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  2. 2. It is the art and science of preventing disease in the geriatric population and promoting their health and efficiency 2
  3. 3. In treating the elderly, remember that the best intervention is prevention. 3
  4. 4. Geriatrics  Senility  Decline in sexual prowess  Diminution in endocrine activity  Loss of elasticity of blood vessels  Rise in B.P 4
  6. 6. Changes in the body systems of the elderly 6
  7. 7. Common age-related systemic changes 7
  8. 8. GERIATRIC PEOPLE PROBLEMS  HEALTH PROBLEMS 1.Joint problems 2.Impairment of special senses 3. Cardio vascular disease 4.Hypothermia 5.Cancer, Prostate enlargement, Diabetes& Accidental falls  Psychological problems 1. Emotional problems 2. Suicidal tendency 3.& Senile dementia, Alzheimer’disease  Social problems  Poverty, Loneliness, Dependency, Isolation, Elder abuse, Generation Gap 8
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  10. 10. Polypharmacy “many drugs”…indicates the use of more medication than is clinically indicated or warranted. 5+ drugs 2000 = 200 million visits to the doctor  No prescription (30%)  Prescription of 1 - 2 drugs (30%)  Prescription of 3+ drugs (30%) 10
  11. 11. Physician Factors  Presuming patient expects prescription medication and no medication review  Prescribing without sufficient investigation of clinical situation  Unclear, complex, incomplete instruction; not simplifying the regimen  Ordering automatic refills  Lack of knowledge of geriatric clinical pharmacology……inappropriate prescribing 11
  12. 12. Patient Factors  Seeing multiple physicians and pharmacies  Hoarding of medications  Inaccurate reporting of ALL medicines concurrently being taken  Assuming that when medication starts, they can continue indefinitely  Changes in daily habits  Changes in cognition, depression, insufficient funds, declining function, living alone 12
  13. 13. Polypharmacy leads to…  Adverse drug reactions  Drug-drug interactions  Decreased medication compliance  Poor quality of life  Unnecessary drug expense 13
  14. 14. Effects of Physiologic Aging  Absorption  Delayed gastric emptying; decreased gastric acidity; decreased splanchic blood flow  Drug Distribution  Higher percentage of fat; decreased total body water; decreased plasma albumin concentration 14
  15. 15. Effects of Physiologic Aging  Serum Concentration  Change in body composition changes serum concentration of water-soluble drugs  Change in fat mass affect concentration of fat-soluble medications  Drug Clearance  Altered liver metabolism; decreased renal excretion of drugs 15
  16. 16. Adverse Drug Reactions  Simulate conventional image of ‘growing old’: unsteadiness, confusion, nervousness, fatigue, insomnia, drowsiness, falls, depression, incontinence, malaise  Criteria for potentially inappropriate medication use in older adults (US Consensus Panel of Experts, 2003) 16
  17. 17. Adverse Drug Reactions  Fifth leading cause of death in older adults  Falls from orthostatic hypotension  Confusion and disorientation  Hepatic toxicity  Renal toxicity  *Creatinine clearance formula 17
  18. 18. Iatrogenic Problems  Anticholinergics: confusion; orthostatic hypotension; dry mouth; blurred vision; urinary retention  Tricyclics: confusion and unstable gait  Antiemetics: confusion; orthostatic hypotension; blurred vision; falls; dry mouth; urinary retention 18
  19. 19. Iatrogenic Problems  Digoxin: toxicity  H2 Blockers: confusion  Benzodiazepines: CNS toxicity  Narcotics: constipation; “start low; go slow” 19
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  21. 21. Pharmacokinetics (PK)  Absorption  bioavailability: the fraction of a drug dose reaching the systemic circulation  Distribution  locations in the body a drug penetrates expressed as volume per weight (e.g. L/kg)  Metabolism  drug conversion to alternate compounds which may be pharmacologically active or inactive  Elimination  a drug’s final route(s) of exit from the body expressed in terms of half-life or clearance 21
  22. 22. Effects of Aging on Absorption  Rate of absorption may be delayed  Lower peak concentration  Delayed time to peak concentration  Overall amount absorbed (bioavailability) is unchanged 22
  23. 23. Hepatic First-Pass Metabolism  For drugs with extensive first-pass metabolism, bioavailability may increase because less drug is extracted by the liver  Decreased liver mass  Decreased liver blood flow 23
