『The Completely Revised Edition of Key Points on Elderly Medication』 is a book that completely supplements 『Key Points on Elderly Medication』, which was published in 2017 and has established itself as a representative domestic book in the field of elderly medication management.
This book was divided into Part 1: Core Elderly Drug Treatment and Part 2: Disease-Specific Elderly Drug Treatment in Part 1, but in this completely revised edition, it is divided into Part 1: General Theory: Characteristics and Drug Management of the Elderly and Part 2: Specific Theory: Common Diseases in the Elderly, focusing on the characteristics of the elderly and suggesting drug therapy for 10 common diseases in the elderly.

This book has also been significantly expanded in volume.
It has 636 pages, which is almost twice as long as the 392 pages of Part 1, and has greatly expanded the scope of disease specialization and the number of drugs.
In particular, the content has been significantly expanded because, as an expert in geriatric medicine, the author has lectured at training sessions for pharmacists at all levels across the country since the publication of the first volume, and has greatly supplemented the questions he received from pharmacists and the parts that pharmacists did not understand well.
Additionally, the theoretical shortcomings in Part 1 have been completely updated through major academic papers and references.


Part 1, General Theory, which covers the characteristics and drug management of the elderly, organizes all the characteristics and theories that can occur in the elderly, such as pharmacokinetics and pharmacodynamic changes in the elderly, physiological changes due to aging, geriatric syndromes, atypical symptoms in the elderly, comprehensive geriatric assessment, chain prescriptions, comprehensive drug management, drugs inappropriate for the elderly, basic theory of drug interactions, drug-drug interactions, interactions between health functional foods and drugs, food-drug interactions, drug management for hospitalized and discharged patients, drug discontinuation before surgery, drug management in long-term care facilities, palliative care for terminally ill patients, and elder abuse.


Part 2, which deals with common diseases in the elderly, explains the specific symptoms of 10 major diseases in the elderly, including circulatory system diseases, respiratory system diseases, renal and urinary system diseases, endocrine system diseases, gastrointestinal system diseases, nervous system diseases, psychiatric diseases, musculoskeletal system diseases, sensory system diseases, and infectious diseases, and suggests drug therapies accordingly.
If the first volume of 『Key Points on Elderly Medicine』 has contributed to pharmacists' ability to properly manage elderly patients' medication history and provide medication guidance over the past seven years, this fully revised edition will enable them to practice more accurate and reliable elderly medicine by understanding the characteristics of the elderly more broadly and identifying symptoms of major diseases.

Pharmacokinetic and pharmacodynamic changes in the elderly

Physiological changes in drug absorption phase due to aging
ㆍSalivary secretion ↓
ㆍGastric acid secretion ↓ (hypoacidity), gastric pH ↑
→ Reduced absorption of vitamins, minerals, iron, calcium, and B12 (reduced intrinsic factor)
ㆍGastrointestinal blood flow (intestinal blood flow)↓
ㆍDecrease in active transporters in the intestines
ㆍStomach movement, expulsion speed ↓
→ Difficulty swallowing, delayed onset time
ㆍTrypsin secretion in the pancreas↓
→ Digestive function declines and you start looking for digestive aids

Changes in drug absorption rate and amount with aging
ㆍDrugs absorbed through active transport
→ As we age, our absorption rate slows down due to aging.
ㆍDrugs that are absorbed through manual transport
→ As we age, gastrointestinal motility slows down, slowing down the absorption rate.
ㆍElderly people tend to have a delayed onset of drug action, but the total amount absorbed is less than that of younger people.
Same as
→ The decrease in gastric peristalsis speed (increase in absorption time) and the decrease in gastric blood flow (decrease in absorption amount) counteract each other, so there is no change in absorption rate.
ㆍConclusion: Do not increase the dosage arbitrarily even if the drug effect does not appear or appears late (it is not that the drug effect does not appear due to changes in the pharmacodynamics and pharmacodynamics of the elderly, but rather that the onset time is delayed)

