THE HEART OF THE MATTER
a special program of the National Emergency Medicine Association (NEMA) 

Week: 519.5 Guest: Louis Grenzer, M.D. Topic: Medication and the Elderly - One Part Host: Richard Roeder Producer: Ed Graham

NEMA: This is a conversation about medication and the elderly. My guest is cardiologist Dr. Louis Grenzer from Baltimore, Maryland.

NEMA: Dr. Grenzer, one of the issues that the elderly have to deal with all the time is when they take their drug and how much of their drugs they take and many elderly people have conditions that without their drugs, they wouldn't be alive anymore but the older people are, the less capable they are of handling large amounts of medication, their livers respond at a slower rate to the medication in their blood stream. How do you approach an elderly patient when they are a new patient to you and you find out that they have a heart condition? How do you approach administering medications? Do you start with extremely low doses? Explain a little bit about what you do in a situation like that?

GRENZER: There are a lot of special considerations in administering drugs to elderly patients. Probably the most important thing is that elderly patients have more diseases than younger patients so that elderly patients very commonly are on many drugs at the same time. Sometimes they're on five or even ten or more drugs and so one has to worry more in elderly patients about drug interactions because sometimes two drugs that are given simultaneously will affect the dose and the side effects and so forth of each other, one has to worry about drug disease interactions because there are certain drugs that cause complications related to the disease you have. I'll just give one example. Beta-blockers are a drug that we commonly use for heart problems and if you happen to have asthma or wheezing from bronchitis, beta-blockers will make it worse. That would be an example of a drug disease interaction that would have to be taken into account. But because elderly people are frequently on many drugs, we have to be much more wary of the interactions, both between the two different drugs and the drug and your disease. As far as dosages which you alluded to, drugs are usually either broken down in the liver or excreted through the kidneys and in both cases in older people, the kidneys don't work quite as well, the liver doesn't break down drugs quite as well so we do have to be careful about dosages in older people. It's certainly a good rule of thumb for a doctor to start out with lower doses in older persons than he would in a younger person. Now since the excretion of drugs by the kidneys and the breakdown of drugs by the liver varies in older patients, you don't want to, however, not increase the dose if the initial dose is not effective in that patient. It may vary from patient to patient.

NEMA: I assume that patience is a very important part of establishing the right level of medication for someone with a disease process going on. Do you want to go to a very low dose and work your way up and make sure you don't get jumpy and push things too quickly?

GRENZER: Certainly it's better to start with a low dose and work up than to start with a high dose, get complications and be in trouble so we have to use lower doses, you're quite right, in older patients because of the way drugs are excreted and broken down.