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Regardless of which product is used, there
is no single strategy that is effective for providing
dental hygiene for all individuals with dementia.
When dementia affects the individual’s cogni-
tive perception, a caregiver’s attempts to assist
with personal hygiene can be interpreted as
confusing or threatening, and it can be difficult
to achieve cooperation.
41,42
Many different tech-
niques have been evaluated in the literature,
including eye level approach, verbal cueing,
avoiding physical restraints, avoiding baby talk,
and experimenting with various techniques such
as face to face care versus “mirror-mirror” care
(standing behind the individual). Supplementing
brushing with rinses and oral swabs can help,
but the patient must understand how to swish
and spit rather than swallow, which often requires
creative strategies tailored to the personality and
preferences of the patient.
42-44
Providing oral
care to someone with cognitive or functional
dependence is a significant challenge, but one
worth addressing, as oral health interventions
are associated with a reduction in the risk of a
range of adverse outcomes, including aspiration
pneumonia.
45
Financial status is a significant barrier to optimal
oral health in older patients. Although one study
in the primary care setting demonstrated that
the inclusion of a dental health check as part of
a preventive care program was a feasible and
effective way to increase dental visits among a
population age 75 or older, elderly patients may
experience barriers to paying for dental care.
46
In most cases, Medicare does not cover routine
dental work, and although Medicaid reimburse-
ment rates can vary from state to state, low reim-
bursement rates may discourage some dental
practices from accepting Medicaid beneficiaries
as patients.
41
For residents of long-term care
facilities, particularly those with dementia, visits
by dental health professionals may not be ideal.
Given the association of poor oral health with
systemic disease, this disparity can significantly
influence healthcare outcomes.
47,48
D
Dysphagia generally means difficulty swal-
lowing but is actually defined in more than one
way. Oropharyngeal dysphagia (OD), for instance,
is difficulty initiating swallowing or coordinating
the movement of food or liquid from the mouth
to the upper esophagus. Esophageal dysphagia
(ED) is difficulty transporting the food or liquid
through the esophagus into the stomach.
49
OD is
the more common form in older adults. The prev-
alence of dysphagia in those age >65 years is
not exactly known but estimated to be between
10% to 30%. However, the prevalence varies by
subgroup, and comparing community-dwelling
populations to long-term care populations, the
prevalence is suggested to be higher, up to 50%
in the institutionalized setting.
50-52
In the hospital
setting, dysphagia is associated with longer
inpatient stays, higher incidence of complica-
tions, increased need for rehabilitation services,
and increased need for post-discharge care in
skilled units or long-term care facilities.
52
The most common cause of OD is neurolog-
ical, associated with conditions such as stroke or
Parkinson disease, and swallowing can also be
affected by drugs such as antipsychotics, barbi-
turates, anticholinergics, diuretics, and mucosal
anesthetics.
49
Dysphagia occurring after stroke
is reversible or improvable in a majority of cases;
however, dysphagia associated with dementia
or Parkinson disease has a poorer prognosis.
53,54
Drug-induced esophageal injury such as ulcer-
ations or strictures can also result in ED. Although
there are some classes of medications, such as
NSAIDs or bisphosphonates, for which the risk of
esophageal injury is more understood,
55,56
almost
any medication could cause injury if adminis-
tered improperly.
57,58
Failure to administer medi-
cation with an adequate amount of water is a
common oversight and can result in caustic
injury or esophageal obstruction. Although the
likelihood of a drug causing a caustic injury to
the esophagus can be related to pH or dissolu-
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| Fundamentals of Geriatric Pharmacotherapy
tion properties, this can be also problematic for
bulk-forming laxatives such as methylcellulose
or polycarbophil.
59,60
In addition, case reports of
local adverse effects have been reported for a
number of medications associated with dry swal-
lowing or inadequate water.
56,59,60
KEY POINT:
Administration of medications
with adequate water is important but
often overlooked and should be reassessed
in the presence of GI symptoms.
The three most significant consequences
of dysphagia are choking risk, aspiration pneu-
monia, and malnutrition.
51-53,61,62
A decrease in
ability to forcefully cough due to loss of pharyn-
geal support or compromised reflexes for
coughing, gagging, or swallowing may occur
because of age-related changes in the pharynx
as well as decreased central nervous system
(CNS) reflex activity.
