Principles of Pharmacology

  • Jerry Avorn
  • Jerry Gurwitz


The proper use of medications represents one of the most important ways in which the practice of geriatric medicine differs importantly from conventional medical care. Pharmacotherapy is perhaps the single most important medical intervention in the care of elderly patients, and its proper performance requires a special understanding of the unique physiologic properties of drugs in this group, as well as a grasp of the sociocultural and epidemiologic aspects of medication use in aging. The advent of Medicare coverage of some prescription medications taken by elderly persons has focused attention on the special problems and opportunities offered by pharmacotherapy in geriatrics at a time of growing public awareness of the benefits, risks, and costs of prescription drugs. Thus, physicians have both an opportunity and a responsibility to examine this topic in all its aspects, from those as “micro” as receptor physiology and the molecular biology of aging, to those as “macro” as the study of adverse drug effects in large populations and the questions raised by governmental coverage of medication costs.


Elderly Patient Nursing Home Adverse Drug Effect Nursing Home Patient Serum Drug Level 
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  1. 1.
    Reidenberg MM, Levy M, Warner H, et al. Relationship between diazepam dose, plasma level, age, and central nervous system depression. Clin Pharmacol Ther 1978; 23: 371–374.PubMedGoogle Scholar
  2. 2.
    Casteden CM, George CF, Marcer D, et al. Increased sensitivity to nitrazepam in old age. Br Med J 1977; 1: 10–12.CrossRefGoogle Scholar
  3. 3.
    Meyer BR, Lewin M, Dreyer DE, et al. Optimizing metoclopramide control of cisplatin-induced emesis. Ann Intern Med 1984; 100: 393–395.PubMedGoogle Scholar
  4. 4.
    O’Malley K, Stevenson IH, Ward CA, et al. Determinants of anticoagulant control in patients receiving warfarin. Br J Clin Pharmacol 1977; 4: 309–314.PubMedCrossRefGoogle Scholar
  5. 5.
    Shephard AMM, Hewick DS, Moreland TA. Age as a determinant of sensitivity to warfarin. Br J Clin Pharmacol 1977; 4: 315–320.CrossRefGoogle Scholar
  6. 6.
    Bellville JW, Forrest WH, Miller E, et al. Influence of age on pain relief from analgesics. JAMA 1971; 217: 1835 1841.Google Scholar
  7. 7.
    Kaiko RF. Age and morphine analgesia in cancer patients with postoperative pain. Clin Pharmacol Ther 1980; 28: 823–826.PubMedCrossRefGoogle Scholar
  8. 8.
    Scott JC, Stanski DR. Decreased fetanyl and alfentanil dose requirements with age: a simultaneous pharmacokinetic and pharmacodynamic evaluation. J Pharmacol Exp Ther 1987; 240: 159–166.PubMedGoogle Scholar
  9. 9.
    Vestal RE, Wood AJJ, Shand DG. Reduced betaadrenoreceptor sensitivity in the elderly. Clin Pharmacol Ther 1979; 26: 181–186.PubMedGoogle Scholar
  10. 10.
    Avorn J, Everitt DE, Weiss S, et al. Increased antidepressant use in patients prescribed beta-blockers. JAMA 1986; 255: 357–360.PubMedCrossRefGoogle Scholar
  11. 11.
    Schmucker DL. Aging and drug disposition: an update. Pharmacol Rev 1985; 37: 133–148.PubMedGoogle Scholar
  12. 12.
    Campion EW, deLabry LO, Glynn RJ. The effect of age on serum albumin in healthy males: report from the Normative Aging Study. J Gerontol 1988; 43: M18 - M20.PubMedCrossRefGoogle Scholar
  13. 13.
