This document discusses drug therapy in elderly patients. It outlines several key points:
1) Pharmacokinetics and pharmacodynamics are altered in elderly patients, requiring lower doses and careful monitoring. Polypharmacy also increases adverse drug reactions.
2) Absorption, distribution, metabolism and excretion of drugs are impacted by aging processes like decreased organ function. This prolongs drug effects.
3) Adverse drug events are common in the elderly due to these changes. Non-adherence also increases risks. The Beers criteria list potentially inappropriate medications in this group.
4) When prescribing for elderly patients, doctors should simplify regimens, start low and slow, and monitor closely for side effects given increased
Quality use of medicines in geriatric patients with their Physiological changes with aging, altered Pharmacokinetics and Pharmacodynamics with ADR's, Guidelines for prescribing the older people and the role of clinical pharmacist in geriatric prescribing.
Quality use of medicines in geriatric patients with their Physiological changes with aging, altered Pharmacokinetics and Pharmacodynamics with ADR's, Guidelines for prescribing the older people and the role of clinical pharmacist in geriatric prescribing.
principles of GI drug administration.pptxNoorHashmee
PRINCIPLES OF GASTROINTESTINAL DRUG ADMINISTRATION
Introduction
Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.
It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ‘five rights’ or ‘five R’s’ of medication administration.
These ‘rights’ came into being during an era in medicine in which the precedent was that an error committed by a provider was the provider’s sole responsibility and patients did not have as much involvement in their own care.
The 10 Rights of Medications Administration
1. Right patient
Check the name on the prescription and wristband.
Ideally, use 2 or more identifiers and ask the patient to identify themselves.
2. Right medication
Check the name of the medication, brand names should be avoided.
Check the expiry date.
Check the prescription.
Make sure medications, especially antibiotics, are reviewed regularly.
3. Right dose
Check the prescription.
Confirm the appropriateness of the dose using the BNF or local guidelines.
If necessary, calculate the dose and have another nurse calculate the dose as well.
4. Right route
Again, check the order and appropriateness of the route prescribed.
Confirm that the patient can take or receive the medication by the ordered route.
5. Right time
Check the frequency of the prescribed medication.
Double-check that you are giving the prescribed at the correct time.
Confirm when the last dose was given.
6. Right patient education
Check if the patient understands what the medication is for.
Make them aware they should contact a healthcare professional if they experience side effects or reactions.
7. Right documentation
Ensure you have signed for the medication AFTER it has been administered.
Ensure the medication is prescribed correctly with a start and end date if appropriate.
8. Right to refuse
Ensure you have the patient's consent to administer medications.
Be aware that patients do have a right to refuse medication if they have the capacity to do so.
9. Right assessment
Check your patient actually needs the medication.
Check for contraindications.
Baseline observations if required.
10. Right evaluation
Ensure the medication is working the way it should.
Ensure medications are reviewed regularly.
Ongoing observations if required
Clinical Significance
The 'five rights' first have important clinical significance by their integration into the methodologies used for instructing nursing students about the applications of the 'rights' framework in clinical practice.
GERIATRIC PHARMACOLOGY Geriatric pharmacology is a specialized field focusing...Abhinav S
Geriatric pharmacology is a specialized field focusing on medication use in elderly individuals
It explore challenges like polypharmacy, age-related changes in drug metabolism, and the importance of personalized treatment plans for older patients.
20% of hospitalization for those > 65 are due to the medication they’re taking
Clinical pharmacy is a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, and disease prevention.
Community Pharmacy.
Hospital Pharmacy.
Clinical Pharmacy.
Industrial Pharmacy.
Compounding Pharmacy.
Consulting Pharmacy.
Ambulatory Care pharmacy.
Regulatory Pharmacy.
Polypharmacy appropriate and inappropriate based on risk and benefit assessment case study, negative consequences of polypharmacy, deprescribing tools,
Polypharmacy and Rational Prescribing in Elderly Patients.pptxAhmed Mshari
Polypharmacy is typically defined as the prescription of five or more medications.
It also refers to the prescription of medications that do not have a specific current indication, that duplicate other medications, or that are known to be ineffective for the condition being treated.
In other words, polypharmacy is the use of multiple medications that are unnecessary and have the potential to do more harm than good.
