S3

Population group

Figure 5 Incidence of visual impairment by age: United States, 1992. Source: From Ref. 137.

Population group

Figure 5 Incidence of visual impairment by age: United States, 1992. Source: From Ref. 137.

Figure 6 Insulin pen (Innoletâ„¢, Novo Nordisk, Denmark) with large graduations and numbers for diabetic patients with minor visual capabilities. Moreover, it requires only 6 N for activation, which is far below the average.

administration. Impaired vision may affect (i) the ability to accurately measure liquids, (¿0 the ability to correctly read instructions, and (ii'i) the ability to differentiate between various types of medications (both the labeling of these drugs and their physical characteristics) (148,151-153).

Hearing The frequencies that are noticed by human beings range from 500 to 4000 Hz. In amblyacousia caused by degeneration of sensoric cells, the highest frequencies (>2000 Hz) vanish first followed by the lower ones. There are several drug delivery devices that need audiological capabilities (154-156). For instance, some powder inhalers are activated by moving a ring until it stops giving a clear "click" noise. If a patient does not hear the audio signal, he cannot be sure to have obtained the correct dose. The rotating of powder-releasing capsules in inhalers is quite loud and still recognizable by geriatric patients. However, connecting of a catheter to an insulin pump or perforating the capsule in an inhaler before administering is indicated by a more silent noise that cannot be registered by patients with amblyacousia (156).

Swallowing and chewing In addition to those changes occurring in the oral cavity (Table 6), there are other factors that may inhibit an elderly patient's ability to both swallow and chew. For instance, xerostomia, or dry mouth, is a condition that is prevalent among older people. Xerostomia may be caused by any one of the following conditions: (i) Elderly patients often do not consume adequate amounts of liquid and are thus dehydrated; (ii) Many elderly patients "mouth breathe" because of asthma or other respiratory diseases; and (iii) Elderly patients often take medications having anticholinergic side effects (e.g., antidepressants and neuroleptics) (136,157-160). Patients experiencing xerostomia often have difficulty swallowing tablets or capsules because they tend to adhere to the esophageal mucosa when it is dry (116,126,161-164). In addition, esophageal lesions are common among the elderly and may affect a patient's ability to swallow; this is compounded by the inhibition of peristalsis by the weakened esophageal musculature (126,128). The ability of elderly patients to chew is also compromised (126,135,139,141), perhaps as a result of the decreased bulk and tone of the oral musculature as one ages (135). Additionally, it has been estimated that 50% of all elderly persons in the United States are fully edentulous (i.e., toothless) (126,141). The absence of teeth not only hinders one's ability to chew, it also changes the bacterial flora within the oral cavity from predominantly anaerobic to aerobic (126).

Consciousness Many geriatric patients suffer from a reduced consciousness. Special diseases like Morbus Alzheimer as well as the "normal" obliviousness of elderly patients and headiness may affect the drug therapy. There are a number of aids to remind the patients of dosing the medicine, like alarm clocks (Fig. 7), calendar paks (C-paks), and medication boxes (dosage trays) with or without sealed doses.

Figure 7 Alarm clock for reminding the patient of dosing by subcutaneous injection once a week (Humira, Abbott Laboratories, North Chicago, Illinois, U.S.).

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