    MacLennan WJ, Martin P, Mason BJ. Protein intake and serum albumin levels in the elderly. Gerontology 1977; 23: 360–367.PubMedCrossRefGoogle Scholar
  14. 14.
    Greenblatt DJ, Sellers EM, Koch-Weser J. Importance of protein binding for the interpretation of serum or plasma drug concentrations. J Clin Pharmacol 1982; 22: 259–263.PubMedCrossRefGoogle Scholar
  15. 15.
    Buskirk ER. Health maintenance and longevity: exercise. In: Handbook of the Biology of Aging, 2nd ed. Finch CE, Schneider EL (eds.) New York: Van No-strand Reinhold Company 1985;pp. 898–899.Google Scholar
  16. 16.
    Mooney H, Roberts R, Cooksley WGE, et al. Alterations in the liver with aging. Clin Gastroenterol 1985; 14: 757–771.PubMedGoogle Scholar
  17. 17.
    Vestal RE, Norris AH, Tobin JD, et al. Antipyrine metabolism in man: influence of age, alcohol, caffeine, and smoking. Clin Pharmacol Ther 1975; 18: 425–432.PubMedGoogle Scholar
  18. 18.
    Rowe JW, Andres R, Tobin JD, et al. The effect of age on creatinine clearance in man. J Gerontol 1976; 31: 155163.Google Scholar
  19. 19.
    Lindeman RD, Tobin JD, Shock NW. Longitudinal studies on the rate of decline in renal function with age. J Am Geriatr Soc 1985; 33: 278–285.PubMedGoogle Scholar
  20. 20.
    Greenblatt DJ, Divoll M, Harmatz JS, et al. Kinetics and clinical effects of flurazepam in young and elderly insomniacs. Clin Pharmacol Ther 1981; 30: 475–486.PubMedCrossRefGoogle Scholar
  21. 21.
    Greenblatt DJ, Allen MD, Shader RI. Toxicity of high-dose flurazepam in the elderly. Clin Pharmacol Ther 1977; 21: 355–361.PubMedGoogle Scholar
  22. 22.
    Larson EB, Kukull WA, Buchner D, et al. Adverse drug reactions associated with global cognitive impairment in elderly persons. Ann Intern Med 1987; 107: 169–173.PubMedGoogle Scholar
  23. 23.
    Greenblatt DJ, Harmatz JS, Zinny MA, et al. Effect of gradual withdrawal on the rebound sleep disorder after discontinuation of triazolam. N Engl J Med 1987; 317: 722–728.PubMedCrossRefGoogle Scholar
  24. 24.
    Busto U, Sellers EM, Naranjo CA, et al. Withdrawal reaction after long-term therapeutic use of benzodiazepines. N Engl J Med 1986; 315: 854–859.PubMedCrossRefGoogle Scholar
  25. 25.
    Danielson M, Lundback M. Withdrawal of antihypertensive drugs in mild hypertension. Acta Med Scand 1981;646(suppl 11: 127–131.Google Scholar
  26. 26.
    Fleg JL, Gottlieb SH, Lakatta EG. Is digoxin really important in treatment of compensated heart failure? a placebo-controlled crossover study in patients with sinus rhythm. Am J Med 1982; 73: 244–250.PubMedCrossRefGoogle Scholar
  27. 27.
    Gheorghiade M, Beller GA. Effect of discontinuing maintenance digoxin therapy in patients with ischemic heart disease and congestive heart failure in sinus rhythm. Am J Cardiol 1983; 51: 1243–1250.PubMedCrossRefGoogle Scholar
  28. 28.
    Callaghan N, Garrett A, Goggin T. Withdrawal of anti-convulsant drugs in patients free of seizures for two years. N Engl J Med 1988; 318: 942–946.PubMedCrossRefGoogle Scholar
  29. 29.
    Sackett DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore, Md: The Johns Hopkins University Press; 1979, pp. 11–12.Google Scholar
  30. 30.
    Simonson W. Medications and the Elderly: A Guide for Promoting Proper Use. Rockville, Md: Aspen Systems Corp; 1984.Google Scholar
  31. 31.
    Ostrom JR, Hammarlund ER, Christensen DB, et al. Medication usage in the elderly population. Med Care 1985; 23: 157–164.PubMedCrossRefGoogle Scholar
  32. 32.
