The document discusses drug use in the elderly and techniques to avoid polypharmacy. It notes that the elderly population is growing and takes a significant portion of medications while also being more sensitive to drug effects due to physiological changes. Polypharmacy, defined as taking more than 5 medications, is common in the elderly due to multiple comorbidities and providers. This can increase risks of adverse drug reactions, interactions, and non-adherence. The document recommends techniques for optimal prescribing in the elderly like reviewing all medications, simplifying regimens, and eliminating unnecessary drugs to help prevent polypharmacy and its risks.

1. DRUG USE IN ELDERLY &
TECHNIQUES TO AVOID
POLYPHARMACY
Dr Sahil Kumar
Department of Pharmacology
Maulana Azad Medical College
New Delhi

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 The Aging Imperative
 Challenges of pharmacotherapy in elderly
 Elderly and Medications: Physiological
changes in PK, PD, behavior & lifestyle
 Drug groups requiring monitoring in elderly
 Polypharmacy: Causes & Consequences
 Principles of Optimal prescribing in elderly
 Preventing Polypharmacy
 Conclusion
Topics Covered

3. 3

4. The Aging Imperative
 “Elderly” - 65 years old or older, those from
65 through 74 years old -“early elderly” and
those over 75 years old - “late elderly.”
 Constitute 13% of the population & purchase
33% of all prescription medications.
 20% of hospitalizations for those >65 are
due to medications they’re taking.
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5. The Aging Imperative
 India in a phase of demographic transition.
 Sharp increase in the number of elderly
persons between 1991 and 2001 and it has
been projected that by 2050, it would rise to
about 324 million.
 India has thus acquired the label of “an
ageing nation”.
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6. Challenges of Pharmacotherapy
in Elderly
 Multiple co-morbid states
 Effects of aging physiology
 Polypharmacy
 Medication compliance
 Medication cost
 New drugs available each year
 FDA approved, off-label indications expanding
 Increasing popularity of “nutraceuticals”
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7. ELDERLY AND MEDICATIONS
The physiologic changes that occur
with aging make the body more
sensitive to the effects of medications.
Pharmacokinetic, Pharmacodynamic ,
Behavioral changes, lifestyle changes
occur in elderly.
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8. Aging and Pharmacokinetics
PK - What the body does to the drug.
Absorption
Distribution
Metabolism
Elimination
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9. Physiologic Changes of Aging
Affecting Absorption
 Physiologic change
 ↓ gastric acidity
 ↓ gastrointestinal blood flow
 Delayed gastric emptying
 Slowed intestinal transit time
 General clinical effect
 Decreased transport: Decreased bioavailability for
some drugs like aspirin.
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10. Physiologic Changes of Aging
Affecting Distribution
 Decreased Total body water
 Increased Plasma Conc. of water soluble drugs
 Lower doses are required: Lithium, digoxin, ethanol, etc
 Decreased Lean body mass
 Accumulation into fat of lipid soluble drugs: BZDs.
 Decreased Serum Albumin
 Increased unbound fraction of highly protein bound drugs
 Binds acidic drugs: warfarin, phenytoin, digitalis, etc
 Decreased Alpha1 Acid glycoprotein
 Increased unbound fraction of highly protein bound drugs
 Binds basic drugs: lidocaine and propranolol, etc
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11. Physiologic Changes of Aging
Affecting Metabolism11
Aging ↓ liver mass/ hepatic
blood flow
 Delayed/reduced metabolism of drugs
 Higher plasma levels
 Examples: diazepam, barbiturates,
lidocaine.
 Decline in liver ability to recover from
injury
Lower serum protein levels
 Loss of protein binding