Interaction between the food and drugs have a high effect on the success of treatment patients and on the side effects of drugs . the interaction not in all cases is bad but sometimes can improve the absorption and decrease the side effect. grapefruits interaction has received very high attention recently. Consequently, the presence of food in the digestive tract may reduce absorption of a drug. Often, such interactions can be avoided by taking the drug 1 hour before or 2 hours after eating. Like drugs, foods are not tested as comprehensively so they may interact with prescription or over the-counter drugs. therefor it is advisable for patients to follow the doctor and specialists’ guidelines to acquire greatest advantages with least food tranquilize cooperation.
principles of GI drug administration.pptxNoorHashmee
PRINCIPLES OF GASTROINTESTINAL DRUG ADMINISTRATION
Introduction
Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.
It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ‘five rights’ or ‘five R’s’ of medication administration.
These ‘rights’ came into being during an era in medicine in which the precedent was that an error committed by a provider was the provider’s sole responsibility and patients did not have as much involvement in their own care.
The 10 Rights of Medications Administration
1. Right patient
Check the name on the prescription and wristband.
Ideally, use 2 or more identifiers and ask the patient to identify themselves.
2. Right medication
Check the name of the medication, brand names should be avoided.
Check the expiry date.
Check the prescription.
Make sure medications, especially antibiotics, are reviewed regularly.
3. Right dose
Check the prescription.
Confirm the appropriateness of the dose using the BNF or local guidelines.
If necessary, calculate the dose and have another nurse calculate the dose as well.
4. Right route
Again, check the order and appropriateness of the route prescribed.
Confirm that the patient can take or receive the medication by the ordered route.
5. Right time
Check the frequency of the prescribed medication.
Double-check that you are giving the prescribed at the correct time.
Confirm when the last dose was given.
6. Right patient education
Check if the patient understands what the medication is for.
Make them aware they should contact a healthcare professional if they experience side effects or reactions.
7. Right documentation
Ensure you have signed for the medication AFTER it has been administered.
Ensure the medication is prescribed correctly with a start and end date if appropriate.
8. Right to refuse
Ensure you have the patient's consent to administer medications.
Be aware that patients do have a right to refuse medication if they have the capacity to do so.
9. Right assessment
Check your patient actually needs the medication.
Check for contraindications.
Baseline observations if required.
10. Right evaluation
Ensure the medication is working the way it should.
Ensure medications are reviewed regularly.
Ongoing observations if required
Clinical Significance
The 'five rights' first have important clinical significance by their integration into the methodologies used for instructing nursing students about the applications of the 'rights' framework in clinical practice.
GERIATRIC PHARMACOLOGY Geriatric pharmacology is a specialized field focusing...Abhinav S
Geriatric pharmacology is a specialized field focusing on medication use in elderly individuals
It explore challenges like polypharmacy, age-related changes in drug metabolism, and the importance of personalized treatment plans for older patients.
20% of hospitalization for those > 65 are due to the medication they’re taking
Clinical pharmacy is a health science discipline in which pharmacists provide patient care that optimizes medication therapy and promotes health, and disease prevention.
Community Pharmacy.
Hospital Pharmacy.
Clinical Pharmacy.
Industrial Pharmacy.
Compounding Pharmacy.
Consulting Pharmacy.
Ambulatory Care pharmacy.
Regulatory Pharmacy.
Polypharmacy appropriate and inappropriate based on risk and benefit assessment case study, negative consequences of polypharmacy, deprescribing tools,
Polypharmacy and Rational Prescribing in Elderly Patients.pptxAhmed Mshari
Polypharmacy is typically defined as the prescription of five or more medications.
It also refers to the prescription of medications that do not have a specific current indication, that duplicate other medications, or that are known to be ineffective for the condition being treated.
In other words, polypharmacy is the use of multiple medications that are unnecessary and have the potential to do more harm than good.
Interaction between the food and drugs have a high effect on the success of treatment patients and on the side effects of drugs . the interaction not in all cases is bad but sometimes can improve the absorption and decrease the side effect. grapefruits interaction has received very high attention recently. Consequently, the presence of food in the digestive tract may reduce absorption of a drug. Often, such interactions can be avoided by taking the drug 1 hour before or 2 hours after eating. Like drugs, foods are not tested as comprehensively so they may interact with prescription or over the-counter drugs. therefor it is advisable for patients to follow the doctor and specialists’ guidelines to acquire greatest advantages with least food tranquilize cooperation.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
2. Outline Ageing and altered drug effects
Step wise approach to review medications for elder people
Polypharmacy
Appropriate prescribing in the elderly
Drugs and side effects in the elderly
Adverse drug effects
Non- Adherence and what to do
3. Introduction
Optimizing drug therapy is an essential part of
caring for an older person
Patients aged 60 years and over are the main
consumers of drugs because of increased
pathology requiring multiple drugs.