49,50
Coupled with reductions
in the activity of ciliary transport and age-related
changes in immune responsiveness, individuals
with dysphagia are at increased risk for aspiration
pneumonia.
52,62
This is the most common cause
of death in patients with dysphagia and is esti-
mated to occur in 5% to 15% of cases recorded
as community-acquired pneumonia.
52,62
Difficulty
swallowing food or liquid also compromises nutri-
tion. Even when the consistency of food or liquid
is altered to facilitate swallowing, the palatability
of the altered diet often presents an obstacle
to ensuring good nutrition and is a major factor
affecting quality of life.
63
Although there are some common signs and
symptoms that suggest dysphagia based on
patient report, the health professional must be
able to recognize nonverbal cues that suggest
swallowing difficulty as well.
64-66
Common
complaints can include the sensation of food
sticking in the throat, discomfort or pain on swal-
lowing, coughing, or choking. Patients may also
experience dyspnea, runny nose, watery eyes,
nasal or oral regurgitation, and a “wet” vocal
quality.
64-66
Some signs of aspiration are silent but
can be observed on x-ray as lung crepitation and
consolidation. In the presence of unexplained
fever or low oxygen saturation, aspiration pneu-
monia is one of the respiratory conditions that
should be on the differential diagnosis list.
52,62
The assessment and management of dysphagia
is truly an inter-professional endeavor. Opti-
mally, the assessment of swallowing function
is performed by a speech therapist or speech
language pathologist (SLP), but the referral for
this service can be prompted by observations
by a variety of health professionals or care-
givers who recognize the signs of dysphagia or
possible aspiration. There are two basic types of
swallow evaluations: the Clinical Swallow Evalu-
ation and the Videofluoroscopic Swallow Study.
The clinical study is done at the bedside. The
basic assessment of dysphagia begins with an
evaluation of the individual’s level of conscious-
ness, posture, voluntary cough, voice quality,
and saliva control.
64-66
The SLP will evaluate the
strength, movement, and coordination of the
muscles in the mouth and throat and will observe
the individual’s ability to swallow saliva, food,
and liquid. Alternatively, a diagnostic proce-
dure referred to as a modified barium swallow
employs continuous images, either through
x-rays or a fiberoptic endoscope, to view barium
as it passes through the pharynx, esophagus,
and stomach. This method can detect whether
barium enters the respiratory tract and provide
data about how the pharyngeal and esophageal
muscles are functioning.
65,66
There are a variety of different management
strategies that can be recommended based on
the type and severity of the swallowing problem
identified. For some individuals, exercises to
strengthen the muscles of the mouth or throat,
or the use of maneuvers to better coordinate the
movement of food or liquid through the chewing
and swallowing process, are recommended.
67-70
These can also have a favorable effect on vocal
quality.
71
However, one of the most common
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interventions is to alter the texture or consis-
tency of the food or liquid.
63
A mechanically
altered diet consists of finely cut or chopped
solids that are easier to chew and introduce no
large solid pieces into the mouth. Alternatively,
a puree diet alters the texture of the food item
into a soft form that does not require chewing.
For liquids, a cornstarch-based thickener can be
added to achieve a nectar or honey consistency.
Providing nutrition via a tube is controversial and
will be discussed later.
From the point of view of the pharmacist,
one of the most important considerations for the
individual with dysphagia is how to ingest oral
medication. When the ability to swallow medica-
tions is compromised, the choices are crushing
oral dosage forms, selecting a liquid formulation,
or selecting an alternate route of drug delivery
(e.g., transdermal, intramuscular). Oral adminis-
tration is preferable based on the understanding
of age-related changes in pharmacokinetics
(see Chapter 3).
Absorption and bioavailability of most
medications will remain relatively efficient in
the GI tract, as opposed to alternative routes
that may be more compromised by age-related
changes in skin and subcutaneous tissues.