  24. 24. Factors Affecting Absorption  Route of administration  What it taken with the drug  Divalent cations (Ca, Mg, Fe)  Food, enteral feedings  Drugs that influence gastric pH  Drugs that promote or delay GI motility  Comorbid conditions  Increased GI pH  Decreased gastric emptying  Dysphagia 24
  25. 25. Effects of Aging on Volume of Distribution (Vd) Aging Effect Vd Effect Examples  body water  Vd for hydrophilic drugs ethanol, lithium  lean body mass  Vd for for drugs that bind to muscle digoxin  fat stores  Vd for lipophilic drugs diazepam, trazodone  plasma protein (albumin)  % of unbound or free drug (active) diazepam, valproic acid, phenytoin, warfarin  plasma protein (1-acid glycoprotein)  % of unbound or free drug (active) quinidine, propranolol, erythromycin, amitriptyline 25
  26. 26. Aging Effects on Hepatic Metabolism  Metabolic clearance of drugs by the liver may be reduced due to:  decreased hepatic blood flow  decreased liver size and mass  Examples: morphine, meperidine, metoprolol, propranolol, verapamil, amitryptyline, nortriptyline 26
  27. 27. Metabolic Pathways Pathway Effect Examples Phase I: oxidation, hydroxylation, dealkylation, reduction Conversion to metabolites of lesser, equal, or greater diazepam, quinidine, piroxicam, theophylline Phase II: glucuronidation, conjugation, or acetylation Conversion to inactive metabolites lorazepam, oxazepam, temazepam ** NOTE: Medications undergoing Phase II hepatic metabolism are generally preferred in the elderly due to inactive metabolites (no accumulation) 27
  28. 28. Other Factors Affecting Drug Metabolism  Gender  Comorbid conditions  Smoking  Diet  Drug interactions  Race  Frailty 28
  29. 29. Concepts in Drug Elimination  Half-life  time for serum concentration of drug to decline by 50% (expressed in hours)  Clearance  volume of serum from which the drug is removed per unit of time (mL/min or L/hr)  Reduced elimination  drug accumulation and toxicity 29
  30. 30. Effects of Aging on the Kidney  Decreased kidney size  Decreased renal blood flow  Decreased number of functional nephrons  Decreased tubular secretion  Result:  glomerular filtration rate (GFR)  Decreased drug clearance: atenolol, gabapentin, H2 blockers, digoxin, allopurinol, quinolones 30
  31. 31. Estimating GFR in the Elderly  Creatinine clearance (CrCl) is used to estimate glomerular rate  Serum creatinine alone not accurate in the elderly   lean body mass  lower creatinine production   glomerular filtration rate  Serum creatinine stays in normal range, masking change in creatinine clearance 31
  32. 32. Determining Creatinine Clearance  Measure  Time consuming  Requires 24 hr urine collection  Estimate  Cockroft Gault equation (IBW in kg) x (140-age) ------------------------------ x (0.85 for females) 72 x (Scr in mg/dL) 32
  33. 33. Limitations in Estimating CrCl  Not all persons experience significant age-related decline in renal function  Some patient’s muscle mass is reduced beyond that of normal aging  Suggest using 1 mg/dL if serum creatinine is less than normal (<0.7 mg/dL)  Not precise, may underestimate actual CrCl 33
  34. 34. Pharmacodynamics (PD)  Definition: the time course and intensity of pharmacologic effect of a drug  Age-related changes:   sensitivity to sedation and psychomotor impairment with benzodiazepines   level and duration of pain relief with narcotic agents   drowsiness and lateral sway with alcohol   HR response to beta-blockers   sensitivity to anti-cholinergic agents   cardiac sensitivity to digoxin 34
  35. 35. PK and PD Summary  PK and PD changes generally result in decreased clearance and increased sensitivity to medications in older adults  Use of lower doses, longer intervals, slower titration are helpful in decreasing the risk of drug intolerance and toxicity  Careful monitoring is necessary to ensure successful outcomes 35
  36. 36. Optimal Pharmacotherapy  Balance between overprescribing and underprescribing  Correct drug  Correct dose  Targets appropriate condition  Is appropriate for the patient Avoid “a pill for every ill” Always consider non-pharmacologic therapy “Any symptom in an elderly patient should be considered a drug side effect until proved otherwise.” 36
  37. 37. Consequences of Overprescribing  Adverse drug events (ADEs)  Drug interactions  Duplication of drug therapy  Decreased quality of life  Unnecessary cost  Medication non-adherence 37
  38. 38. Principles of Prescribing in the Elderly  Avoid prescribing prior to diagnosis  Start with a low dose and titrate slowly  Avoid starting 2 agents at the same time  Reach therapeutic dose before switching or adding agents  Consider non-pharmacologic agents 38
