This document discusses key issues in geriatric pharmacology and how medication can affect balance and increase fall risks in older patients. It notes that aging leads to changes in drug metabolism and pharmacodynamics that increase risks of adverse drug events. Common culprit medications for falls include benzodiazepines, antidepressants, and cardiac drugs. The case study involves an elderly woman who fell frequently and was on multiple medications. Principles for safe prescribing in older adults include starting low doses, avoiding polypharmacy, and annual medication reviews.

1. Balancing Gait by
Balancing Prescription
Medications
By Dr. Aboo Nasar M.D., M.P.H., M.B.A
Attending Geriatric Physician for Senior Medical Associates

2. Objectives
Know and understand
1. Key issues in geriatric pharmacology
2. Effects of age on pharmacokinetics and
pharmacodynamics
3. Risk factors for adverse drug events for older patients
4. Principles of prescribing for older patients and how it
affects gait balance and increased risks for falls

3. Case Summary
Ms. WS is a 82 y/o F who comes to ER with falls, she had
recurrent falls, occasionally incontinent of urine, feels dizzy
when she stands.
PMHx : HTN, CAD, Dementia, CHF
Meds: Furosemide 80 mg bid, Amlodipine 10 mg po qd,
Ditropan 5mg bid, Donepezil, Coreg 25 mg bid, Lisinopril 40
mg, Seroquel 200mg/day, clonidine patch TTS3 change q
weekly

4. Case Summary
P/E: HR 60, BP 90/56 seated and 110/72 lying
thin and mildly cachectic
Reasons behind her recurrent falls?

5. Why Geriatric Pharmacotherapy is
important
Now, people 65+ are 13% of the U.S. population and purchase 33% of prescription drugs.
By 2040 these numbers will increase to 25% of the population and 50% drug usage.

6. ● Challenges of Geriatric Pharmacology
● Age-Associated changes in pharmacokinetics
● Age-Associated changes in pharmacodynamics
● Optimizing prescribing
● Adverse drug effects
● Nonadherence
● Drug-drug and drug-disease interactions
Why Geriatric Pharmacotherapy is
important

7. Metabolism
The Liver is the most common site of drug metabolism
Metabolic clearance of a drug may be reduced because:
1. Age decreases liver blood flow, size, and mass
2. Drug Clearance is reduced for drugs subject to phase I
pathways or reactions

8. Other Factors that Affect Drug
Metabolism
● Age and Gender
● Hepatic congestion from heart failure
● Smoking

9. Kidney Function is Critical for
Drug Elimination
● Most drugs exit the body via the Kidney
● Reduced elimination increases drug accumulation and
toxicity
● Aging and common geriatric disorders can impair kidney
function

10. The Effects of Aging on the
Kidney
● Kidney size
● Renal Blood Flow
● Number of Functioning Nephrons
● Renal Tubular Secretion
Result: Decreased Kidney Function

11. Factors Contributing to
Elimination
1. Drug Half life
2. Clearance: Volume of serum from which the drug is
removed per unit of time

12. Pharmacodynamics
Definition: Time Course and intensity of the pharmacologic
effect of a drug
May change with aging for example:
● Benzodiazepines may cause more sedation and poorer
psychomotor performance in older adults.
● Older patients may experience longer pain relief with
morphine

13. Optimizing and Balancing
Prescribing
● Achieve balance between over and under prescribing of
beneficial therapies
● >20% of ambulatory adults receive at least one potentially
inappropriate medication
● Nearly 4% of office visits and 10% of hospital admissions
result in prescription of medications classified as never or
rarely appropriate

14. Beers Criteria
● Intend to improve drug selection and reduce exposure to
potentially inappropriate medications in older adults
● Recommendations are evidence-based and in 5 categories
1. Drugs to avoid
2. Drugs to avoid in patients with specific diseases or syndromes
3. Drugs to use with caution
4. Selected drugs whose dose should be adjusted based in kidney
function
5. Selected drug-drug interactions