Physiological changes in drug distribution phases due to aging
ㆍBody fluid ↓ (total body water ↓, kidney ability to concentrate urine ↓, thirst detection ability ↓)
→ Increased drug concentration
ㆍBlood albumin (protein) level ↓, muscle (protein) ↓
→ Reduced distribution volume of water-soluble drugs
ㆍAbdominal fat tissue ↑
→ Increased distribution volume of lipid-soluble drugs → Increased half-life
ㆍChanges in drug distribution volume due to aging
ㆍElderly people have reduced protein intake
→ Water-soluble drugs must be distributed in albumin, etc.
→ Increase in free water-soluble drugs that are not bound to albumin
→ Water-soluble drugs have stronger effects and side effects even when administered in the same amount.
ㆍElderly people have a relatively increased body fat volume.
→ Fat-soluble drugs accumulate more and more in fat with repeated administration.
→ Later, it is gradually released from the fat
→ The effects and side effects continue to appear later.
→ It can be understood that the half-life of lipid-soluble psychiatric drugs is increased.
Conclusion: The dosage should be reduced compared to younger people, as the efficacy and side effects may increase.

Physiological changes in drug metabolism stages due to aging
ㆍLiver size decreases → Clearance decreases (drug metabolism and excretion decreases)
→ First pass rate ↓
ㆍPortal vein blood flow↓
ㆍDecreased cardiac output → decreased hepatic blood flow
ㆍDrug half-life↑
ㆍDrug blood concentration ↑
ㆍIncreased levels of drug active metabolites

Changes in drug metabolism phases with aging
ㆍPhase Ⅰ Oxidation: CYP450 enzymes
▶ Function and speed decrease with aging
▶ Even if the liver function of an elderly person is normal, their metabolic rate may be slower than that of a young person.
▶ Interactions may occur when taking multiple medications.
CYP 3A4: Most interactions
CYP 2C9: Interaction
CYP 2C19: Interaction
CYP 1A2: Interaction
ㆍPhase Ⅱ Glucuronidation: UGT enzymes
▶ Almost no effect of aging
▶ No need to worry about drug interactions when taking multiple medications
▶ Drugs that are metabolized only by glucuronidation without metabolism by CYP 450 enzymes are preferred for the elderly (e.g.
lorazepam, warfarin)

Physiological changes in drug excretion due to aging
ㆍKidney size (25-30%)↓
ㆍGlomerular filtration rate (GFR)↓(CrCl↓)
ㆍNumber of nephrons↓
ㆍTubular redistribution↓
ㆍRenal blood flow decreases (decrease by 1% per year after age 50)
ㆍNo change in tubular permeability pressure (filter pressure) (reduced renal blood flow, narrowing of renal outflow arteriole = 0)
ㆍIn the case of the elderly, SCr does not change: less creatinine is produced due to decreased muscle mass in the body. The excretion rate from the kidneys also decreases = 0
→ It should be remembered that CrCl may be reduced even if SCr is normal.

Changes in drug excretion phases with aging
ㆍAs we age, glomerular filtration rate (GFR) decreases, and cardiac output to the glomeruli decreases.
→ Increased drug half-life
ㆍIncreased steady state drug concentration
Drug side effects and toxicity occur more frequently
→ The dosage should be reduced compared to younger people
→ Psychiatric medications must adhere to the Start low, Go slow principle.

Pharmacodynamic changes with aging
ㆍIn the case of the elderly, even if the same dosage is administered, the side effects and toxicity of neuropsychiatric drugs are stronger than in young people.
Crab appears
ㆍAs a result of weakening of the BBB and various aging processes, drugs tend to be distributed at higher concentrations to CNS receptors.
→ Increased sensitivity to drugs
ㆍAging → Due to decreased acetylcholinesterase activity and decreased M1 receptor transmission
→ Young people are more susceptible to the anticholinergic effects of anticholinergic drugs than older people
→ Anticholinergic drug side effects have become a major problem.
--- From “Part 1 General Theory: Characteristics and Drug Management of the Elderly”

cardiovascular disease

Orthostatic hypotension in the elderly

orthostatic hypotension
Systolic blood pressure (SBP) decreases by 20 mmHg or more or diastolic blood pressure (DBP) decreases by 10 mmHg or more within 3 minutes of standing up (a decrease of 10 to 15 mmHg in systolic blood pressure and 5 to 10 mmHg in diastolic blood pressure is normal for the elderly)

dynamics
20% of those aged 65 and over, 30% of those aged 75 and over, and 50% of frail elderly people residing in nursing homes.

characteristic
Blood pressure increases when lying down, decreases when standing up