Oral dosage forms are often less expensive
than transdermal or intramuscular. Among
oral formulations, crushing or opening tablets
or capsules may be preferred over liquid
because liquid formulations tend to be more
costly and the volume of liquid and the nature
of the vehicle must be considered. Products
formulated primarily for children will require
higher volumes to achieve an adult dose. For
medications formulated for adults, the volume
necessary may be relatively small (e.g., 5–
10 mL) for any one medication. Again, the
overall volume of liquid could ultimately be
large if multiple doses of multiple medica-
tions must be consumed. This can be espe-
cially problematic with elixir formulations that
contain alcohol in the vehicle or in suspensions
that use sorbitol. A small amount in a single
dose might be negligible, but as the volume or
number of doses increases, these can cause
drug-alcohol interactions or cause or exacer-
bate significant diarrhea. If an oral dosage form
can be crushed, this can be avoided. However,
crushing or opening tablets or capsules may be
unacceptable for some medications, such as
formulations that are enteric-coated, extended-
or controlled-release or medications that are
direct irritants or whose bioavailability or safety
profile is altered if the dosage form is compro-
mised. In these cases, replacing products with
an immediate-release version (ensuring appro-
priate dosing interval based on product) is
necessary, or liquid, transdermal, or injectable
forms must be considered.
KEY POINT:
A report of dysphagia by
the SLP or the presence of chart orders for
altered diet or liquid consistency should
prompt the pharmacist to evaluate the
patient’s ability to swallow medications.
If aspiration pneumonia is suspected,
the infection is likely to be polymicrobial.
72-74
In general, anaerobes and Streptococcus
spp. are the primary suspects; however, some
researchers have questioned the empiric value
of selecting antimicrobial therapy based on these
assumptions alone.
73,74
In fact, one investigation
determined that lack of anaerobic coverage in
the drug therapy regimens for elderly patients
with aspiration pneumonia was not associated
with a poorer outcome, even though anaerobic
organisms had been identified via culture.
73
New
ideas suggest that relevant variables to consider
may be the individual’s functional status (activi-
ties of daily living score), the presence of chronic
underlying respiratory conditions, and whether
an enteral feeding tube is present.
73,74
These
variables may suggest a higher prevalence of
anaerobic to aerobic organisms, Enterobacte-
riaceae, Pseudomonas aeruginosa, and drug-
resistant organisms, allowing more aggres-
sive therapy to be directed at these targets for
patients with such risk factors.
75
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There are no specific differences in the approach
to dysphagia based simply on age; however,
there are some subgroups to consider when
designing a treatment strategy, such as individ-
uals with cognitive and functional impairments or
those with a nasogastric or percutaneous endo-
scopic gastrostomy tube. Although a variety of
interventions for safe eating and drinking can be
recommended by the SLP, the ability to adhere
to recommendations is influenced by cogni-
tive and functional dependence. Adherence
rates in the literature range widely, from 0% to
80%.
76-80
It should not be a surprise that adher-
ence to altered diet recommendations is chal-
lenging. The enjoyment of food and drink is such
a fundamental part of quality of life that restric-
tions create dissatisfaction and resistance. It is
an unhappy situation for everyone when what
is safe is at odds with what is desired, and all
individuals in this position will have to make a
personal choice regarding how to prioritize and
adhere to safe swallowing recommendations
for long-term risk management. Sometimes,
the choice will be nonadherence. Unfortunately,
the individual’s motivation or ability to adhere is
often overestimated, which may result in a lack
of awareness of what the eating and drinking
behaviors of the patient really are (privately or
at the hands of caregivers). For instance, in one
review of the literature, data describing compli-
ance with safe swallowing techniques suggested
SLPs estimated patient compliance to be 71.9%;
however, the average compliance rate among
the patient group was actually only 35.6%. The
authors observed that patients were taught safe
swallowing technique until they could success-
fully demonstrate performing the technique.
But in many cases the intervention was not long
enough to ensure understanding, and there was
often poor patient motivation to continue. The
authors suggested one of the keys to successful
adherence was training and supervision.
81
Data
describing the impact of a training program for
hospital staff found that the initial compliance
rate was 51.9% for recommendations for fluid
and diet consistency, amount of food given,
physical strategies employed, and supervi-
sion. The most common caregiver reasons for
noncompliance were inappropriate techniques
and consistencies for thickened liquids by staff,
lack of awareness of SLP recommendations,
and inadequate patient supervision. The authors
saw improvements with training but found that
repeated training on a regular basis was needed
because of high rates of staff turnover.
