The document discusses physiological changes with aging and their implications for pharmacotherapy in elderly patients. It notes that aging results in changes to absorption, distribution, metabolism and excretion of drugs. This can increase the risk of adverse drug reactions and interactions due to altered pharmacokinetics and pharmacodynamics. The role of clinical pharmacists is highlighted in optimizing drug therapy for elderly patients by identifying inappropriate prescribing, ensuring proper dosing and monitoring for safety issues like non-compliance and polypharmacy. Guidelines for prescribing in elderly emphasize starting with low doses and simplifying drug regimens.

1. PRESENTED BY
Saniya Shaikh
M. Pharm 2nd semester
Department of Pharmacy practice
S.A.C College Of Pharmacy

2. Contents:
• Introduction
• Physiological changes with aging
• Altered pharmacokinetics (ADME)
• Altered pharmacodynamics
• Adverse drug reactions
• Role of clinical pharmacist in Geriatrics
• Guidelines for prescribing for elder people
• Conclusion
• References

3. INTRODUCTION
• World is ageing faster.
• Life expectancy has increased.
• Proportion of elderly population (>65) is increasing
Between 2000 and 2050: the proportion of the world's population over
60 years will double from about 11% to 22% (from 605 million to 2
billion).
Reasons: improved standard of living with better housing, clean water,
immunization programmes, better medical treatments (especially
drugs).

4. • A specialty of medicine that is concerned with the disease and health
problems of older people, usually those over 65 years of age.
• Ageing may be considered to be the loss of adoptability of an
individual with time.
• For men, life expectancy is 16 yr at age 65 and 9 yr at age 75.
• For women, life expectancy is 19 yr at age 65 and 12 yr at age 75.
• Overall, women live about 5 yr longer than men, probably because
of genetic, biologic and environmental factors.
• These differences in survival have not changed, despite changes in
women’s lifestyle (eg, increased smoking, increased stress).

5. SPECIAL CONSIDERATIONS OF THE ELDERLY AS UNIQUE GROUP
WITHIN THE POPULATION
CONSIDERATION CHARACTERISTICS
Population The elderly (i.e., those older than age 65) currently represent
about 10 % of Indian population
Health The elderly experience a greater incidence of disease, physical
impairments and physiological disorders than young adults
Institutionalization The elderly occupy a greater share of hospital beds (≈ 33%) and
long term care facilities than young adults
Drug use The elderly consume more drugs (≈ 25% of total use) per capita
than young adults
Drug effects The elderly experience a greater incidence of adverse drug
effects and drug-drug interactions than young adults

6. PHYSIOLOGIC CHANGES WITH AGING:
PARAMETER PHYSIOLOGIC CHANGE CLINICAL MANIFESTATION
Body Composition ↓ Lean body mass
↓ Muscular mass
↓ Creatinine production
↓ Skeletal mass
↓ Total body water
↑ Percentage adipose tissue (until age 60,
then until death)
Changes in drug levels
↓ Strength
Tendency toward dehydration

7. PARAMETER PHYSIOLOGIC CHANGE CLINICAL MANIFESTATION
Eyes ↓ Lens Flexibility
↑ Time for pupillary reflexes (constriction,
dilation)
↑ Incidence of cataracts
↑ Glare and difficulty in
adjusting to changes in
lighting,
↓ Visual acuity
Nose ↓ Smell ↓ Taste and appetite
Ears Loss of high frequency hearing ↓ ability to recognize speech
GI Tract ↓ Gastrointestinal blood flow
↑ Gastric pH
Delayed gastric emptying
Slowed intestinal transit
Tendency toward constipation
and diarrhea
Joints Degeneration of cartilaginous tissues
↓ Elasticity
Tightening of joints,
Tendency toward
osteoarthritis

8. PARAMETER PHYSIOLOGIC CHANGE CLINICAL MANIFESTATION
Liver ↓ Hepatic mass
↓ Hepatic blood flow
Changes in blood flow
Kidneys ↓ Renal blood flow
↓ Renal mass
↓ Glomerular filtration
↓ Tubular secretion and reabsorption
Changes in drug levels with ↑
risk of adverse drug effects,
tendency toward dehydration
Endocrine system ↓ estrogen & progesterone secretion
(menopause), ↓ Testosterone secretion,
↓ Growth hormone secretion,
↑ Incidence of thyroid abnormalities
↑ Incidence of Diabetes mellitus
↓ Muscle mass
↓ Bone mass
Changes in skin water
intoxification
Immune system ↓ T-cell function
↓ B-cell function
Tendency toward some
infections and possibly cancer
↓ Antibody response to
immunization or infection

9. PARAMETER PHYSIOLOGIC CHANGE CLINICAL MANIFESTATION
Cardiovascular
system
↓ Intrinsic heart rate and Maximal Heart
rate,
↓ Baroreceptor activity
↓ Diastolic relaxation
↑ Conduction time
Tendency toward syncope
↓ ejection fraction
CNS ↓ Weight and volume of the brain
↓ number of dopamine receptors
Alterations in several aspects of cognition
Tendency to parkinsonian
symptoms
Age-related changes in physiology can affect the pharmacokinetics and
pharmacodynamics of numerous drugs