Cause
Autonomic dysfunction and fluid volume depletion

Causes of worsening
Dehydration, diarrhea, summer heat, myocardial ischemia, adrenal insufficiency, vomiting, sepsis

worsening drugs
Diuretics, blood pressure medications, vasodilators, erectile dysfunction medications, antipsychotics, hypnotics, tricyclic antidepressants (TCAs), narcotic analgesics, dopamine agonists, levodopa

chronic orthostatic hypotension
It develops gradually and gradually, and gets worse with age due to decreased baroreceptor function, diastolic dysfunction, geriatric hypertension, autonomic dysfunction (due to synucleinopathy brainstem problems, Lewy body dementia, Parkinson's disease, stroke, etc.), venous insufficiency, alcoholism, diabetes, anemia, etc.

Clinical symptoms
Dizziness upon waking, headache, blurred vision, stiff neck, general weakness, feeling of needing to urinate or defecate, shortness of breath, angina, ischemic myocardial infarction, fainting

For the elderly
As you get up, you may experience slurred speech, more falls, confusion, and cognitive impairment.

Reduce the dose of the causative drug
Find out which medications are making things worse among the medications you are taking.

Get up slowly
Be especially careful if you have been lying down for a long time or if you get out of bed.

Lifestyle
Be careful when coughing, straining, or standing for long periods of time while standing (especially on hot days), elevate the head of the bed by 20 to 30 degrees, wear compression stockings that reach up to the waist, and wear an abdominal band.
A. Cross your legs, B. Calf contraction exercise while standing, C. Squat position, D. Lean forward and stand up (abdominal pressure → increase venous return)

cure
To prevent blood from rushing to the legs → abdominal bandage, compression stockings
To enhance norepinephrine → pyridostigmine, atomoxetine
To replace norepinephrine deficiency → midodrine, droxidopa

Drug therapy
ㆍMidodrine: Peripherally selective alpha-1 receptor agonist (does not pass through the BBB)
Increases peripheral vascular resistance, reduces blood flow to the lower extremities and abdominal veins, and maintains blood pressure.
The effect appears within 30 minutes to 1 hour and lasts up to 4 hours (the duration of action is not long).
Main side effects: urinary retention, increased cardiovascular risk (contraindicated in patients with severe heart disease or uncontrolled hypertension)
ㆍMidodrine and droxidopa should be taken after waking up, before lunch, or in the late afternoon (at least 4 hours before bedtime) due to the side effect of supine hypertension.
Droxidopa: Improves freezing of gait and dizziness upon standing in Parkinson's disease.
Major side effects: headache, nausea, fatigue, increased cardiovascular risk (caution in patients with heart failure or kidney failure)
Fludrocortisone (Florinef): Mineralocorticoid that causes water retention
Major side effects: edema (caution in patients with heart failure), hypokalemia, supine hypertension
ㆍPyridostigmine (Dosmin): Approved as a treatment for myasthenia gravis
Main side effects: abdominal pain, diarrhea, increased sweating, urinary retention
ㆍAtomoxetine (Strattera): Approved as a treatment for attention deficit hyperactivity disorder (ADHD) syndrome
Main side effects: supine hypertension, insomnia, loss of appetite
Acarbose (Glucobis): An alpha-glycosidase inhibitor diabetes medication.
Improves postprandial hypotension by blocking carbohydrate absorption (carbohydrates → insulin secretion → insulin has an arterial vasodilation effect → hypotension)
Main side effects: bloating, gas, flatulence

Challenges in Elderly Care
ㆍDifficulty in measuring blood pressure while lying down Instead of the usual method of measuring blood pressure while sitting, you should measure while lying down and then standing up.
ㆍIf you are over 50 years old, it is recommended to measure while lying down and standing up.
Recommendations for people over 65 years of age: Measure your blood pressure while lying down, then stand up and measure again within 1-3 minutes (check for a difference of 20 mmHg or more between systolic and diastolic values).