81
Pharmacists need to be aware of these
practice-related challenges because the same
barriers that hamper optimal administration of
food and drink will also hamper medication
administration. In repeated observations of “med
pass” activities in the long-term care setting, one
of the most common medication administration
errors is often inappropriate crushing of oral
dosage forms. In one evaluation that compared
pharmacist observation of the facility med pass,
retrospective chart review, and review of facility
incident reports, it was the direct observation that
was most sensitive to detecting administration
errors.
82
Out of a total of 1,423 doses passed, the
direct observation method detected 369 errors
(25.9%). However, a retrospective chart review
only identified documentation of 148 of these
occurrences (10.4%). Incident reports captured
none. Although most administration errors were
evaluated to be minor in severity, a 25% error
rate is high, and the most common error type
recorded was inappropriate crushing of medica-
tions (30.1%). The error rate varied depending
on the nurse administering the medications, from
zero to a rate of one error every two doses, but
all of the nurses who filled out the post-observa-
tion questionnaire stated they would be willing
to be observed again. These findings support
the value of direct observation as the best way
to detect administration errors, and they suggest
opportunities for interprofessional collaboration
for continued staff training, skills assessment,
and quality improvement.
82
Crushed medications should be mixed with
a small amount of jelly or similar substance. Jelly
is most often preferred because it is an appro-
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priate texture and consistency for an individual
with dysphagia, the sweetness can help mask
the medication taste, and it is commercially
available in single-serving size packets that are
stable at room temperature. Pudding or similar
foods can also work but are often less prac-
tical in an institution because of packaging and
stability issues. It is important that crushed medi-
cation not be mixed into an entire portion of food
or drink at a meal, because this requires the
patient to consume the entire portion to ingest
the intended dose. In addition, this is not appro-
priate for empty stomach administration instruc-
tions, and it is a challenge especially when the
crushed medication alters the taste of the food,
which may already be less palatable due to
puree consistency.
The administration of medication through a
tube requires special precautions.
83
Both liquid
and crushed medications have the potential to
adhere to or clog the inside of the tube, and
consideration must also be given to the timing
of medication administration around the infusion
of enteral nutrition formulations (usually medi-
cations should not be added directly to enteral
formulations to avoid contamination and nutrient
incompatibilities). In addition to tube obstruc-
tion, toxicity or subtherapeutic doses may be
consequences of incorrect administration. One
study suggested that 74% of hospital staff used
at least two incorrect methods for administering
medications through a tube.
84
If medication administration through a tube
is necessary, the first consideration is the type
of tube and where it is placed.
83
The location in
the GI tract must be compatible with the site of
action/absorption for the medication to be admin-
istered. For example, medication expected to
act locally in the stomach, such as antacids or
sucralfate, would be ineffective if given through
a tube terminating in the intestine. The bioavail-
ability of medications undergoing extensive GI
first pass can also be increased if given through
a tube with an intrajejunal terminus.
83
These
medications include levodopa, beta blockers,
nitrates, opioids, and tricyclic antidepressants.
Administration of medications through a tube is
one scenario where liquid formulations may be
preferable if possible (although again, consider
total volume and cost when choosing).
83,85,86
Unfortunately, specific recommendations for
administration via tube are not always published
for all medications and are often based on
clinician consensus.
86
Several considerations
are suggested when deciding how best to
administer medication via this route. One such
consideration for liquids is the osmolarity of the
formulation. For products with an osmolarity of
>1,000 mOsm/kg (e.g., acetaminophen, docu-
sate, lactulose, hydroxyzine, ferrous sulfate,
multivitamin, lithium, diphenoxylate/atropine), it
is recommended to dilute the formulation with
10–30 mL water to avoid side effects such as
nausea, cramping, or diarrhea.
83,85,86
If crushed medications are to be given,
large-bore tubes are preferable, and medica-
tions should be given as a slurry with at least
30 mL water to flush the tube before and after
administration. For those medications with a
narrow therapeutic index, especially those
which are likely to adhere to the tube or interact
with components of enteral formulations (e.g.,
phenytoin and warfarin), a more intensive moni-
toring plan should be implemented to ensure
drug therapy outcomes are not compromised
with fluctuations in bioavailability.