Ageing alters pharmacokinetics and
pharmacodynamics
Pharmacological and non- pharmacological
factors associated with ageing predispose
older persons to an increased risk of adverse
drug events
4. Age associated
mechanisms of
altered drug effects
Particular care must be taken in determining
drug doses when prescribing for older adults
An increased volume of distribution may
result from the proportional increase in body
fat relative to skeletal muscle with aging
Decreased drug clearance may result from the
natural decline in renal function with age,
even in the absence of renal disease
Larger drug storage reservoirs and decreased
clearance prolong drug half-lives and lead to
increased plasma drug concentrations in older
people
5. Age associated
mechanisms of
altered drug effects
Changes in pharmacokinetics and
pharmacodynamics
Multiple chronic diseases and consequence
polypharma
Diminished vasomotor regulation and
impaired glucose tolerance
Hepatic function also declines with advancing
age, and age-related changes in hepatic
function may account for significant variability
in drug metabolism among older adults
7. Drug Absorption
There is a decrease in
small bowel surface area
Decreased active
transport
Increased GI pH
• Decrease in absorption of
certain drugs (Antifungals)
• Increase in absorption of
certain drugs (Nifedipine,
(weak acid), Amoxycillin)
Slower gastric
motility/emptying
Increased fat/decreased
muscle
• Transdermal, IM, SQ
Dysphagia may
potentially alter
absorption
8. Drug Distribution
Changes in body
composition such as
increase in adipose tissue
and decrease in total body
water and lean body mass
Changes result in an
increase in volume of
distribution of lipid soluble
drugs
Eg diazepam, verapamil
These drugs are excreted
at a much slower rate thus
prolonging half-life, taking
longer to reach steady
concentration
Water soluble drugs have a
decreased volume of
distribution, leading to
higher plasma
concentration
Eg digoxin, lithium,
cimetidine
9. Drug Metabolism
Liver is responsible for
drug metabolism and
kidney is responsible
for excretion
Age- related changes
lead to decreased liver
size, hepatic blood flow
and enzyme activity.
A decrease in hepatic
blood flow prolongs the
duration of effect in
drugs that undergo
first pass metabolism
e.g propranolol theophylline nitrates
10. Drug excretion
Decrease in:
• Kidney mass
• Nephron size and number
• Renal blood flow
• Tubular secretion
• Glomerular filtration rate
• Most drugs are excreted in the kidney and can be measured using the serum creatinine
• Therefore, either 24-hour creatinine collection or Crockcroft and Gault equation can be used.
11. Excretion
cont
• Renal excretion of drugs depends on
glomerular filtration rate (GFR)
• This affects especially drugs that are
excreted by 60% by the kidney, such as
• ACEI, atenolol, allopurinol, metformin, digoxin,
H2 blockers, lithium, etc.
• These require dose adjustment and monitoring
in the elderly
• Toxicity also increases when combining two
drugs that compete for renal secretion
• E.g., probenicid and penicillin
• Serum drug levels may be used to monitor
certain drug levels
12. Pharmacodynamic
Changes:
• What the drug does to the body.
• Affected by receptor binding.
Pharmacodynamics:
• Drug-receptor interactions cause changes in the
drug effect.
• Receptors function less efficiently
• Reduction in the density of beta receptors
• Reduction in the parasympathetic control
• Reduction in brain receptors
• Increase in blood-brain barrier permeability
• Decrease in cerebral blood flow
• Reduction in homeostatic mechanisms
In elderly:
14. Polypharmacy
The use of multiple medications by a patient
Minimum number of medications used to define
"polypharmacy" is variable, but generally ranges
from 5 to 10
Also consider the number of over-the-counter and
herbal/supplements used(ginkgo biloba &warfarin
and St Johns Wort& serotonin-reuptake inhibitors)
Problematic polypharmacy is defined as the use of
multiple medications in a way that is not
considered to be appropriate
15. Polypharmacy
Metabolic changes and decreased
drug clearance associated with aging;
this risk is compounded by increasing
numbers of drugs used.
Prescribing cascades
Adherence
16. Adverse drug
effects
Defined as injury resulting from the
use of drug at usual doses.
Some drug reactions are idiosyncratic
and thus unpredictable, 60-70% occur
because of known pharmacological
effects.
Adverse drug reactions have been
estimated to account for 7.9-24% of
all hospitalizations of elderly patients.
