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Rapid Responses: Rapid Responses published:
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Heat waves, drugs and dehydration in elderly
- Agnès Sommet, Anne Castot, Jean-Louis Montastruc (10 July 2009)
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Special care for the elderly
- Hugh Mann (13 July 2009)
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Re: Heat waves, drugs and dehydration in elderly
- Les O. Simpson (15 July 2009)
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Parkinson's medication should not be reduced without very good reason.
- Richard W Genever (23 July 2009)
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Hypodermclysis in dehydrated elderly - a missed opportunity
- Dr. Joachim Zeeh (26 July 2009)
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The role of long-range weather forecasting in caring for older people
- Duncan R Forsyth (3 August 2009)
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Agnès Sommet, Pharmacoepidemiologist Department of Clinical Pharmacology, EA 3696, 37 allées Jules-Guesde, 31000-Toulouse, France, Anne Castot, Jean-Louis Montastruc
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We read with great interest the editorial from Olde Rikkert et al1 on heat waves and dehydration in the elderly. As mentioned by the authors, the exceptional heat wave in 2003 leaded to an excess mortality, in particular in old people. In France for example, this heat wave was associated with about 14800 deaths, mainly among people over 70 years.2 Since there are interactions between physiological dysfunctions induced by heat and drugs, some pharmacological classes may represent a risk factor of morbi-mortality during heat waves. Few studies have investigated the role of drugs in sanitary consequences of heat waves. In order to evaluate this relation, we performed a study in the French Pharmacovigilance Database to evaluate adverse drug reactions (ADRs) in patients older than 70 years reported during the 2003 summer to the French Network of Pharmacovigilance Centers.3 Sixty-eight “serious” ADRs related to heat occurred in patients older than 70 years were registered in the French Pharmacovigilance Database during summer 2003. These ADRs were mainly metabolic (dehydration, hydroelectrolytic disorders) and neuropsychiatric (confusion, disorientation, coma). Drugs more frequently involved were diuretics, angiotensin converting enzyme inhibitors, serotoninergic antidepressants, proton pump inhibitors, digoxin, benzodiazepines and sartans. The involvement of diuretics underlines that dehydration represents the main pathophysiological problem during unexpected warm periods. Angiotensin converting enzymes inhibitors and sartans induce hyponatremia, arterial hypotension and renal insufficiency. Apart from their action on hydro electrolytic movements and renal metabolism, these drugs, as serotonin-reuptake inhibitors, could also modify water ingestion through a central effect. Hyponatremia and confusion was also described with proton pump inhibitors, especially in elderly people. Confusion and disorientation could be partly explained by digoxin and benzodiazepine exposure. However, because of their pharmacodynamic and pharmacokinetic properties, other pharmacological classes could interfere with thermoregulation processes. Antipsychotics, H1 antihistamine and imipraminic drugs are known to disturb central thermoregulation by their action on hypothalamic centres. Drugs leading to a sweating decrease - mainly atropinic drugs and carbonic anhydrase inhibitors - reduce the capacity for heat loss. Drugs leading to vasoconstriction, as sympathomimetic and beta-blocking agents, reduce heat loss by convection. In order to better investigate and quantify the risk of different pharmacological classes during heat waves among other risk factors, pharmacoepidemiological studies should be performed. In summer 2007, French Medicament Agency supported a multicentric case-control pilot study called SIRIUS to evaluate in real conditions the role of drugs in heat- related adverse effects.4 Drugs exposure in patients older than 65 years hospitalized with hyperthermia or dehydration were compared with controls. Since there was no heat wave during this period, this study suffers from a lack of power. However, similar methodology will be used in further studies in case of new heat wave’s occurrence. Results of such studies could help physicians to reconsider patients’ treatments during a heat wave, and inform patients at risk