83,85,86
In addi-
tion, some medications are more reliably admin-
istered intravenously if oral administration is not
possible. Fluoroquinolones are an example of
a medication class for which the bioavailability
is usually thought to be similar when given by
mouth or intravenously; however, when crushed
and administered through a tube, their bioavail-
ability can vary erratically. Intravenous adminis-
tration may therefore be preferable if possible,
but if the fluoroquinolone must be administered
through the tube it must be separated by at least
2 hours before or 4 hours after enteral formu-
lations. Moreover, it is recommended that the
medication be mixed with a larger volume of
water, 20–60 mL, before administration.
83
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When medications must be crushed, there are
special considerations that the caregiver should
be aware of to avoid errors. One such consider-
ation is the teratogenicity of the medication being
handled. The medication counseling provided to
a male or postmenopausal female patient may
not include detailed information about the tera-
togenicity of the medication, but it should not be
assumed that it is the patient alone that would
need to handle the medication product during
administration. In many care settings, physical
contact by the caregiver with the products them-
selves may be minimal, if any, due to unit-dose
packaging that allows the tablet or capsule to be
popped directly into a medicine cup. However,
this is not true in all settings, and when a medica-
tion must be opened or crushed, the likelihood of
exposure increases. For many drugs, even those
considered pregnancy category X, the degree of
absorption through the skin may not be clinically
insignificant. However, staff members concerned
about risk of exposure should be aware of what
they are handling. Regular handwashing after
each patient’s medication administration is
a part of standard practice; in addition, staff
members who are pregnant, trying to become
pregnant, or who are breastfeeding may also
consider the use of gloves while handling these
types of products.
It is also important to be aware of those
medications for which crushing is not appro-
priate but another form of dissolution can be
employed. For instance, potassium supplements
with extended-release granules suspended in
wax matrix should not be crushed, but the wax
matrix will readily dissolve, releasing the tiny
granules, in a small amount of water. Another
example is the opening of proton pump inhibitors
(PPIs) to mix the contents with a small amount
of an acidic juice. For some capsules containing
microencapsulated pellets, the dosage form can
be opened and poured down a large bore tube,
provided the contents are not crushed. When the
pharmacist filling the prescription or providing
drug regimen review is aware that a patient may
require crushed medications, it may be advis-
able to recommend auxiliary labeling or special
instructions be added to the chart order or the
product labeling to flag special administration
needs.
G R
D
GERD is the most prevalent GI disorder in the
United States. Monthly symptoms are reported
in >40% of patients and daily symptoms
reported in about 10%.
87
Symptoms are typically
described as heartburn or regurgitation but can
also include “extraesophageal” symptoms such
as cough, hoarseness or laryngitis, postnasal
drip, worsening asthma symptoms, or noncar-
diac chest pain.
88,89
Consequences of GERD
can include local effects on the esophagus,
such as esophagitis, ulceration, bleeding, and
Barrett’s esophagus, but GERD can also lead
to weight loss, anorexia, and anemia. There are
also associations between GERD and exacerba-
tions of chronic obstructive pulmonary disease
and insomnia. As such, GERD has a significant
impact on overall health, quality of life, and
healthcare utilization.
90,91
The prevalence of GERD increases with
age and is influenced by physiologic changes in
the GI tract, including slowed gastric emptying,
decreased saliva production, reduced intra-
abdominal length of the lower esophageal
sphincter, and increased incidence of hiatal
hernia.
87,92
However, symptom presentation is
often atypical in frail patients and may be milder
or asymptomatic. When symptoms do present,
they are often alarm symptoms or may be
associated with dysphagia, cough, wheezing,
and chest pain. The highest rates of atypical
symptoms are reported in the oldest patients,
increasing the risk of misdiagnosis or inappro-
priate prescribing.
92
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KEY POINT:
Atypical GERD
symptoms can result in polypharmacy if
the symptoms are attributed to cardiac,
respiratory, or sleep disorders.
GERD can also be caused or exacerbated
by medication and food. Drug-induced esoph-
ageal injury was discussed in the previous
section.
55-60
Common agents include bisphos-
phonates, aspirin, NSAIDs, antibiotics, potas-
sium supplements, iron supplements, calcium-
channel blockers, theophylline, cholinesterase
inhibitors, and antipsychotic medications. The
risk of drug-induced GERD increases not only
with polypharmacy but with an increased amount
of time spent reclining or lying down, and with
inadequate fluid intake with medication admin-
istration. Common foods associated with GERD
include dairy, acidic food such as tomatoes and
fruits, fatty foods, caffeine, alcohol, peppermint,
and chocolate.