15. Commonly Overprescribed
Drugs
● Androgens/Testosterone
● Anti-infective agents
● Anticholinergic agents
● Urinary & GI antispasmodics
● Antipsychotics
● Benzodiazepines
● Digoxin
● NSAIDS

16. Commonly Under Prescribed
Drugs
● ACE inhibitors for patients with diabetes and proteinuria
● Angiotensin-receptor blockers
● Anticoagulants
● Antihypertensives and Diuretics
● Beta Blockers
● Bronchodilators
● Statins

17. Adverse Drug Events
● An injury resulting from the use of a drug
● Adverse drug reaction (ADR): a type a ADE referring to harm
directly caused by a drug at unusual dosages.
● ADEs are responsible for 5% to 28% of acute geriatric
medical admissions
● Incidence of ADEs in hospitals 2.6%

18. In nursing homes, $1.33 is spent on ADEs for every $1.00 spent on medications

19. ADEs in the Ambulatory Setting
● ADE rate 50.1 per 1,000 person-years (preventable ADE rate
13.8)
● Cardiovascular drugs, diuretics, NSAIDs, hypoglycemics,
and anticoagulants
● Most ADEs (>95%) are considered predictable

20. Risks Factors for ADEs
● 6 or more concurrent chronic conditions
● 12 or more doses of drugs/day
● 9 or more medications
● Prior adverse drug event
● Low body weight or low BMI
● Age 85 or older
● Estimated CrCl < 50 mL/min

21. Drug – Drug Interactions
● May Lead to ADEs
● Risk increases as Number of medications increase
● Most Common: Cardiovascular and Psychotropic drugs

22. Most Common Adverse Effects of
Drug-Drug Interactions
● Neuropsychological (Primarily Delirium)
● Arterial Hypertension
● Acute Kidney Failure
● Falls

23. Epidemiology of Falls
● 1 in 3 Adults > 65 Years reports falling each year
● ½ of those > 80 years
● ½ of nursing-home residents
● Nearly 60% of those with history of falls
● Complications of falls are the leading cause of death from
injury in people ages > 65 years

24. Causes: Medication Use
● Specific Classes, for example:
● Benzodiazepines
● Other Sedatives
● Antidepressants
● Antipsychotics
● Cardiac Medication
● Hypoglycemic agents
● Recent medication dosage adjustments
● Total number of medications

25. Treatment
● In the Nursing Home setting, Vitamin D Supplementation
can decrease fall risk and fractures. JAMA 2004
Tai Chi and Qi Gong

26. Principles for Prescribing for
Older patients: The Basics
● Start with low dose
● Titrate upward slowly, as tolerated by patient
● Avoid starting 2 drugs at the same time

27. Before Prescribing A New Drug,
Consider:
● Is the medication necessary?
● What are the therapeutic end points?
● Do the benefits outweigh the risks?
● Is it used to treat effects of another drug?
● Could 1 drug be used to treat 2 conditions?
● Could it interact with diseases, other drugs?
● Does the patient know what it is for, how to take it, and
what ADEs to look for?

28. Principles of Prescribing
Annually
● Ask patients to bring in all medications (OTCs, prescribed,
supplements) for review
● Ask about side effects and screen for drug and disease
interactions
● Look for duplicate therapies for pharmacologic effect
● Eliminate unnecessary medications and simplify dosing
regimens

29. AGS Guidelines
Prescribe Exercise, balance, strength and gait training
Thorough Medication review, limit psychoactive drugs
Manage Postural Hypotension
Proper footwear
Dance, Tai Chi
Vit D Supplement
Manage HR and Rhythm problems

30. Do Not Prescribe A Medication
Without Conducting a Drug
regimen Review
Choose Wisely
*Based on American Board of Internal Medicine Foundation’ Choosing
Wisely® Campaign