  39. 39. Prescribing Appropriately  Determine therapeutic endpoints and plan for assessment  Consider risk vs. benefit  Avoid prescribing to treat side effect of another drug  Use 1 medication to treat 2 conditions  Consider drug-drug and drug-disease interactions  Use simplest regimen possible  Adjust doses for renal and hepatic impairment  Avoid therapeutic duplication  Use least expensive alternative 39
  40. 40. Preventing Polypharmacy  Review medications regularly and each time a new medication started or dose is changed  Maintain accurate medication records (include vitamins, OTCs, and herbals) 40
  41. 41. Enhancing Medication Adherence  Avoid newer, more expensive medications that are not shown to be superior to less expensive generic alternatives  Simplify the regimen  Utilize pill organizers or drug calendars  Educate patient on medication purpose, benefits, safety, and potential ADEs 41
  42. 42. Summary  Successful pharmacotherapy means using the correct drug at the correct dose for the correct indication in an individual patient  Age alters PK and PD  ADEs are common among the elderly  Risk of ADEs can be minimized by appropriate prescribing 42
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  44. 44. What is the Beers Criteria?  Originally conceived in 1991 by Mark Beers, MD (geriatrician)  1991  1997  2003  2012  AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults  AKA Beers List, Beers Criteria 44
  45. 45. • Identifies medications that pose potential risks outweighing potential benefits for people ≥65 years ↓ •Informs clinical decision- making concerning the prescribing of medications for older adults ↓ • Improves medication safety & quality of care 45
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  48. 48. STOPP Criteria Screening Tool of Older Persons’ potentially inappropriate Prescriptions 65 rules relating to the most common and the most potentially dangerous instances of inappropriate prescribing in older people O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. European Geriatric Medicine. 2010 Jan 6; 1(1):45-51. Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011 Jun 13;171(11):1013-9. 48
  49. 49. A. Cardiovascular System 1. Digoxin at a long-term dose > 125µg/day with impaired renal function * (increased risk of toxicity). * estimated GFR <50ml/min 2. Loop diuretics: for dependent ankle oedema only i.e. no clinical signs of heart failure (no evidence of efficacy, compression hosiery usually more appropriate). as first-line monotherapy for hypertension (safer, more effective alternatives available). 3. Thiazide diuretic with a history of gout (may exacerbate gout). 4. Beta-blockers: with Chronic Obstructive Pulmonary Disease (COPD) (risk of increased bronchospasm). in combination with verapamil (risk of symptomatic heart block). 5. Use of diltiazem or verapamil with NYHA Class III or IV heart failure (may worsen heart failure). 6. Calcium channel blockers with chronic constipation (may exacerbate constipation). 7. Dipyridamole as monotherapy for cardiovascular secondary prevention (no evidence for efficacy).
  50. 50. START Criteria Screening Tool to Alert doctors to the Right Treatment 22 rules relating to common instances of prescribing omission O’Mahony D, Gallagher P, Ryan C, Byrne S, Hamilton H, Barry P, O’Connor M, Kennedy J. STOPP & START criteria: A new approach to detecting potentially inappropriate prescribing in old age. European Geriatric Medicine. 2010 Jan 6; 1(1):45-51.
  51. 51. A. Cardiovascular System 1. Warfarin in the presence of chronic atrial fibrillation, where there is no contraindication to warfarin. 2. Aspirin in the presence of chronic atrial fibrillation, where warfarin is contraindicated, but not aspirin. 3. Aspirin or clopidogrel with a documented history of coronary, cerebral or peripheral vascular disease in patients in sinus rhythm, where therapy is not contraindicated. 4. Antihypertensive therapy where systolic BP consistently >160 mmHg, where antihypertensive therapy is not contraindicated. 5. Statin therapy in patients with documented history of coronary, cerebral or peripheral vascular disease, where the patients’ functional status remains independent for activities of daily living and life expectancy is more than 5 years 6. ACE inhibitor:  in chronic heart failure, where no contraindication exists  following acute myocardial infarction. 7. Beta blocker in chronic stable angina, where no contraindication exists.
  52. 52. Questions 52
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