93
Based on recommendations of the American
College of Gastroenterology, antacids can
be used for intermittent symptoms, but acid
suppression therapy is the primary treatment
for GERD.
94
PPIs have better efficacy than
histamine-2 receptor antagonists (H2RAs), so
either a step-up or step-down approach can be
employed, depending on the clinical presenta-
tion. Step-up therapy employs the H2RA therapy
for more mild symptoms with a step up to a PPI.
Alternatively, step-down therapy begins more
aggressively with the PPI, with higher initial
doses prescribed for the healing of ulcers and
continued for 6 weeks. The dose may be reduced
and ultimately switched to H2RA therapy as
symptom control allows.
In general, the recommendations for treating
GERD in elderly patients are similar to those for
the general adult population.
95
After the diag-
nosis of GERD has been made, the selection
of appropriate therapy is relatively straightfor-
ward; the bigger challenge is often the accu-
racy of diagnosis and determining appropriate
duration of use.
96-98
GERD can be a chronic
or relapsing condition, and, especially in the
absence of dietary or nonpharmacological
interventions, symptoms can return. However,
symptom response to PPI therapy is not neces-
sarily an accurate marker of correct diagnosis,
especially among individuals with atypical symp-
toms, and long-term use of PPIs has also been
associated with complications.
96-101
There are
data linking use of acid-suppressing medica-
tions to hip fracture. One of the putative mecha-
nisms suggested for this association is reduced
absorption of calcium. There are both positive
and negative studies published examining the
relationship; however, in general, the relationship
appears strongest for high-dose, long-term use,
especially among frail cohorts at highest risk for
fracture.
102-104
In addition, chronic acid suppression can
alter the natural gut flora, increasing the risk of
pneumonia and Clostridium difficile (C. diff.)–
associated diarrhea. The association of PPI use
with community-acquired pneumonia has been
evaluated in a number of settings and suggests
that recent (<30 days) or current use of PPI
therapy was associated with risk of pneumonia,
particularly among frail patients or those with
recurrent pneumonia.
105-107
Elderly patients are
already at relatively higher risk of developing
C. diff. diarrhea, particularly when treated with
antibiotic therapy. However, in addition, the use
of acid-suppressing therapy may be an inde-
pendent risk factor for developing this condi-
tion.
108-111
This association has been evaluated
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| Fundamentals of Geriatric Pharmacotherapy
in a number of age and ethnic groups.
112,113
Although one study of older patients in the
community setting did not find that PPI use was
a risk factor for hospitalization with C. diff. diar-
rhea, the occurrence of a prescription within
90 days of the hospitalization was used as the
surrogate for medication use.
114
Other studies
have suggested that PPIs, but not H2RAs, are
associated with increased incidence of both
first-time and recurrent C. diff. diarrhea.
115,116
For the health professional performing a drug
regimen review, it can often be challenging to
discern the appropriateness of drug therapy
such as chronic PPIs. This class of medica-
tion is commonly prescribed in hospitals as
part of stress ulcer prophylaxis protocols, often
outside the guidelines recommending appro-
priate scenarios for use.
117,118
They are frequently
used in patients over 60 receiving NSAIDs or
co-prescribed with antiplatelet therapy.
119,120
PPIs
are often continued on discharge to the next care
venue, whether a skilled nursing unit, long-term
care unit, other care environment, or the outpa-
tient setting. Ideally, if standardized guidelines
are employed at the time of prescribing, and
optimal medication reconciliation and records
review are performed on transfer, appropriate
medication-indication match could be verified,
and the continuation of a medication without
long-term indications would not occur.
117-120
However, where there is lack of adequate docu-
mentation, the presence of an underlying indi-
cation will often simply be assumed, and while
both over- and under-prescribing can occur, a
common problem is that the duration of therapy
is extended longer than necessary.
Sometimes, the diagnosis is even added to
the medical record after the medication therapy
is initiated or refilled, making it very difficult for
health professionals in the new venue to deter-
mine whether discontinuation would be appro-
priate. There have been multiple publications
focusing on the challenges associated with
over-prescribing or inappropriate prescribing
of PPIs.