17. Risk factors for
ADE in older
patients
• Age > 85 years
• Low body weight or body mass index
• >= 6 concurrent chronic diagnoses
• Estimated creatinine clearance < 50 ml per minute
• >= 9 medications
• >= 12 doses of medications per day
• A prior adverse drug reaction
18. Common
presentations of
adverse drug effects
in the elderly
Confusion: benzodiazepines,
phenothiazines
Gait disorder: butyrophenones,
anticonvulsants
Postural hypotension:
antihypertensives, diuretics
Incontinence: anticholinergic agents
Hypothermia: ethanol, tricyclic
antidepressants
Constipation: anticholinergic agents,
verapamil, opioids
19. Guidelines
for
effective
prescribing
Use Use new drugs with particular caution
Encourage Encourage treatment adherence
Treat Treat adequately
Start Start low, go slow
Know Know the drugs you use
Use Use non-drug treatment whenever possible
Obtain Obtain a complete drug history
20. Questions you
should ask
before
prescribing
medication for
an elderly
patient
Check Check whether the person is physically able to take
the medication correctly
Check Check whether the frequency is correct.
Check Check whether the dosage is correct
Ask Ask which medications the patient is taking including
over the counter medications and vitamins.
21. Adherence
Degree to which a patient correctly
follows medical advise
Physical and cognitive impairment
is an issue
Caregivers/patients need to
understand the therapy.
Non-compliance is especially poor
with long- term medications
22. Factors
predisposing
to non-
adherence to
treatment
Complexity of
dosing schedule
Frequent changes
in medication or
brands
Multiple
medications
Unpleasant side-
effects
Difficult to open
containers
Cost of medication
Difficult routes of
administration
Inadequate patient
education and
understanding
Cognitive
impairment
Visual impairment
Impairment of
physical function
23. Handling
non-
adherence
Simplify drug regimens
Avoiding polypharmacy
Educate patients and provide carefully written
instructions
Warning the patient of common adverse drug reactions
Performance of cognitive and physical assessments
Encouraging face-to-face interview
24. Special
challenges
Doctors shopping and involvement of multiple professionals, thus no
health care professional takes responsibility for the care of the patients
Poor communication between professionals
Failure of patients to bring all drugs to every consultation
Limited doctor/patient communication
Poor patient education
Use of both generic and trade names
25. Beers criteria
• List of medications considered potentially
inappropriate for use in older patients,
mostly due to high risk for adverse events.
• Medications are grouped into five
categories: those potentially inappropriate in
most older adults, those that should
typically be avoided in older adults with
certain conditions, drugs to use with
caution, drug-drug interactions, and drug
dose adjustment based on kidney function.
• Limitation: Drugs used in USA
• WEBSITE:
https://www.americangeriatrics.org/
29. Useful tips
Document the
indication for a new
drug therapy
1
Educate patients on
the benefits and risks
associated with the
use of a new therapy
2
Maintain a current
medication list
3
Document response
to therapy
4
Periodically review
the ongoing need for
a drug therapy
5
Editor's Notes
Optimizing drug therapy is an essential part of caring for an older person. The process of prescribing a medication is complex and includes: deciding that a drug is indicated, choosing the best drug, determining a dose and schedule appropriate for the patient's physiologic status, monitoring for effectiveness and toxicity, educating the patient about expected side effects, and indications for seeking consultation.
Avoidable adverse drug events (ADEs) are the serious consequences of inappropriate drug prescribing. The possibility of an ADE should always be borne in mind when evaluating an older adult individual; any new symptom should be considered drug-related until proven otherwise.
Prescribing for older patients presents unique challenges. Premarketing drug trials often exclude geriatric patients and approved doses may not be appropriate for older adults [1]. Many medications need to be used with special caution because of age-related changes in pharmacokinetics (ie, absorption, distribution, metabolism, and excretion) and pharmacodynamics (the physiologic effects of the drug).
Particular care must be taken in determining drug doses when prescribing for older adults. An increased volume of distribution may result from the proportional increase in body fat relative to skeletal muscle with aging. Decreased drug clearance may result from the natural decline in renal function with age, even in the absence of renal disease [2]. Larger drug storage reservoirs and decreased clearance prolong drug half-lives and lead to increased plasma drug concentrations in older people.
As examples, the volume of distribution for diazepam is increased, and the clearance rate for lithium is reduced, in older adults. The same dose of either medication would lead to higher plasma concentrations in an older, compared with younger, patient. Also, from the pharmacodynamic perspective, increasing age may result in an increased sensitivity to the effects of certain drugs, including benzodiazepines [3-6] and opioids [7].
Hepatic function also declines with advancing age, and age-related changes in hepatic function may account for significant variability in drug metabolism among older adults [8]. Especially when polypharmacy is a factor, decreasing hepatic function may lead to adverse drug reactions (ADRs).
Many medications need to be used with special caution because of age-related changes in pharmacokinetics (ie, absorption, distribution, metabolism, and excretion) and pharmacodynamics (the physiologic effects of the drug).