    Hammarlund ER, Ostrom JR, Kethley AJ. The effects of drug counseling and other educational strategies on drug utilization of the elderly. Med Care 1985; 23: 165–170.PubMedCrossRefGoogle Scholar
  33. 33.
    Darnell JC, Murray MD, Martz BL, et al. Medication use by ambulatory elderly: an in-home survey. J Am Geriatr Soc 1986; 34: 1–4.PubMedGoogle Scholar
  34. 34.
    German PS, Klein LE, McPhee SJ, et al. Knowledge of and compliance with drug regimens in the elderly. J Am Geriatr Soc 1982; 30: 568–571.PubMedGoogle Scholar
  35. 35.
    Kendrick R, Bayne JRD. Compliance with prescribed medication by elderly patients. Can Med Assoc J 1982; 127: 961–962.PubMedGoogle Scholar
  36. 36.
    Mazzullo J. The nonpharmacologic basis of therapeutics. Clin Pharmacol Ther 1972; 13: 157–158.PubMedGoogle Scholar
  37. 37.
    Trends in Nursing and Related Care Homes and Hospitals: United States, Selected Years 1969–80. National Center for Health Statistics; 1984. US Dept of Health and Human Services publication PHSS 84–1825.Google Scholar
  38. 38.
    Robers PA. Extent of medication use in U.S. long-term-care facilities. Am J Hosp Pharm 1988; 45: 93–100.PubMedGoogle Scholar
  39. 39.
    Physicians’ Drug Prescribing Patterns in Skilled Nursing Facilities. Office of Long Term Care; 1976. US Dept of Health, Education, and Welfare publication OS 7650050.Google Scholar
  40. 40.
    Ray WA, Federspiel CF, Schaffner W. A study of antipsychotic drug use in nursing homes: epidemiologic evidence suggesting misuse. Am J Public Health 1980; 70: 485–491.PubMedCrossRefGoogle Scholar
  41. 41.
    Ingman SR, Lawson IR, Pierpaoli PG, et al. A survey of the prescribing and administration of drugs in a longterm care institution for the elderly. J Am Geriatr Soc 1975; 23: 309–316.PubMedGoogle Scholar
  42. 42.
    Beers M, Avorn J, Soumerai SB, et al. Psychoactive medication use in intermediate-care facility. DAMA. 1988; 260: 3016–3020.CrossRefGoogle Scholar
  43. 43.
    Buck JA. Psychotropic drug practice in nursing homes. J Am Geriatr Soc 1988; 36: 409–418.PubMedGoogle Scholar
  44. 44.
    Institute of Medicine Committee on Nursing Home Regulation. Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press; 1986: 378–379.Google Scholar
  45. 45.
    Sherman DS, Avorn J, Campion EW. Cimetidine use in nursing homes: prolonged therapy and excessive doses. J Am Geriatr Soc 1987; 35: 1023–1027.PubMedGoogle Scholar
  46. 46.
    Dall JLC. Maintenance digoxin in elderly patients. Br Med J 1970; 2: 705–706.PubMedCrossRefGoogle Scholar
  47. 47.
    Fonrose HA, Ahlbaum N, Bugatch E, et al. The efficacy of digitalis withdrawal in an institutionalized aged population. J Am Geriatr Soc 1974; 2: 208–211.Google Scholar
  48. 48.
    Hull SM, Mackintosh A. Discontinuation of maintenance digoxin therapy in general practice. Lancet 1977; 2: 1054–1055.PubMedCrossRefGoogle Scholar
  49. 49.
    Wilkins CE, Khurana MS. Digitalis withdrawal in elderly nursing home patients. J Am Geriatr Soc 1985; 33: 850851.Google Scholar
  50. 50.
    Garibaldi RA, Brodine S, Matsumiya. Infections among patients in nursing homes: policies, prevalence and problems. N Engl J Med 1981; 305: 731–735.PubMedCrossRefGoogle Scholar
  51. 51.
    Zimmer JG, Bentley DW, Valenti WM. Systemic antibiotic use in nursing homes: A quality assessment. J Am Geriatr Soc 1986; 34: 703–710.PubMedGoogle Scholar
  52. 52.