■Geriatric hypertension

Characteristics of geriatric hypertension
1.
systolic hypertension (high systolic blood pressure)
2.
pseudohypertension (hardening of the arterial walls)
3.
Orthostatic hypotension (older people with hypertension are at higher risk of orthostatic hypotension)
4.
Postprandial hypotension (temporary decrease in blood pressure after a meal).
5.
Blood pressure fluctuates greatly throughout the day.
6.
There are many cases of white coat hypertension (blood pressure increases when looking at a white coat).
7.
The drop in blood pressure at night is small (usually, even in patients with high blood pressure, blood pressure drops by 10-15% at night, but in the case of the elderly, blood pressure often does not decrease at night and only decreases in the early morning.
In such cases, the prognosis is poor, including increased risk of heart disease.
8.
If there is a difference in blood pressure between the two arms or legs, there is a high possibility of peripheral arterial disease.
9.
The occurrence of heart failure is common.
10.
Renin activity is reduced (responsiveness to ACEⅠ, ARB blood pressure medication is relatively weaker compared to young people).
11.
Renal arterial hypertension is common (secondary increase in blood pressure due to renal arteriosclerosis is common) (renal artery stenosis → decreased renal blood flow → renin secretion).
12.
Side effects of blood pressure medications are likely to occur and last a long time.

Systolic hypertension (SBP 140 or higher, DBP less than 90) (isolated systolic hypertension, ⅠSH)
In the elderly, the elasticity and resilience of the aorta decrease due to arteriosclerosis, which causes systolic hypertension (in young people, both systolic and diastolic hypertension are high, but in the elderly, systolic hypertension is high while diastolic hypertension actually decreases)
→ Diuretics and CCBs, which are blood pressure medications with good systolic blood pressure lowering properties, are the first-line drugs.

pseudohypertension (measured higher than normal due to arteriosclerosis)
In older people, the stiffness of the arteries increases, especially due to arterial calcification, so higher pressures are needed to measure blood pressure with a commonly used blood pressure monitor.
In this case, indirect blood pressure measurement is measured higher than the actual blood pressure in the arteries, and this type of hypertension is called pseudohypertension.

Pseudohypertension is relatively common in the elderly with severe arteriosclerosis, and its incidence in the elderly is less than 5%.

When blood pressure measured with a general blood pressure monitor is high but there are no signs of hypertension, no target organ damage (left ventricular hypertrophy, hypertensive retinal changes, ischemic heart disease, changes in renal function), and blood pressure is continuously measured as high despite relatively strong use of antihypertensive drugs, and symptoms of hypotension (dizziness,
If syncope occurs, pseudohypertension is suspected.

Orthostatic hypotension (common in elderly hypertensive patients)
When systolic blood pressure drops by 20 mmHg or more 1 to 3 minutes after standing up suddenly, it is called orthostatic hypotension, and is a common phenomenon in the elderly.

When you stand up suddenly, 500 to 700 ml of blood is suddenly rushed to the lower part of the body, causing a decrease in cardiac output, which temporarily causes hypotension.
In normal people, normal blood pressure is maintained even when standing due to the action of the regulatory organs of the brain and blood vessels.
However, in the elderly, baroreceptor sensitivity decreases, resulting in impaired accommodative function.
The higher the systolic blood pressure, the more severe the orthostatic hypotension.

Prevention and treatment methods: wearing a pelvic girdle, compression stockings, crossing the legs, calf contraction exercises while standing, squat position, leaning forward when getting up, etc.

Postprandial hypotension (common in the elderly)
After a meal, blood in the body rushes to the internal organs.
Therefore, blood pressure decreases to some extent after a meal. When systolic blood pressure decreases by 20 mmHg or more 30 minutes to 1 hour after a meal, it is called postprandial hypotension and is a common phenomenon in the elderly.

If an elderly person experiences dizziness or fainting after eating, postprandial hypotension should be suspected and blood pressure should be measured.
Eating large amounts of food (especially carbohydrates) increases insulin levels in the body, causing blood vessels to dilate and lowering blood pressure.


How to relieve postprandial hypotension:
ㆍDrink water 30 minutes before meals.
Avoid large meals (eat small amounts frequently)
ㆍMaintain a diet low in carbohydrates.
ㆍAvoid alcohol consumption.
ㆍDo not wake up suddenly after eating.
ㆍAvoid activity after eating.
ㆍRest in a semi-sitting position for 90 minutes after eating.

Advice on managing geriatric hypertension
ㆍIf your blood pressure is over 140/90 and you are over 65 years old, take blood pressure medication. (For elderly people with cardiovascular disease, it is recommended to keep your blood pressure under 130/80. However, if your blood pressure is too low, you may experience orthostatic dizziness, so adjust your blood pressure appropriately.)
ㆍIf you do not take your blood pressure medication → You may later experience complications such as cerebral hemorrhage, kidney damage, heart attack, or eye damage, so you must take your blood pressure medication properly.

