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Medications in the elderly

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.

Health & Medicine◦
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Old Age•
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Dr. D. K. Brahma Associate Professor Department of Pharmacology NEIGRIHMS, Shillong
 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
 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
 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
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
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
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)
 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
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
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
Adverse drug events (ADEs) Drug interactions Duplication of drug therapy Decreased quality of life Unnecessary cost Medication non-adherence
 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
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
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.
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.
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
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
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
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
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
“To care for those who once cared for us is one of the highest honours.”