    Crossley K, Henry K, Irvine P, et al. Antibiotic use in nursing homes: prevalence, cost, and utilization review. Bull NY Acad Med 1987; 63: 510–518.Google Scholar
  53. 53.
    Zimmer JG, Bentley DW, Valenti WM. Systemic antibiotic use in nursing homes: a quality assessment. J Am Geriatr Soc 1986; 34: 703–710.PubMedGoogle Scholar
  54. 54.
    Nolan L, O’Malley K. Prescribing for the elderly, I: sensitivity of the elderly to adverse drug reactions. 1988; 36: 142–149.Google Scholar
  55. 55.
    Seidl CG, Thornton GF, Smith JW, et al. Studies on the epidemiology of adverse drug reactions, III: reactions in patients on a general medical service. Bull Johns Hopkins Hosp 1966; 119: 299–315.Google Scholar
  56. 56.
    Granck E, Baker SP, Abbey H, et al. Medications and diagnoses in relation to falls in a long-term care facility. J Am Geriatr Soc 1987; 35: 503–511.Google Scholar
  57. 57.
    Lipsitz LA, Wei JY, Rowe JW. Syncope in an elderly, institutionalized population: prevalence, incidence, and associated risk. Q J Med 1985; 55: 45–54.PubMedGoogle Scholar
  58. 58.
    Prudham D, Evans JG. Factors associated with falls in the elderly: a community study. Age Aging 1981; 10: 14 1146.Google Scholar
  59. 59.
    Sobel KG, McCart GM. Drug use and accidental falls in an intermediate care facility. Drug Intel! Clin Pharm 1983; 17: 539–542.Google Scholar
  60. 60.
    Wells BG, Middleton B, Lawrence G, et al. Factors associated with the elderly falling in intermediate care facilities. Drug Intel! Clin Pharm 1985; 19: 142–145.Google Scholar
  61. 61.
    Stephen PJ, Williamson J. Drug-induced parkinsonism in the elderly. Lancet 1984; 2: 1082–1083.PubMedCrossRefGoogle Scholar
  62. 62.
    Ray WA, Griffin MR, Schaffner W. Psychotropic drug use and the risk of hip fracture. N Engl J Med 1987; 316: 363–369.PubMedCrossRefGoogle Scholar
  63. 63.
    MacDonald JB, MacDonald ET. Nocturnal femoral fracture and continuing widespread use of barbiturate hypnotics. Br Med J 1977; 2: 483–485.PubMedCrossRefGoogle Scholar
  64. 64.
    Avorn J, Everitt DE, Weiss S, et al. Increased antidepressant use in patients prescribed beta-blockers. JAMA 1986; 255: 357–360.PubMedCrossRefGoogle Scholar
  65. 65.
    Croog SH, Levine S, Testa MA, et al. The effects of antihypertensive therapy on quality of life. N Engl J Med 1986; 314: 1657–1664.PubMedCrossRefGoogle Scholar
  66. 66.
    Resnick NM. Urinary incontinence in the elderly. Med Grand Rounds 1984; 3: 281–290.Google Scholar
  67. 67.
    Katz PR. Training internists for a role in long-term care. J Gen Intern Med 1987; 2: 450–452.PubMedCrossRefGoogle Scholar
  68. 68.
    Mitchell JB. Physician visits to nursing homes. Gerontologist 1982; 22: 45–48.PubMedCrossRefGoogle Scholar
  69. 69.
    Waxman HM, Klein M, Carver EA. Drug misuse in nursing homes: an institutional addiction. Hosp Community Psychiatry 1985; 36: 886–887.PubMedGoogle Scholar
  70. 70.
    Taggart HM, Alderdice JM. Fatal cholestatic jaundice in elderly patients taking benoxaprofen. Br Med J Clin Res 1982; 284: 1372.CrossRefGoogle Scholar
  71. 71.
    Temple R. FDA Discussion Paper on Testing of Drugs in the Elderly. Washington DC: Food and Drug Administration; 1983.Google Scholar

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© Springer Science+Business Media New York 1990

Authors and Affiliations

  • Jerry Avorn
  • Jerry Gurwitz

There are no affiliations available

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