24-hour creatinine collection is measured with 24-hour urine collection, is therefore time consuming
A more systematic approach is required to guide the tailoring of medication regimens to the needs of individuals. One important principle is to match the medication regimen to the patient's condition and goals of care. This includes a careful consideration of the medications that should be discontinued or substituted [34] (table 1).
It is particularly important to reconsider medication appropriateness late in life. A model for appropriate prescribing for patients late in life has been proposed [35] (table 2). The process considers the patients’ remaining life expectancy and the goals of care in reviewing the need for existing medications and in making new prescribing decisions. For example, if a patient's life expectancy is short and the goals of care are palliative, then prescribing a prophylactic medication requiring several years to realize a benefit may not be considered appropriate. This is increasingly being recognized as an important consideration when managing individuals with advanced dementia [36]. Additionally, therapeutic medications (eg, antibiotics for pneumonia) may not increase comfort or quality of life when palliative care is the objective [
Polypharmacy is defined simply as the use of multiple medications by a patient. The precise minimum number of medications used to define "polypharmacy" is variable, but generally ranges from 5 to 10 [21]. While polypharmacy most commonly refers to prescribed medications, it is important to also consider the number of over-the-counter and herbal/supplements used. Problematic polypharmacy is defined as the use of multiple medications in a way that is not considered to be appropriate [22].
The issue of polypharmacy is of particular concern in older people who, compared with younger individuals, tend to have more disease conditions for which therapies are prescribed. It has been estimated that 20 percent of Medicare beneficiaries have five or more chronic conditions and 50 percent receive five or more medications [23]. Among ambulatory older adults with cancer, 84 percent were receiving five or more and 43 percent were receiving 10 or more medications, in one study [24].
The use of greater numbers of drug therapies has been independently associated with an increased risk for an adverse drug event (ADE), irrespective of age [25], and increased risk of hospital admission [26,27]. Polypharmacy has also been associated with decreased physical and cognitive capability, even after adjusting for disease burden [28]. However, it is difficult to eliminate the impact of confounding factors in considering the relationship between polypharmacy and a variety of outcomes in observational studies
There are multiple reasons why older adults are especially impacted by polypharmacy:
●Older individuals are at greater risk for ADEs due to metabolic changes and decreased drug clearance associated with aging; this risk is compounded by increasing numbers of drugs used.
●Polypharmacy increases the potential for drug-drug interactions and for prescription of potentially inappropriate medications [30].
●Polypharmacy was an independent risk factor for hip fractures in older adults in one case-control study, although the number of drugs may have been an indicator of higher likelihood of exposure to specific types of drugs associated with falls (eg, central nervous system [CNS]-active drugs) [31].
●Polypharmacy increases the possibility of "prescribing cascades" [32]. A prescribing cascade develops when an ADE is misinterpreted as a new medical condition and additional drug therapy is then prescribed to treat this medical condition (see 'Prescribing cascades' below). Prescribing cascades are part of the definition of problematic polypharmacy.
●Use of multiple medications can lead to problems with adherence in older adults, especially if compounded by visual or cognitive impairment. A 2017 systematic review of observational studies suggested that drug regimen complexity is associated with medication nonadherence [2
The possibility of an adverse drug event (ADE) should always be borne in mind when evaluating an older adult; any new symptom should be considered drug-related until proven otherwise. Pharmacokinetic changes lead to increased plasma drug concentrations and pharmacodynamic changes lead to increased drug sensitivity in older adults. (See 'Introduction' above.)
●Clinicians must be alert to the use of herbal and dietary supplements by older patients, who may not volunteer this information and are prone to drug-drug interactions related to these supplements. ADEs result in four times as many hospitalizations in older, compared with younger, adults. Prescribing cascades, drug-drug interactions, and inappropriate drug doses are causes of preventable ADEs. (See 'Adverse drug events' above.)
●ADEs are a particular problem for nursing home residents; atypical antipsychotic medications and warfarin are the most common drugs involved in ADEs in this population
Various criteria sets exist identifying medications that should not be prescribed, or should be prescribed with great caution, in older adults. However, clinicians need to consider each patient's individual situation, and they should use their best clinical judgment rather than strictly adhere to prescribing guidelines when making prescribing decisions. (See 'Inappropriate medications' above.)
●Clinicians also under-prescribe medications, such as statins, that could provide benefit for older adults. Clinicians may be better at avoiding overprescribing of inappropriate drug therapies than at prescribing indicated drug therapies. Patient financial constraints and unavailability of prescribed doses may contribute to medication underutilization. (See 'Underutilization of appropriate medication' above.)