12. Physiologic Changes of Aging
Affecting Elimination
 Physiologic change
 Decreased GFR
 Decreased renal blood flow
 Decreased renal mass
 General clinical effect
 Decreased clearance, Increased (t½) of
drugs eliminated from the kidney.
 Eg. atenolol, gabapentin, ranitidine,
digoxin, allopurinol, quinolones
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13. Aging and Pharmacodynamics
 PD- What the drug does to the body.
 ⇑ sensitivity to sedation and psychomotor
impairment with benzodiazepines
 ⇑ level and duration of pain relief with
narcotic agents
 ⇑ drowsiness with alcohol
 ⇑ sensitivity to anti-cholinergic agents
 ⇑ cardiac sensitivity to digoxin
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14. Aging and Behavioral changes
Cognitive changes associated with vascular
and other pathologies.
Age related dementia leads to problems in
compliance.
Death of a closed one can be a trigger for
depression.
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15. Aging and Lifestyle Changes
Economic stresses associated with reduced
income or increased expenses due to illness.
May have to choose
 OTCs instead of expensive doctor visits
 Use of outdated medications
 Use of home remedies
 Share medications
 Nutritional status may affect how body
metabolizes medications
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17. Major Drug Groups Requiring
Monitoring in Elderly
 CNS drugs
 Sedative-hypnotics: Benzodiazepines and barbiturates
 Analgesics: Opioids
 Antipsychotic, antidepressants: Haloperidol, lithium, TCAs
 Cardiovascular drugs
 Antihypertensives: Thiazides, beta-blockers
 Antiarrhythmic drugs
 Quinidine and procainamide: ↓ clearance and ↑ (t½)
 Antimicrobial drugs
 Beta-lactams and aminoglycosides: ↓ clearance
 Anti-inflammatory drugs
 NSAIDs: GI bleed and irritation
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18. POLYPHARMACY
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20. Polypharmacy
 Taking >5 medications at the
same time.
 At any given time, an elderly
patient takes, on average, four
or five prescription drugs and
two over-the-counter (OTC)
medications.
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21. Causes of Polypharmacy in Elderly
 Presence of several chronic disorders.
 Receiving health care from several physicians.
 Purchasing medications from more than one
pharmacy.
 “The prescribing cascade”.
 The discovery of a broad range of pharmaceuticals
for a wide variety of conditions.
 In addition, complementary and alternative
medicines, such as herbal therapies, are becoming
increasingly popular among all patients, including
the elderly.
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22. Consequences of Polypharmacy
 Adverse drug Reactions (ADRs)
 Medication Errors
 Drug interactions
 Duplication of drug therapy
 Decreased quality of life
 Unnecessary cost
 Medication non-adherence
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23. Adverse Drug Reactions
(ADRs)
 Responsible for 5-28% of acute geriatric
hospital admissions.
 Greater than 95% of ADEs in the elderly are
considered predictable and approximately
50% are considered preventable.
 New or sudden-onset GI distress is often
caused by medication.
 Most common ADEs among elderly patients -
nausea, vomiting, diarrhea, constipation, and
abdominal pain.
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25. DRUG INTERACTIONS
DR. UMA TEKUR
DRUG INTERACTIONS

