base for the elderly
requires identification of various subgroups.
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296
| Fundamentals of Geriatric Pharmacotherapy
The American Heart Association does not have
different recommendations for dental proce-
dure prophylaxis for elderly patients; rather, the
considerations are based on medical history and
risk factors.
30
considerations may more likely be individuals
with and without dentures, and individuals with
and without cognitive impairment. Another factor
that should be routinely considered when a
dental visit is scheduled is the presence of anti-
coagulants on the medication regimen. Although
bleeding risk associated with invasive dental
procedures often prompts the suspension of
warfarin or other anticoagulant or antiplatelet
therapy before the appointment, there is concern
that the risk of thromboembolic events associ-
ated with subtherapeutic anticoagulation may
outweigh the perceived bleeding risk in some
cases.
34
Consensus guidelines recommend that
for individuals with a stable international normal-
ized ratio (INR; defined in this case as >2 but
<4), the risk of bleeding associated with outpa-
tient dental procedures, including tooth extrac-
tion, is very small and that anticoagulant therapy
should not be suspended. In addition, in most
cases a single dose of antibiotics for prophylaxis
does not warrant adjustment of anticoagulation
regimen.
35
Rather, an INR evaluation is recom-
mended 72 hours prior to the procedure. Indi-
viduals receiving antibiotics, especially more
than one dose, should also undergo a follow-up
INR evaluation 2–3 days after initiating the antibi-
otic. Finally, these individuals should not receive
orders for COX-2 inhibitors or nonsteroidal anti-
inflammatory drugs (NSAIDs) for dental pain
associated with the procedure.
35
KEY POINT:
Warfarin therapy is often
not optimally managed before or after
dental procedures, resulting in unnecessary
subtherapeutic anticoagulation.
Oral care for dentures is different than
regular brushing and flossing of natural teeth.
36-38
Like natural teeth, dentures should be brushed
daily; however, harsh toothpastes (especially
whitening products) should be avoided, and the
dentures should also be removed and cleaned
regularly with a cleaning solution.
39
Although
mild soap and water can be used, products that
bear the ADA seal of acceptance have been
evaluated for their effectiveness, safety to the
individual, and safety for the denture materials.
Dentures should be removed and rinsed under
water after eating, and it is recommended to
rinse or gently brush the inside of the mouth
as well. When dentures are not being worn,
they should also be kept moist to avoid drying
and warping. Dentures can be placed in water
or a soaking solution; the dentist providing the
dentures can recommend the best solution,
as this may depend on the materials used in
their formulation. After soaking overnight, the
dentures should be rinsed again before putting
them back in the mouth. For denture wearers at
risk for or experiencing oral thrush, additional
care must be taken not to reintroduce organisms
into the mouth via the dentures, which must be
thoroughly cleaned. Mouth rinsing after admin-
istration of inhaled corticosteroids may need to
be more stringent for denture wearers, with some
data suggesting that rinsing three times may be
necessary to sufficiently remove residual medi-
cation from mouth surfaces.
28
Oral care for an individual with functional
or cognitive impairment can be especially chal-
lenging. Geriatric “sensitivity exercises” often
require pairs of learners to give and receive
oral care, often while blindfolded or physi-
cally restrained in other ways. It is a physically
awkward maneuver, especially when the care-
giver cannot perceive the degree of pressure of
the brush on the surfaces of the mouth. The exer-
cise illustrates the difficulty of achieving optimal
cleansing while avoiding discomfort, even when
the care recipient is actively participating and
cooperating with the experience. This need for
caution increases the risk of suboptimal oral
cleansing; therefore, some studies suggest
that in addition to brushing, wiping oral mucosa
with a brush soaked in chlorhexidine can help
improve malodor and reduce the risk of opportu-
nistic infections.
40
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