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Old age & drugs
- 1. Old age & Drugs Dr. Nidhi Maheshwari
- 2. 3 • Elderlies 12 treatment/year • patients < 45 5treatment/year • 13% of total population • 33% of all prescription drugs • By 2040, represent 25% of total population, Consume 50% of all prescription drugs.
- 3. • Pk-pd changes • Non-compliance • Multiple medications • Self medication • Drug interactions
- 4. Pharmacokinetic changes • ↓ hepatic blood flow & ↓ metabolising enzymes • Eg. Haolthane, • Diazepam • ↓ renal function • Aminoglycosides- dose ↓ (1 to 0.75 to 0.5), duration ↓ ( to one/day) • Infusing vancomycin over 2 hrs (90 % excretion from kidney) • Baroreflex sensitivity ↓ - postural hypotension marked • ↑ prostate gland mass Avoid anticholinergic action Cumulative Toxicity
- 5. Pharmacodynamic changes • ↑ sensitivity of opioid receptors sufentail, alfentanil, fentanyl are twice potent. • Receptor changes – Change in receptor numbers – Changes in receptor affinity. – Post receptor alteration • ↓ response to β2 agonists may require higher doses of Salbutamol • ↓ anti HT action of β2 antagonists, ↑ antiHT action of CCBs and Diuretics
- 8. Non- compliance • Multiple drugs together • Forgetfulness • Mood changes • Difficulty in swallowing
- 9. Use of multiple medications • Herbal medications or uncoventional medications-history not asked • eg. Ginkgo biloba extract-warfarin causes bleeding • St. John’s wort with Serotonin reuptake inhibitors- Serotonin syndrome • garlic
- 10. Self medications
- 11. Drug interactions • venlafaxine and propafenone-hallucinations and psychomotor agitation • Sodium valproate and levetiracetam-psychic disturbances • phenobarbital and lamotrigine-blood dyscrasias
- 12. • Warfarin + selective & non-selective NSAIDs or SSRI’s or Omeprazole or lipid lowering agents or amiodarone/fluorouracil--- bleeding • Cotrimoxazole-hypoglycemic 6 times • Digoxin + clarithromycin digoxin toxicity raised 12 times more • K+ sparing diuretics-hyperkalemia 20 times more
- 13. • Lithium with thiazides --reduce dose of lithium in elderlies or replace • Carmazepine or valproic acid is preferred • Avoid antipsychotics + antidepressants • Antacids decrease in urinary acid secretion – increase in urine pH – reduction in salicyclate levels esp. in pt. on chronic aspirin treat.
- 14. Prescribing cascade • Cholinesterase inhibitors (donepezil, rivastigmine, galantamine)-S/e diarrhoea, urinary incontinence---Rx-anticholinergics • Antipsychotics or metoclopramidesymptoms of parkinsonismstarted on anti- parkinsonism s/e orthostatic hypotension, delirium
- 15. Criteria’s • Beer criteria’s-to assess inappropriate drug prescribing • STOPP-screening tool of older person’s prescriptions • Drug burden index • FORTA-Fit for the aged
- 16. Cont….. • Doxy with lots of water-prevent ulcers • To avoid osteoporosis –Use glucocorticoids with calcium and vit D • To prevent gastric acidity-H2 anatagonists • Prefer thiazides in minimum effective dose or with K sparing diuretic • Prefer B1 blocker, ACEI, ARBs, CCBs • Absorption of many drugs may be impaired – gastric acidity & function exc. Acid labile erythromycin • Avoid ppnl, , thiazide diuretics in higher doses • Frequent thiazides-high dose-hypokalemia, hyperuricamia, hyperglycemia • Hyperkalemia esp. With potassium sparing diuretics
- 17. • Reduce dose-Lignocaine, lithium, quinidine, aminoglycoside, digitalis • Raise interval- Digitalis, aminoglycoside • Assess clinically-atenolol, diazepam • TDM frequently-Phenytoin, theophylline (dose adjustment) • Avoid drugs with anticholinergic and hypotension as side effects
- 18. 20 • NSAIDs-May cause GI bleed and renal damage • INDOMETHACIN- CNS side effects • Naproxen-piroxicam-cumulative toxicity • Ibuprofen, nimesulide, cox-2 inhibitors may be prefered • Digoxin, Beta agonists, Beta blockers - Less effect • Better response-Ca blockers, ACE-I, diuretics • Ppnl-ppt asthma, pvd, chf-common in elderlies • Ppnl-BA and t1/2 increases with age • Prefer aspirin or clopidogrel over dipridamole as antiplatelet
- 19. 21 • Digitalis • Reduction in clearance & little reduction in Vd may increase T1/2 > 50 % • Renal function test should be done prior starting Rx • Frequent checking of electrolytes increase risk of arrythmias • ADR-Warfarin, Digoxin, Insulin, Oral antiplatelets, hypoglcemics
Editor's Notes
- We will take more than 60 as old age
- Aging is the progressive, universal decline first in functional reserve and then in function that occurs in organisms over time. Aging is heterogeneous. It varies widely in different individuals and in different organs within a particular individual. Aging is not a disease; however, the risk of developing disease is increased, often dramatically, as a function of age. The biochemical composition of tissues changes with age; physiologic capacity decreases, the ability to maintain homeostasis in adapting to stressors declines, and vulnerability to disease processes increases with age. After maturation, mortality The biochemical composition of tissues changes with age; physiologic capacity decreases, the ability to maintain homeostasis in adapting to stressors declines, and vulnerability to disease processes increases with age. After maturation, mortality
- Each of these patients fill on the average 12 Rx/year compared to only 5/year on average for patients &lt; 45.
- Affected by liver-tolbutamide, ppnl, tca, Diazepam-forms metabloites-longer t/12.In elderlies it increases-&gt;oxazepam, lorazepam, alprazolam is preferred. halothan toxicity is more frequent in adults, more prone to its hepatotoxicity, used as a maintenance anaethetic after i.v. induction-&gt;isofurane/desflurane for major Usually halothane forms metaboitewhich is heaptotoxic, Midazolam and propofol given for short surgeries.preoperative H2 anatgonists are given. No anti cholinergic action Hypoglycemic side effects are more with oral hypoglycemics Streptomycin dose 1g, 0.75g, 0.5 g when age young, 50, 75 yrs postural hypotension-&gt; isosorbide, levodopa, tca, antipsychotics,b blockers, diuretics, antihistamines Mild anticholinergic activity can accentuate bladder voiding difficulty-antipsychotics, antihistamines, atropine (can not be given as preanesthetic medication ), antispasmodics-dicyclomine
- Remifantynyl-&gt; raised effect
- Issue of polypharmacy is more in elderlies as they tend to have more disease conditions
- the drugs commonly involved in potentially hazardous drug interactions were verapamil, methotrexate, amiodarone, lithium, warfarin, cyclosporine and itraconazole
- It develops when an adverse drug event is misinterpreted as a new medical condition & additional drug therapy is then prescribed to treat this medical condition
- elderly have more pain more often due to disease like arthritis cancer low back pathology.Find out cause of pain For mild pain start start with paracetamol Platelet Inhibitors Dipyridamole - postural hypotension, coronary steal phenomenon Prefer clopidogrel or aspirin