26. Drug Interaction is defined as the
pharmacological activity of one
drug being altered by the
concomitant use of another drug
or by the presence of some other
substance.
DEFINITION
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27. Watch for Drug-Drug, Drug-Disease,Watch for Drug-Drug, Drug-Disease,
and Drug-Food Interactionsand Drug-Food Interactions
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28. Drug-Drug Interactions
 Absorption may be ⇑ or ⇓.
 Drugs with similar effects can result in
additive effects.
 Drugs with opposite effects can
antagonize each other.
 Drug metabolism may be inhibited or
induced.
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29. Common Drug-Drug Interactions
Combination Risk
ACE inhibitor + potassium Hyperkalemia
ACE inhibitor + K sparing diuretic Hyperkalemia, hypotension
Digoxin + antiarrhythmic Bradycardia, arrhythmia
Digoxin + diuretic
Antiarrhythmic + diuretic
Electrolyte imbalance; arrhythmia
Diuretic + diuretic Electrolyte imbalance; dehydration
Benzodiazepine + antidepressant
Benzodiazepine + antipsychotic
Sedation; confusion; falls
CCB/nitrate/vasodilator/diuretic Hypotension
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30. Drug Disease Interaction
 Drug – Condition interaction occurs when a drug
worsens or exacerbates an existing medical
condition.
 Nasal decongestants + Hypertension … BP↑
 NSAIDs + Asthmatic Patients … Airway obstr.
 Nicotine + Hypertension … Heart Rate↑
 Metformin + Heart failure … Lactate level↑
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31. Drug Food Interactions
 GARLIC when combined with diabetes medication
could cause dangerous decrease in blood sugar.
 ORANGE JUICE increases the absorption of
aluminum and leads to severe constipation.
 MILK contains elements like Mg and Ca which
chelate antibiotics like tetracycline and hence
decrease its absorption and effect.
 GRAPEFRUIT JUICE inhibits CYP3A4;
increasing levels of antidepressants (sertraline),
benzodiazepines, verapamil.
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32. Role of Pharmacist
 Be vigilant in monitoring for potential drug
interactions.
 Advising patients regarding proper use.
 Educate the patient on foods and beverages
to avoid when taking certain medications.
 Advising patients in disease conditions.
 Keep up-to-date on potential drug-drug and
drug-food interactions of medications to
counsel the patients.
(ASHP Guidelines American Society of Health-System Pharmacists)
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33. Newer Approaches to check
interactions
Free Online Drug Interaction Checking
Software:
https://www.drugs.com/drug_interactions.p
hp (Drugs.com)
http://reference.medscape.com/drug-
interactionchecker (Medscape)
http://desktopindia.com/Drug-inter.aspx
(Doctor’s Desktop: Medical Practice
Software - Indian)
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35. 35

36.  Android App –
“MICROMEDEX Drug
Interactions”
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37. Principles of optimal
prescribing in elderly
& Preventing
Polypharmacy
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38. Principles of optimal
prescribing in elderly
 Knowing which drugs frequently cause problems.
 Ask about drug allergies, adverse reactions, alcohol.
 Investigate and document all medications the patient
is taking, including OTC and herbal products.
 “Brown bag" method.
 Choose a drug that can be given once or twice, rather
than three times a day.
 Simplify the patient's regimen as much as possible
by, for example, prescribing a single agent rather
than multiple drugs to treat a condition.
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39. Avoiding Polypharmacy
 Avoid “a pill for every ill”. Always consider
non-pharmacologic therapy.
 Start low and go slow but treat adequately.
 Maximize dose before switching to another drug.
 Avoid starting two drugs at the same time.
 Review medications regularly and each time a new
medication started or dose is changed.
 Eliminate duplicate medications—those prescribed
by different healthcare providers for the same
problem—and drugs with no therapeutic benefit or
clinical indication.
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40.  Encourage client to use one pharmacy.
 Find out how often and in what doses the patient
has been taking all medications, and compare
that with what the prescription calls for. About
40% of elderly patients fail to take their drugs as
instructed.
 Be aware of conditions that might increase the
risk of certain drug-drug interactions.
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Avoiding Polypharmacy

41.  Substitute safer medications whenever possible.
Avoid treating an adverse reaction caused by
one drug with a second drug; if possible,
discontinue the drug that's causing the problem
or reduce the dosage.
 Maintain accurate medication records (include
vitamins, OTCs, and herbals).
 Suggest using innovative pill box reminders for
correct adherence and avoid confusion when
taking many pills.
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Avoiding Polypharmacy

42. Innovative pill box reminders
 Medminder® : $40-65. Looks like traditional
pill boxes, 7 day (qid) boxes that lock. Flashing
light/audible/text message/phone calls for
reminders. Also, caregivers can get reports via
text/emails/internet.
 Locked medication systems (eg e-pill): $200-500.
Dispensers that lock/alarm.
 iPhone apps: Free-$3.99. Virtual pillbox. Can
set medications, dosages and times a dose is
needed. Alarms, reminders, etc.
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Medminder ®
e-pill
Virtual pillbox

44. Conclusion
 Successful pharmacotherapy means using the
correct drug at the correct dose for the correct
indication in an individual patient.
 Age alters PK and PD.
 Polypharmacy is prescribing more than 5 drugs at
the same time.
 ADRs and Drug Interactions are common among
the elderly because of polypharmacy.
 These can be minimized by appropriate
prescribing and avoiding polypharmacy.
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46. THANK YOU
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