I. Antibiotics
(1) The elderly often have reduced liver function, so antibiotics mainly inactivated by the liver, such as chloramphenicol, erythromycin, neomycin, tetracycline, etc., should be used with caution.
(2) The elderly often have reduced renal function and the clearance of drugs through the kidneys is slowed down. Aminoglycosides and tetracyclines should be reduced or the dosing interval extended according to the renal function.
Digitalis drugs: More arrhythmias such as heart failure and atrial fibrillation occur in the elderly, and more people use digoxin. The half-life of digoxin is prolonged in the elderly due to kidney function and other problems, which increases the incidence of digoxin poisoning in the elderly. Therefore, the elderly should pay special attention to the presence of the following risk factors for digoxin poisoning.
①Electrolyte disturbance and acid-base balance. (a) Hypokalemia, in particular, can lead to severe ventricular arrhythmias, and hyperkalemia can aggravate atrioventricular conduction delay.
②Renal insufficiency. (ii) Aging renal arteriosclerosis, hypertension, diabetes mellitus, and hyperuricemia can decrease glomerular filtration rate and reduce digitalis excretion.
(iii) Chronic obstructive pulmonary disease. Myocardial sensitivity to digitalis increases due to combined hypoxemia, hypercarbia and heart failure.
(iv) Severe myocardial ischemia may lead to digitalis proarrhythmia.
⑤ Mucinous edema can prolong the half-life of digoxin.
(6) Combination of multiple drugs. Drugs such as quinidine, verapamil and amiodarone, which have additional effects on the sinus node and atrioventricular node, not only increase digoxin blood levels but also aggravate conduction disturbances; potassium-removing diuretics can cause hypokalemia and increase the risk of toxicity.
In order to reduce the incidence of digoxin poisoning in the elderly, blood gas analysis, electrolytes and liver and kidney function examination must be performed before the drug is administered, and the dosage should be decided according to the muscle and liver clearance rate, and digoxin blood concentration should be monitored to avoid and detect digoxin poisoning in time.
Second, antihypertensive drugs: treatment of old hypertension do not make the blood pressure fall too fast too low, otherwise it is easy to lead to stroke and myocardial infarction. Anti-hypertensive drugs that act on the central system may lead to psychiatric symptoms, and the use of such drugs in the elderly is generally not advocated.
Table 1 Choice of antihypertensive drugs
Drug type
Indications
Contraindications
Restricted use
Diuretics
Heart failure
Gout
Dyslipidemia
Systolic hypertension
Pregnancy
Geriatric hypertension
Beta-blockers
Exertional angina
Asthma
Hypertriglyceridemia
Post-myocardial infarction
Chronic obstructive pneumonia
Type 2 diabetes mellitus
Tachyarrhythmia
Atrioventricular block of degree II-III
Physical laborers
Heart Failure
Peripheral vascular disease
Heart failure
Bilateral renal artery stenosis
Left ventricular hypertrophy
Blood muscle hepatic >
Post-myocardial infarction
Hyperkalemia
Diabetic microproteinuria
Pregnancy
Calcium channel blockers
Angina pectoris
Heart Failure
Peripheral vascular disease
Cardiac conduction block
Geriatric hypertension
(non-dihydropyridines)
Systolic hypertension
Reduced glucose tolerance
Alpha-blockers
Prostate hypertrophy
Postural hypotension
Reduced glucose tolerance
Table 4 Comparison of antihypertensive drugs in elderly patients
Thiazide diuretics
Beta-blockers
Calcium channel blockers
Safety
Electrolyte disturbances: hypokalemia; acute renal insufficiency and dehydration
Bronchospasm
Electrolyte disorders: hyperkalemia, especially in chronic kidney disease; first dose hypotension; acute renal insufficiency; angioedema
Non-dihydropyridines: atrioventricular block, bradycardia; dihydropyridines: hypotension, reflex tachycardia
Drug interactions
Digoxin.
Digoxin, diltiazem, verapamil
Diuretics, potassium retention
Cyclosporine, grapefruit juice
Tolerability
Postural hypotension, sexual dysfunction
Depression, sexual dysfunction
Dry cough caused by
Peripheral edema, constipation, gum enlargement
Efficacy
Hypertension, simple systolic hypertension, heart failure, diabetes mellitus, patients at high risk of cardiovascular disease, prevention of stroke
Hypertension, heart failure, post-infarction, patients at high risk of cardiovascular disease
Hypertension, heart failure, post-infarction, patients at high risk of vascular disease, diabetes mellitus, chronic kidney disease, stroke prevention
Hypertension, diabetes, patients at high risk of vascular disease, chronic stable angina, ischemic heart disease and symptom control in atrial fibrillation
, beta-blockers: Beta-blockers are widely used in hypertension, ischemic heart disease, myocardial infarction, heart failure, arrhythmias and hypertrophic cardiomyopathy.
The main adverse effects of β-blockers are.
(i) smooth muscle spasm (bronchospasm and chills in the limbs).
(ii) cardiac depression (bradycardia, conduction block and negative inotropic effects).
(iii) Invasion of the central nervous system (insomnia, depression, fatigue).
(iv) Interference with insulin sensitivity (elevated blood glucose).
