Zusammenfassung
Kognitive Einschränkungen sind angesichts der Demenzepidemie ein großes Problem der alternden Gesellschaft. Modifizierbare Ursachen sind bei fehlender Kausaltherapie der Demenz von besonderem Interesse. Der vielleicht wichtigste reversible Grund für die kognitiven Defizite und das Delir, das immerhin bei 12–50% der älteren stationären Patienten beobachtet wird, sind Arzneimittel. Ein Drittel der Delirien geht auf Arzneimittel zurück. Zudem ist die Polypharmazie, die aufgrund der zunehmenden Multimorbidität im Alter häufiger vorliegt, ein gravierender Risikofaktor. Die Hypothese der anticholinergen zentralnervösen Verursachung ist nicht ausreichend, um dieses Phänomen zu beschreiben. Besonders häufig sind psychotrope Arzneimittel, v. a. Benzodiazepine, Opiate, trizyklische Antidepressiva und typische Neuroleptika, involviert, aber auch „periphere“ Arzneimittel wie Oxybutynin oder Fluorchinolone spielen eine Rolle. Grundsätzlich ist eine rationale Arzneimitteltherapie der wichtigste Schlüssel zur Prävention. Die meisten delirogenen Substanzen werden auf Negativlisten wie der Beers-Liste geführt und lassen sich durch positiv bewertete Substanzen ersetzen, so etwa gemäß der FORTA-Klassifikation. Neben der Behandlung anderer Ursachen, z. B. von Dehydratation, Infekten und Fieber, ist es wichtig, den Einsatz von Psychopharmaka als Hauptursache kognitiver Einschränkungen zu vermeiden oder zu optimieren.
Abstract
Cognitive impairment is a growing problem in aging societies, and dementia is turning into an epidemic. Modifiable conditions are of major interest, as a causal treatment of dementia is still unknown. Drugs represent a major reversible contributor to cognitive deficits and delirium which is seen in 12–50% of elderly in-hospital patients. A third of patients with delirium is being attributed to drugs, and age-related multimorbidity and subsequent polypharmacy are dominant risk factors. The anticholinergic mechanism is not sufficient to explain delirant drug side effects. Most prevalent in the induction of delirium are psychotropic drugs, in particular benzodiazepines, opiates, tricyclic antidepressants, and typical neuroleptics. In addition, “peripheral” drugs such as oxybutynin or fluorquinolones are involved. Rationalization of drug therapy is the clue for the prevention of cognitive impairment and delirium; most causative drugs are contained in negative lists (e.g., Beers list) and should be replaced by positively labelled drugs (e.g., by virtue of the FORTA classification). On top of the treatment of other modifiable causes for delirium (such as dehydration, infections, and fever), the avoidance or at least optimization of psychotropic drug prescriptions are key elements of the prevention of cognitive impairment in the elderly.
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Interessenkonflikt
Der korrespondierende Autor weist auf folgende Beziehungen hin: M. Wehling war von 2004 bis 2006 aufgrund einer Tätigkeit für die Fa. AstraZeneca beurlaubt. Seit dem 1. Januar 2007 ist er wieder Professor für klinische Pharmakologie an der Universität Heidelberg in Mannheim. Er war und ist für Sanofi-Aventis, Novartis, Takeda, Roche, Pfizer, Bristol-Myers, Daichii-Sankyo, Lilly, Novo Nordisk, Shire und LEO Pharma als Gutachter, Berater und Referent tätig.
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Wehling, M. Medikation im Alter. Internist 53, 1240–1247 (2012). https://doi.org/10.1007/s00108-012-3125-3
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DOI: https://doi.org/10.1007/s00108-012-3125-3