98,117,121
Patients with a recent ulcer or
other appropriate diagnosis or whose symp-
toms have been documented to respond to
acid suppression therapy should clearly not be
denied access to treatment. However, the long-
term continuation of therapy in the absence of
a true indication is inappropriate and increases
the risk of long-term complications associated
with the drug. In addition, patients who remain
refractory to PPI therapy should be re-evaluated
for nonreflux etiology of symptoms.
122,123
Mean-
ingful medication reconciliation must be able
to verify drug therapy against documentation
describing both indication and intended duration
of use. Although this is true for any medication
prescribed for any reason, it is particularly rela-
tive to PPI therapy.
KEY POINT:
Medication reconciliation that
assesses true medication-indication match
is vital to the assessment of appropriate
PPI prescribing and duration of therapy.
N V
Nausea and vomiting are two of the most common
symptoms when someone is ill, and they can
occur for many reasons. They are among the top
side effects reported with drug therapy and are
reported in the product labeling of almost every
medication. Nausea and vomiting are especially
common with chemotherapeutic agents and
opiates, reported in 40% to 90% of individuals
treated for cancer and 20% to 40% of individ-
uals treated with opiate analgesics, with much of
the data reported in either the palliative or post-
operative settings.
124-130
Nausea and vomiting
can be a part of the clinical presentation of
many illnesses and part of the atypical clinical
presentation of almost any illness exacerbation
among frail patients. For example, in addition to
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11 - Gastrointestinal Disorders and Nutrition |
305
GI illnesses such as gastroenteritis or constipa-
tion, pain syndromes, anxiety, thyroid disorders,
vestibular disorders, renal or hepatic dysfunc-
tion, pancreatitis, cardiovascular events, and
syncope can all present with nausea or vomiting.
Nausea and vomiting are common after surgical
procedures and also near the end of life.
131,132
These symptoms have both short- and
long-term consequences. The short-term conse-
quences are those almost any individual who has
ever been ill can understand: the acute discom-
fort of being sick to one’s stomach and needing
to vomit, associated with stomach cramping,
residual muscle pain in the torso following
vomiting, and often feelings of dizziness or
weakness. Protracted symptoms of nausea
and vomiting can take a significant physical
and psychological toll, from loss of appetite to
significant weight loss and anorexia. This can be
associated with dehydration, electrolyte distur-
bances, physical deconditioning, and functional
decline.
Treatment requires two approaches: imme-
diate relief of symptoms and removal or at least
improvement of the underlying cause of the
problem. Either approach is dependent on the
etiology of the nausea and vomiting.
133-136
There
are a variety of prescription and nonprescription
interventions for symptom treatment, with the
primary pharmacological targets being dopa-
mine antagonism (block dopamine receptors
in the chemoreceptor trigger zone or increase
peristalsis in upper GI tract), 5-HT3 antagonism
(block serotonin receptors in the chemoreceptor
trigger zone, act at vestibular and vomiting
centers), or to block histamine or cholinergic
muscarinic receptors (reduce gastric secre-
tions).
133-136
Commonly employed agents include
phenothiazines, droperidol, metoclopramide,
anticholinergics, and 5-HT3 receptor antago-
nists such as ondansetron and granisetron.
The treatment of nausea and vomiting in older
patients is often an exercise in balance, as many
antiemetic mediations carry unfavorable side
effects. Ideally, regardless of the agent chosen,
drug therapy directed at symptom control is
short term while the underlying cause is being
addressed. However, if that is not possible, there
is a degree of trial and error involved in selecting
the antiemetic therapy that effectively relieves
symptoms without causing intolerable side
effects, a challenge made especially difficult in
the presence of comorbidities or polypharmacy.
Side effects can be anticipated by understanding
the mechanisms of action of the various anti-
emetic drugs. For instance, dopamine-blocking
medications can exacerbate extrapyramidal
side effects. One study suggests age is a signifi-
cant risk factor for sedation, extrapyramidal side
effects, and delirium with phenothiazine medi-
cation.
137
Among medications with this mecha-
nism of action, trimethobenzamide is thought to
be the least potent antiemetic; therefore, having
the least favorable ratio of efficacy to side effect
risk.