Therefore, it should be contraindicated in people with heart block, asthma, chronic obstructive pulmonary disease, peripheral vascular disease, pulselessness of lower extremities and intermittent claudication; caution should be exercised in insulin-dependent diabetic patients. Pay attention to the adverse reactions of the central nervous system. Elderly cardiovascular patients are often combined with cerebrovascular lesions, and the use of fat-soluble beta-blockers (such as propranolol, indolol and metoprolol) is prone to new or aggravated symptoms of depression, insomnia and irritability on top of the existing ones. Water-soluble beta-blockers (such as atenolol) can be used instead. If symptoms are severe, beta-blockers should be discontinued and replaced with other drugs. Beta-blockers should be taken in small doses and incremental doses should be taken slowly. For patients with heart failure, β-blockers should be started on the basis of hemodynamic stability after adequate control with ACEI, diuretics and digitalis. The elderly are poorly tolerated to β-blockers and have great individual variability, especially those who have not taken β-blockers must be more careful to avoid “first dose reaction”. β-blockers have synergistic effects with nitrates, so pay attention to dose reduction when combining the two drugs, especially at the beginning to avoid side effects such as postural hypotension. Negative inotropic and negative conduction effects are enhanced when combined with verapamil and diltiazem, which can lead to hypotension or even cardiac arrest, and care must be taken. When discontinuing beta-blockers, the dosage should be gradually reduced to avoid “withdrawal syndrome”. Long-term (more than 2 weeks) application of beta-blockers need to discontinue the drug, must be gradually reduced within 2 weeks, not abruptly stop, abruptly stop in general within 1 to 10 days (peak on the 6th day) can occur frequent angina, acute emergency infarction, or even sudden death.
Calcium channel blockers: divided into dihydropyridines and non-dihydropyridines.
Non-dihydropyridines, such as verapamil and diltiazem, have significant negative inotropic and negative frequency effects, which can inhibit the cardiac conduction system and cause constipation, and there is a risk of excessive cardiac inhibition if beta-blockers are used in combination. Therefore, when using non-dihydropyridines in the elderly, it is important to start with small doses and adjust the dosage under close observation to prevent the occurrence of conduction disturbances, such as sinus bradycardia, sinus block, atrioventricular block or bundle branch block. Verapamil is also an important cause of constipation in the elderly.
And dihydropyridines, such as nifedipine and amlodipine, can be combined with beta-blockers; the main adverse effects are headache, facial flushing and ankle edema due to vasodilation, and can also cause reflex heart rate acceleration. However, if the dose is gradually increased from small doses, these adverse reactions can be significantly reduced or reduced.
The use of calcium channel blockers try to use long-acting preparations, long-term application of calcium channel blockers suddenly stop the drug can appear withdrawal syndrome, more obvious in the elderly, manifested as increased angina, blood pressure rebound, and even myocardial infarction and hypertensive crisis, so the long-term application of calcium channel blockers can not suddenly stop the drug, must gradually reduce the dose, in 1 to 2 weeks to achieve discontinuation.
ACEI and ARB: They are suitable for all types of hypertension, especially for patients with left ventricular hypertrophy, left ventricular insufficiency or heart failure, diabetes mellitus with microproteinuria, renal damage with proteinuria, etc. They should not be used for severe renal insufficiency, bilateral renal artery stenosis and obvious aortic valve and mitral valve stenosis. Although ACEI and ARB have protective effects on renal function, in patients with decompensated heart failure, dehydration and renal insufficiency, especially in elderly patients, first-dose hypotension is likely to occur, resulting in increased mortality in the acute phase. Therefore, elderly patients should be monitored for hypotension and renal function immediately upon initiation of use. If serum myohypoglycemia rises sharply by more than 30% in a short period of time, temporary discontinuation or dose reduction is required. Because ACEI and ARB can cause hyperkalemia, blood electrolytes and myohepatitis levels should be monitored regularly, especially when combined with potassium retention diuretics. ACEI and ARB may cause hypotension when used with other vasodilators and diuretics. The most common side effect of ACEI is persistent dry cough, which can be replaced by ARB if not tolerated.
Sedative-hypnotics: Barbiturates can cause mild restlessness or even significant psychiatric symptoms in the elderly; the half-life of Valium increases with age and is prone to accumulation in the body. Unrestricted use of sleeping pills in the elderly is prone to mental retardation, atherosclerotic dementia, etc. They should be used for a short period of time, and they should not smoke or drink alcohol while taking them, otherwise they will aggravate the side effects.
Thiazide drugs: Endorphin, chlorpromazine and other drugs are prone to extrapyramidal side effects in elderly patients, and may also cause postural hypotension and interfere with the thermoregulatory system. Tricyclic antidepressants, such as doxepin and promethazine, are likely to cause postural hypotension, urinary retention, cardiac rhythm disturbances and dementia in the elderly.
Narcotics: Elderly people should use narcotics with caution and pay attention to the dosage when they must be used. Dulcolax, morphine, etc. are likely to produce serious side effects such as severe respiratory depression and coma in the elderly.
Ephedra, licorice and rhubarb: ephedra has central and sympathetic excitatory effects, which can easily lead to insomnia, hypertension, angina pectoris in the elderly, and also cause urinary retention in elderly men; licorice can easily cause pseudo-aldosteronism, with increased blood pressure, swelling and decreased blood potassium; rhubarb can easily cause severe diarrhea, and should be used with caution in the elderly.