and their family of these drug-related dangers. Agnès Sommet1* Anne Castot2 Jean-Louis Montastruc1 1: Department of Clinical Pharmacology, Unité de Pharmacoépidémiologie EA 3696, Université de Toulouse, Hôpitaux Universitaires, Faculté de Médecine, 37 allées Jules-Guesde, 31000- Toulouse, France 2: Chef du Département de la Surveillance du Risque, du Bon Usage et de l’Information sur les Médicaments, Agence Française de Sécurité Sanitaire des Produits de Santé, 143/147 boulevard Anatole France 93285- Saint-Denis Cedex, France sommet@cict.fr References 1. Rikkert MG, Melis RJ, Claassen JA. Heat waves and dehydration in the elderly. BMJ 2009;339:b2663 2. Fouillet A, Rey G, Laurent F, Pavillon G, Bellec S, Guihenneuc- Jouyaux C, et al. Excess mortality related to the August 2003 heat wave in France. Int Arch Occup Environ Health 2006;80:16-24. 3. Michenot F, Sommet A, Bagheri H, Lapeyre-Mestre M, Montastruc JL, the French Network of PharmacoVigilance Centres. Adverse drug reactions in patients older than 70 years during the heat wave occurred in France in summer 2003:a study from the French PharmacoVigilance Database. Pharmacoepidemiol Drug Saf 2006 ;15 :735-40. 4. Sommet A, Shams R, Valnet-Rabier MB, Jean-Pastor MJ, Castot A, Lapeyre-Mestre M, et al. Drugs and heat wave: SIRIUS, a multicentric case- control study in patients older than 65 years during 2007 summer in France. Thérapie 2009, in press. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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The elderly need special care, because they are paradoxically frail but sturdy survivors who have not succumbed to life's many perils. So as physicians, we should respect the durability and success of their homeostatic mechanisms and minimize our pharmaceutical interventions. For example, when treating the elderly for dependent ankle edema due to venous incompetence, it is best to avoid diuretics and instead use compression stockings and exercise. This will reduce the likelihood of dehydration, with all its sequelae, including heat exhaustion and heat stroke. Competing interests: None declared |
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Les O. Simpson, retired experimental pathologist Dunedin, New Zealand, 9077
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In their interesting contribution, Sommet et al failed to address the question, "What are the pathophysiological consequences of dehydration ?" The question is of particular relevance as their observations concerned patients aged 75 years and older. In 1989, Ajmani and Rifkind from the Institute of Aging, reported that as a part of the aging process, blood viscosity increased, probably as a consequence of raised levels of fibrinogen. As a result, tissue perfusion was compromised. Because dehydration will amplify the blood viscosity problem with potentially lethal consequences, it would seem essential that the blood viscosity/dehydration problem be addressed promptly. Competing interests: None declared |
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Richard W Genever, Consultant Geriatrician and Movement Disorders Lead Chesterfield Royal Hospital NHS Foundation Trust, Calow, Chesterfield. S44 5BL
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Olde Rikkert and colleagues rightly raise the importance of recognising dehydration in older people but their assertion that Parkinson's disease (PD) drugs should be reconsidered, stopped or their doses reduced needs to be challenged 1. Missed (or even reduced) doses of dopaminergic agents such as levodopa or dopamine agonists have been associated with the potentially life-threatening condition neuroleptic malignant-like syndrome (NMLS) 2,3. This condition, which is associated with confusion, rigidity, pyrexia and elevated muscle enzymes, is more likely in dehydrated individuals and during hot weather 4,5. In recognition of this issue and other problems faced when inpatients with PD do not receive the correct medication, the Parkinson's Disease Society has been running the 'Get it on time' campaign to raise awareness in the medical and nursing professions 6. In the absence of evidence that those with Parkinson's disease require less treatment in hot weather and an established link between reduced PD drugs and NMLS the advice for this group of patients should be to continue their usual therapy (unless they are advised by a movement disorder specialist that they are over-medicated) and the focus should be on ensuring adequate hydration. Any other approach could have the potential to undermine the