138
Metoclopramide can also cause extra-
pyramidal effects, psychiatric symptoms such as
anxiety and depression, somnolence, and cogni-
tive changes, particularly at doses inappropriate
for renal dysfunction or when used long term,
and it is a common cause of unrecognized drug-
induced Parkinson disease.
139
Antihistaminic
or anticholinergic medications can exacerbate
sedation, dry mouth, constipation, and cognitive
impairment.
138
The availability of over-the-counter products
used to self-medicate can lead to under-reported
nausea and vomiting and under-recognized
drug side effects. Agents such as domperidone
can prolong the QT interval, whereas droperidol
and cannabinoids are more likely to be asso-
ciated with CNS effects such as dizziness,
dysphoria, depression, or hallucination.
140-142
The
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306
| Fundamentals of Geriatric Pharmacotherapy
5-HT3 receptor antagonists have, in general, a
favorable side effect profile but are more costly,
and specific trials differentiating their outcomes
in frail geriatric patients with non-cancer-related
pain have not been published. Applying these
considerations may help narrow the choices,
depending on the etiology of the nausea and
vomiting and the patient’s risk factors.
Older patients with cancer require special
attention. Individuals over 65 have the highest
incidence of cancer, and the course of treatment
is often complicated by comorbidity and poly-
pharmacy. However, some evidence suggests
that the use of supportive therapy, such as anti-
emetics, is underutilized.
143
The 5-HT3 receptor
antagonists are considered first-line for patients
at moderate to high risk of nausea and vomiting,
and in the highest risk scenarios, combination
therapy with 5-HT3 receptor antagonists, aprepi-
tant, and dexamethasone is recommended.
144,145
There are no specific guidelines for modifications
to this approach for elderly patients; however,
there are differences between agents that carry
implications for the older patient, especially in
the presence of comorbidities. For instance, the
product labeling for dolasetron, palonosetron,
and tropisetron include warnings for patients with
cardiovascular disease. Ondansetron is thought
to act at both central and peripheral recep-
tors and may be associated with a higher risk
of dizziness or blurred vision.
143,144
By contrast,
granisetron has fewer CYP450 drug interactions
and may be given on a once-daily interval.
143
Elderly patients with comorbidities or concomi-
tant NSAID use may also be less likely to receive
dexamethasone therapy.
146
In the absence of
clinical trials specifically evaluating the efficacy
and safety of antiemetic therapy in this context,
the choice of therapy is unfortunately often
empiric.
147
The ability to tolerate oral medication impacts the
efficacy of antiemetic therapy for any patient. It
cannot be effective if the patient cannot keep it
down. Therefore, alternate routes of therapy must
often be considered, including orally dissolving,
injectable, transdermal, or rectal formulations.
The ability to take oral medication, to keep
it down after doing so, or to tolerate it without GI
discomfort has direct implications for the long-
term control of any medication-treated condi-
tion, making adverse drug therapy outcomes
both a cause and a consequence of nausea
and vomiting. In the long term, changes in
nutritional factors, such as albumin or vitamin
K stores associated with poor appetite from
chronic nausea, also have implications for drugs
that are highly bound to albumin or for warfarin
sensitivity. When performing a drug regimen
review, the pharmacist can use a variety of surro-
gates to identify whether unrecognized drug-
associated nausea syndrome is occurring, such
as poor appetite, weight loss, repeated medica-
tion refusals, or fluctuations in laboratory param-
eters. In the long-term care setting, this can be
identified from documentation in the chart or
the medication administration record, or in the
outpatient setting patients can be interviewed
regarding reasons for “intelligent nonadherence”
to prescribed therapy. The choice to alter or not
adhere to therapy may often be associated with
previously unreported symptoms. This type of
review can also identify possible inappropriate
administration techniques causing unnecessary
GI distress, such as failure to take bulk-forming
laxatives with adequate water. Another could
be the administration of NSAIDs on an empty
stomach. If modification of the drug, its timing,
or its administration technique can alleviate GI
distress, this may help avoid therapeutic failure
associated with nonadherence.
KEY POINT:
Drug-induced nausea and
vomiting can be “hidden in plain sight.”
Careful chart review and/or interview
techniques can reveal the common pitfalls in
medication use that result in GI distress.
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