The document discusses the significant increase in the elderly population and the implications for medication use and management in geriatric healthcare. It highlights the challenges of polypharmacy, adverse drug events, and the need for careful monitoring and individualized treatment plans to optimize drug therapy for older adults. Additionally, it emphasizes the importance of ensuring quality care and avoiding ageism, while advocating for the dignity and autonomy of elderly patients.

1. Dr. D. K. Brahma
Associate Professor
Department of Pharmacology
NEIGRIHMS, Shillong

2.  Demographic transition – a global
demographic event
 WHO – People 60 years of age and older is
650 million now and forecast to reach 2 Billion
by 2050
 Persons aged 65 years and older constitute
13% of the population and purchase 33% of
all prescription medications
 By 2040, 25% of the population will purchase
50% of all prescription drugs

3.  Medications play crucial role in geriatric health
care as they treat chronic diseases, alleviate pain
and improve quality of life
 Age-related changes in drug disposition and
pharmacodynamic responses have significant
clinical implications
 Increased use of a number of medications in
elderly raises the risk of medicine-related problems
that may occur
 Medication use and the incidence of adverse drug
outcomes increase with advancing age
 It is important to ensure quality use of medicines in
older people

4.  Large number of new drugs available each
year
 Off-label indications are expanding
 Advanced understanding of drug-drug
interactions
 Increasing popularity of “nutriceuticals”
 Multiple co-morbid states
 Polypharmacy
 Medication compliance
 Effects of aging physiology on drug therapy
 Medication cost

5. Rate of absorption may be delayed
• Lower peak concentration
• Delayed time to peak concentration
Factors:
• Increased GI pH
• Decreased gastric emptying
• Dysphagia
• Route of administration
• Co-morbidity conditions
• Presence of drugs (pH and gastric emptying) and
additives

6. Aging Effect Vd Effect Examples
 body water  Vd for hydrophilic
drugs
ethanol, lithium
 lean body mass  Vd 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
Reduced amount of water in the body - fat soluble drugs remain longer in
the body with prolonged effects – of importance for some sedatives and
anxiolytics

7. Pathway Effect Examples
Phase I:
oxidation,
hydroxylation,
dealkylation,
reduction
Conversion
to
metabolites
of lesser,
equal, or
greater
diazepam,
quinidine,
piroxicam,
theophylline
Phase II:
glucuronidatio,
conjugation, or
acetylation
Conversion
to inactive
metabolites
lorazepam,
oxazepam,
temazepam
•Reduced liver function
•Hepatic microsomal
drug metabolizing activity
may be reduced due to:
decreased hepatic
blood flow
decreased liver size
and mass
Examples: morphine,
metoprolol, propranolol,
verapamil, amitryptyline,
nortriptyline (sensitivity to
beta-blockers reduced)

8.  Reduced kidney function - decreased excretion of
some cardiovascular drugs, some antibiotics,
diabetic drugs, antiinflammatory drugs – need to
reduce dosage
 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
 Creatinine clearance (CrCl) is used to estimate
glomerular rate

9. Brain and nervous system more sensitive
to psychotropic and analgesic drugs –
dizziness, confusion, cognitive impairment
Decreased capacity to regulate blood
pressure – blood pressure fall, fainting,
vertigo when using drugs for hypertension
Gastrointestinal sensitivity to anti-
inflammatory drugs - bleeding

10. Balance between overprescribing and
underprescribing
• Correct drug
• Correct dose
• Targets appropriate condition
• Is appropriate for the individual patient
Avoid “a pill for every ill”
Always consider non-pharmacologic therapy

11. Adverse drug events (ADEs)
Drug interactions
Duplication of drug therapy
Decreased quality of life
Unnecessary cost
Medication non-adherence

12.  Responsible for 5-28% of acute geriatric hospital
admissions
 Greater than 95% of ADEs in the elderly are
considered predictable (Type A) and approximately
50% are considered preventable
 Most errors occur at the ordering and monitoring
stages
 Most common medications associated with ADEs
in elderly
• Opioid analgesics
• NSAIDs
• Anticholinergics
• Benzodiazepines
• Also: cardiovascular agents, CNS agents, and
musculoskeletal agents