important message that Parkinson's patients require the correct treatment every time. Richard W Genever References 1. Olde Rikkert MG, Melis RJ, Claasen JA. Heat waves and dehydration in the elderly. BMJ 2009;339:b2663 2. Kipps CM, Fung VS, Grattan-Smith P, de Moore GM, Morris JG. Movement disorder emergencies. Movement Disorders 2005;20 (3):322-334 3. Morris J, Douglas A. It was not just a heatwave! Age and Ageing 2006;35:640-641 4. Ueda M, Hamamoto M, Nagayama H, Utsubo K, Nito C, Terashi A, Katayama Y. Susceptibility to neuroleptic malignant syndrome in Parkinson's disease. Neurology 1999;52 (4):777-781 5. Takubo H, Harada T, Hashimoto T, Inaba Y, Kanazawa I, Kuno S et al. A collaborative study on the malignant syndrome in Parkinson's disease and related disorders. Parkinsonism and related disorders 2003;9 (Supp 1):31-41 6. http://www.parkinsons.org.uk/about_us/policy_and_campaigns- 1/current_campaigns/get_it_on_time_campaign.aspx Competing interests: None declared |
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Dr. Joachim Zeeh, Chefarzt Geriatrische Fachklinik Georgenhaus, D-98617 Meiningen, Germany
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Dehydration in the frail elderly population is a major health issue. This becomes particularly obvious during hot summers. But regardless of season, dehydration is one of the most frequent diagnoses leading to hospitalization in the frail elderly with a high mortality rate (1). If a frail old person presents with an acute or subacute decline of cognitive or physical function, dehydration is among the reasons most often to blame for. The management of acutely unwell old peolple, already too weak to receive oral fluids, presents a common challenge to medical and nursing home staff (2). In their important editorial (3), Olde-Rikkert and colleagues miss the opportunity to reintroduce hypodermoclysis (subcutaneous infusion), an ingenious technique for prevention and treatment of dehydration. In confused and agitated elderly patients, hypodermoclysis has been shown to be safer and more effective than the intravenous route. Hypodermoclysis can easily be administered in non- hospital settings and, thus, may reduce hospital admissions due to dehydration. Hypodermoclysis, although simple, safe and (cost) effective, is grossly underused as a method of fluid delivery for the frail elderly. By promoting this technique, editorialists and opinion leaders could contribute to older people being no longer “denied an element of health care that they are perhaps most well suited to.” (4) References: (1) Remington R, Hultman T. Hypodermoclysis to treat dehydration: a review of the evidence. J Am Geriatr Soc 2007; 55: 2051-2055 (2) Barton A, Fuller R, Dudley N. Using subcutaneous fluids to rehydrate older people: current practices and future challenges. Q J Med 2004; 97: 765-768 (3) Olde-Rikkert MGM, Melis RJF, Claassen JAHR. Heat waves and dehydration in the elderly. BMJ 2009; 339: b2663 (4) Barua, P, Bhowmick BK. Hypodermoclysis – a victim of historical prejudice. Age and Ageing 2005; 34: 215-17 Competing interests: None declared |
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Duncan R Forsyth, Consultant Geriatrician Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, CB2 0QQ
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Sir, I read with interest the article by Olde Rikkert, et. al on the dangers of heat waves and dehydration in frail older people. For several years I have taught my trainees the importance of monitoring long-range weather forecasts in the acute care of frail older people. Prior awareness of the likelihood of prolonged hot weather allows for preventative action to be taken in reducing or stopping diuretics , ACE-inhibitors and NSAIDs in frail vulnerable older people in our acute hospital, most of whom barely manage to maintain adequate fluid intake in normal climatic conditions. Staff are particularly asked to consider the possibility of a heatwave at week-ends and over Bank Holiday weekends, when medical supervision is minimal. More recently I have extended this teaching to general practitioner colleagues caring for the most vulnerable older people - those in care homes or those living alone and in receipt of home care. Most of those who are at greatest risk from dehydration during a heatwave are known to older people's services and so preventative action is possible if only we seek to prevent problems rather than waiting for the crisis to happen! Competing interests: None declared |
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