ㆍWalk for 30 minutes a day, eat plenty of vegetables, eat a diet low in saturated fat, and consume as little salt as possible.
ㆍIf you are taking a lot of medications, there are many medications that can raise blood pressure, so it is recommended that you visit the hospital every 1-2 months to check your blood pressure, get checked for any heart or blood circulation discomfort, and have a blood test.

Drugs that can increase blood pressure as a side effect

Choosing antihypertensive medications for the elderly and the characteristics of each drug

Choosing high blood pressure medication for the elderly
If only systolic blood pressure is high and diastolic blood pressure is low, CCB or thiazide diuretic is given priority. If diabetes is present, ARB is given priority.
If blood pressure is 20 or more points higher than the target blood pressure (140/90), two medications are administered simultaneously from the beginning.

thiazide diuretics
ㆍAdvantages: Good for systolic blood pressure, good for osteoporosis due to increased calcium electrolyte levels.
Especially good for reducing congestive heart failure, edema, and stroke.
Because it is a drug with a fluid-reducing function, it reduces the burden on the heart in congestive heart failure and has the function of reducing edema.
In stroke, the pressure on the cerebral blood vessels is reduced due to fluid loss.
ㆍMechanism of action: Inhibits sodium reabsorption in the distal tubule → decreases body fluid volume.
ㆍSide effects: increased urination, risk of dehydration, worsening of gout, hypokalemia, erectile dysfunction, dizziness, orthostatic hypotension, slight increase in blood sugar, photosensitivity → Slightly increased risk of skin cancer when overexposed to UV rays.
ㆍInteraction: Renal excretion of lithium↓→ Lithium toxicity↑ NSAIDs, which can cause water retention, reduce the effectiveness of antihypertensive drugs.

ㆍNote: Take in the morning as it may increase urination.
ㆍMedication Instructions:
▶ Take in the morning to prevent nocturia.
▶ If you take it twice a day or in the evening, take it before 4 PM.
▶ Avoid excessive exposure to direct sunlight (photosensitivity).
Apply sunscreen or block the sun with clothing.
▶ Symptoms of orthostatic hypotension include dizziness, feeling lightheaded, blurred vision, confusion, fatigue, and weakness.
It occurs within a few seconds to a few minutes immediately after standing up suddenly.
When you wake up, wake up slowly.
▶ Remove any objects that could trip you up in the hallway when going to the bathroom at night.
▶ Observe symptoms of hyperglycemia.
Symptoms include frequent urination at night, blurred vision, poor wound healing, and fatigue.
Check your blood sugar regularly.


Calcium channel blockers (dihydropyridine CCBs)
ㆍAdvantages: Especially good for systolic hypertension, Raynaud's syndrome, and angina.
It is a drug used for both the prevention and treatment of angina, and even when prescribed as a blood pressure medication, it can be prescribed as a good drug that can reduce the risk of developing angina in the future.
Additionally, it is possible to instruct people who have cold hands and feet to take this medicine as it warms them by pumping blood to the hands and feet and improves blood flow to the peripheral tissues.
ㆍMechanism of action: It dilates arterial blood vessels by blocking calcium channels in coronary and peripheral arteries.
Side effects: ankle swelling, headache, increased heart rate (tachycardia), dizziness
ㆍInteraction: Due to the influence of 3A4 metabolism → Avoid consuming large amounts of grapefruit juice
ㆍMedication Instructions:
▶ This medicine dilates blood vessels and lowers blood pressure.
It also has the advantage of reducing the risk of angina.
▶ Side effects to watch for include swelling of the ankles, fatigue, dizziness, headache, flushing or warm feeling in the face, and rapid heartbeat.
▶ Do not drink grapefruit juice sold at the supermarket.

