1. ABHINAV SAWHNEY
M.PHARMACY (PHARMACOLOGY)
AMITY INSTITUTE OF PHARMACY
AMITY UNIVERSITY NOIDA
1

2. It is the art and science of preventing
disease in the geriatric population and
promoting their health and efficiency
2

3. In treating the elderly,
remember that the best
intervention is prevention.
3

4. Geriatrics
 Senility
 Decline in sexual prowess
 Diminution in endocrine activity
 Loss of elasticity of blood vessels
 Rise in B.P
4

5. RISK OF GERIATRICS
 PRONE FOR INFECTIONS
 PRONE FOR INJURIES
 NEED SPECIAL ASSISTANCE
 PRONE FOR PSYCHOLOGICAL PROBLEMS
 PRONE FOR DEGENERATIVE DISORDERS
 INCREASED RISK FOR DISEASE
 INCREASED RISK OF DISABILITY
 INCRASED RISK OF DEATH
5

6. Changes in the body systems
of the elderly
6

7. Common age-related systemic
changes
7

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

9. 9

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. 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. 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. Polypharmacy leads to…
 Adverse drug reactions
 Drug-drug interactions
 Decreased medication compliance
 Poor quality of life
 Unnecessary drug expense
13

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. 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. 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. 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. 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. Iatrogenic Problems
 Digoxin: toxicity
 H2 Blockers: confusion
 Benzodiazepines: CNS toxicity
 Narcotics: constipation; “start low; go slow”
19

20. 20

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. 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. 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. 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. 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. 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. 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. Other Factors Affecting Drug Metabolism
 Gender
 Comorbid conditions
 Smoking
 Diet
 Drug interactions
 Race
 Frailty
28

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. 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. 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. 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. 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. 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. 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. 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. Consequences of Overprescribing
 Adverse drug events (ADEs)
 Drug interactions
 Duplication of drug therapy
 Decreased quality of life
 Unnecessary cost
 Medication non-adherence
37

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. 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. 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. 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. 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

43. 43

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
http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
44

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

46. 46

47. 47

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. 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. 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. 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. Questions
52

53. 53