13. High potential to cause severe ADEs in
elderly – amitriptyline, chlorpropamide,
digoxin >0.125mg/d, disopyramide,
antispasmodics, meperidine, methyldopa,
pentazocine, ticlopidine
High potential but less severe:
antihistamines, diphenhydramine,
dipyridamole, ergot mesyloids,
indomethacin, muscle relaxants

14. ADE interpreted as new
medical condition
Drug 1
Drug 2
ADE interpreted as new
medical condition
Drug 3
Rochon PA, Gurwitz JH. Optimizing drug treatment in elderly people: the prescribing cascase. BMJ 1997;315:1097.

15. Combination Risk
ACE inhibitor + potassium Hyperkalemia
ACE inhibitor + K sparing diuretic Hyperkalemia, hypotension
Digoxin + antiarrhythmic Bradycardia, arrhythmia
Digoxin + diuretic
Antiarrhythmic + diuretic
Electrolyte imbalance; arrhythmia
Diuretic + diuretic Electrolyte imbalance; dehydration
Benzodiazepine + antidepressant
Benzodiazepine + antipsychotic
Sedation; confusion; falls
CCB/nitrate/vasodilator/diuretic Hypotension
Doucet J, Chassagne P, Trivalle C, et al. Drug-drug interactions related to hospital admissions in older adults: a
prospective study of 1000 patients. J Am Geriatr Soc 1996;44(9):944-948.

16. Combination Risk
NSAIDs + CHF
Thiazolidinediones + CHF
Fluid retention; CHF exacerbation
BPH + anticholinergics Urinary retention
CCB + constipation
Narcotics + constipation
Anticholinergics + constipation
Exacerbation of constipation
Metformin + CHF Hypoxia; increased risk of lactic
acidosis
NSAIDs + gastropathy Increased ulcer and bleeding risk
NSAIDs + HTN Fluid retention; decreased
effectiveness of diuretics

17. 1. When meeting the patient - get ready to spent more time and understand the
patient and his problems – see the whole patient as a part of whole
2. Identify the patient`s need of treatment – diagnosis important - Have a
comprehensive view
3. Symptoms can be adverse reactions to drugs
4. Record which other drugs the patient is using
5. Evaluate what has to be prescribed – make a benefit risk assessment, is there any
medication which should be stopped – must avoid Polypharmacy
6. Which dosage and administration form is appropriate
7. Make a plan for the treatment, when to meet for a follow-up of the effects of the
treatment and discuss this with the patient or her or his carer
• Use of lower doses, longer intervals, slower titration are helpful in decreasing the
risk of drug intolerance and toxicity
8. Careful monitoring is necessary to ensure successful outcomes
9. Remember:
• Balance between under prescribing and overprescribing
• Avoid “a pill for every ill”
• Always consider non-pharmacologic therapy
10. Report adverse reactions if they occur

18. Always take utmost care and responsibility
while prescribing medicines to an aged
patient – think, re-think, discuss with
colleague/seniors - if needed and apply
your best intellectual knowledge - Be
cautious with NSAIDS, CNS drugs, CVS
drugs, diuretics and oral hypoglycaemics

19. Brahma DK, Wahlang JB, Marak MD, Ch. Sangma M. Adverse drug reactions in the elderly. J Pharmacol Pharmacother [serial online] 2013 [cited 2017 Sep 24];4:91-4.
Available from: http://www.jpharmacol.com/text.asp?2013/4/2/91/110872

20. We do not want to meet ageism
We do not want to be discriminated
We want to keep our self-determination
We want to keep our dignity, integrity
We want to feel we are a resource
When in need, we want access to high
quality care and services including
palliative care
At the very end of life we should not
Barbro Westerholm.Prof.em, Member of Swedish Parliament. EFNS Stockholm 2012; Presentation - Healthy ageing and medicines - European Medicines
...www.ema.europa.eu/docs/en_GB/document_library/.../2012/.../WC500125120.pdf

21. “To care for those who once
cared for us is one of the
highest honours.”