Types of calcium channels

Types of calcium channel blockers

How to resolve CCB ankle swelling side effects:
ㆍChanged blood pressure medication to ACEⅠ or ARB
ㆍReducing the capacity of L type CCB
ㆍAdding ACEⅠ and ARB to L type CCB
ㆍIn the case of amlodipine 5mg, it is slightly better to change to S-amlodipine 2.5mg.
ㆍChange to lipophilic CCB (manidipine, lercardipine, lacidipine, etc.) (lipophilic CCB has a 57% lower incidence of peripheral edema than existing CCB)
ㆍAdditional diuretics are of little help (because the mechanism of edema is not an increase in plasma volume)

Angiotensin Converting Enzyme Ⅰ inhibitor (ACE Ⅰ)
Angiotensin Receptor Blockers (ARBs)
ㆍAdvantages: This is a particularly useful medicine for those with diabetes, chronic kidney disease, stroke, congestive heart failure, and myocardial infarction. It has the function of expanding both peripheral arteries and veins, thereby reducing the burden on the heart.
In diabetic nephropathy, both the afferent and efferent renal arterioles entering the glomeruli of the kidney are dilated, thereby reducing the pressure burden on the glomeruli.
ㆍMechanism of action: By blocking aldosterone, it dilates arteries and veins, thereby reducing both preload and afterload.
ㆍSide effects: Lip swelling (common in black people), dizziness, hyperkalemia. Carefully monitor renal function and potassium levels. (Although this is a blood pressure medication that protects the kidneys by reducing glomerular pressure, if the afferent arterioles of the kidney are hardened and narrowed, the glomerular pressure may drop too low and cause kidney damage.)
ㆍInteraction: Lithium's renal excretion↓→ Lithium toxicity↑ Hyperkalemia when administered concurrently with drugs that can increase potassium concentration When administered concurrently with NSAIDs, the risk of glomerular damage increases due to decreased renal blood flow.
ㆍMedication Instructions:
▶ If you are pregnant or planning to become pregnant, stop taking the medication and change your blood pressure medication.
▶ If you experience any of the following allergic symptoms, visit a hospital immediately.

Difficulty breathing, swelling of the face, lips, tongue, and throat.
▶ If you have a dry cough and feel uncomfortable, consult a doctor or pharmacist. (ACEⅠ)

Characteristics of each ARB type

Beta blockers (BB)
ㆍAdvantages: It is a drug useful mainly for high blood pressure accompanied by complications such as angina, congestive heart failure, post-myocardial infarction, and atrial fibrillation.
ㆍCharacteristics: It is a second-choice drug, not a first-choice drug, as a blood thinner.
Carvedilol is a preferred drug for blood pressure because it has an alpha-blocking effect and peripheral vasodilation effect.
Nebivolol has a NO (Nitric oxide) function, which lowers blood pressure by expanding peripheral blood vessels and does not cause fatigue or erectile dysfunction, which are typical side effects of beta-blockers.
Instead, it has more of a headache side effect.
ㆍMechanism of action: It is a drug that slows down the heartbeat and reduces the burden on the heart.
ㆍSide effects: (Non-selective blockers are more severe) drowsiness, fatigue, depression, bradycardia, worsening of asthma, masking of hypoglycemic symptoms (except hunger and cold sweats), worsening of erectile dysfunction, decreased libido
ㆍInteractions: Be careful of interactions with other drugs that can slow the heart rate.
ㆍMedication Instructions:
▶ Possible side effects include dizziness and fatigue.
In rare cases, it may impair sexual function.
If these side effects are a concern, talk to your doctor.
▶ If you suddenly stop taking the medication, your heart rate may increase and your heart may be strained. If you stop or change the medication, you should gradually reduce the dosage over two weeks or more.
▶ If you experience shortness of breath (especially with non-selective beta-blockers), consult your doctor.
▶ Take carvedilol with food to prevent possible dizziness. (If you don't feel dizzy, it's okay to take it on an empty stomach.)

Characteristics of each type of beta-blocker

Challenges in Elderly Care
The difficulty of correcting lifestyle habits
ㆍAs we age, we tend to have difficulty following instructions for correcting our lifestyle habits (exercise, diet, etc.).
ㆍThis is especially true for those over 75 years old.
ㆍBecause the sense of taste is reduced, you cannot taste salt, so you end up eating saltier food.
ㆍBecause loss of appetite is common in the elderly, they tend to eat saltier food.
Limiting salt intake is most important. Eat lightly and avoid soups (soup dishes are high in sodium).
Salt intake limit: 1,800 mg/day

Elderly people have reduced kidney function.
ㆍThe risk of hyperkalemia side effects from ACEⅠ and ARB blood pressure medications increases further in elderly people with impaired renal function.
ㆍIt is necessary to check blood electrolyte levels periodically.

--- From “Part 2 General Theory: Common Diseases in the Elderly”