10. Altered Pharmacokinetics
Absorption:
• Reduce the bioavailability of drugs - depends in active absorption
Ex: 5-flurouracil
• Decrease first-pass effect - increase bioavailability and plasma
concentrations of drugs
Ex: Propranolol, Morphine

11. Distribution:
• Vd-decrease for water soluble and increase for lipid soluble drugs
• Decrease serum albumin-increase free fraction of acidic drugs
Ex: Naproxen, Phenytoin, Tolbutamide and Warfarin
• Increase α1-acid glycoprotein (AAG) - decrease free fraction of basic
drugs
Ex: Lidocaine, Propranolol, Quinidine, and Imipramine

12. Metabolism:
• Reduce liver volume- decrease phase I metabolism (hydroxylation,
dealkylation) - decreased clearance and increased t1/2.
Ex: Diazepam, Piroxicam, Theophylline and Quinidine
• Decrease in liver blood flow - decrease metabolism of high-hepatic-
extraction-ratio drugs.
Ex: Imipramine, Lidocaine, Morphine and Propranolol

13. Excretion:
• Age-related reductions in glomerular filtration-increase plasma
concentration
Ex: Amantadine, Aminoglycosides, Atenolol, Captopril, Cimetidine,
Digoxin, Lithium and Vancomycin

14. Altered Pharmacodynamics
• Altered drug response or “sensitivity” due to
1.changes in receptor numbers,
2.changes in receptor affinity,
3.post receptor alterations and
4.age-related impairment of homeostatic mechanisms
Ex: Muscarinic, Parathyroid hormone, β-adrenergic, α1 -adrenergic, and
µ-opioid receptors exhibit reduced density with increasing age

15. • Elderly are more sensitive to the central nervous system effects of
benzodiazepines
• Greater analgesic responsiveness to opioids
• Enhanced responsiveness to anticoagulants
Ex: Warfarin, and Heparin
• Decreased responsiveness to certain drugs
Ex: β-agonists/antagonists

16. ADVERSE DRUG REACTIONS
• ADR are more common in elderly (20-25% more than in the young).
• They are mostly dose related rather than idiosyncratic.
• Drugs that causes postural hypotension (antihypertensive) ataxia
(benzodiazepines) volume and electrolyte imbalances (diuretics) are
more prone to cause ADR in elderly.
• Polypharmacy results in increased drug interaction, ADR and non
compliance.
• Increase in number of drugs predisposes the patients to drug disease
interaction.
• Β-blocker eye drops for glaucoma may lead to a worsening of asthma
or CCF also called the prescribing cascade.

17. Drug Interactions
• Pharmacodynamic
• Antagonism
NSAIDs + AntiHTN - Reduced AntiHTN effect by sodium retention
• DDIs may have mixed mechanisms
Antipsychotics & antidepressants- lower seizure threshold in epilepsy
• 10% of potential DDI’s are clinically significant
• Indicators of DDIs in elderly
Confusion, lethargy, dizziness, weakness, incontinence, depression and
fall

18. • DDIs of importance in elderly
- Enhanced effect
Drug A Drug B Enhanced effect
ACEIs NSAIDs Nephrotoxicity
Antidepressants Enzyme inhibitors Antidepressant effect
Antihypertensives Vasodilators Antihypertensive effect
Aspirin NSAIDs Peptic ulcer
Carbamazepine Enzyme inhibitors Carbamazepine level
Cyclosporin Enzyme inhibitors Immunosuppression
Digoxin Amiodarone/Diltiazem/Verapa
mil
Toxicity

19. • DDIs of importance in elderly
-Reduced effect
Drug A Drug B Reduced effect
Antidepressants Enzyme inducers Antidepressant effect
Antihypertensives NSAIDs Antihypertensive effect
Calcium antagonists Enzyme inducers Antihypertensive effect
Theophylline/Thyroxine Enzyme inducers Theophylline/Thyroxine
Cyclosporine Enzyme inducers Immunosuppression
Digoxin Cholestyramine Absorption

20. COMPLIANCE
•The extent to which a person behavior coincides with medical advice.
•Types:
Not having prescription filled
Taking the wrong dose
Incorrect time
Forgetting to take a medication
Intentional noncompliance
Ceasing medication so soon

21. Role of clinical pharmacist in Geriatrics
• Inform medical & nursing staff of potential hazards of altered PK/PD,
polypharmacy & poor compliance.
• Recommend avoidance(extra caution) of drugs that have high risk of
problems in elderly.
• Ensure doses are adjusted to age-related changes in PK/PD.
• Involve patient’s family in education about their medications to enable
assistance with managing medications & enhancing compliance at
home.
• Recommend strategies to prevent complications of hospitalization.

22. • Regularly review patients chronic medications
• Ensure an indication for each drug
• Ensure contraindication to any prescribed medication does not exist
(suggest safer alternative)
• Ensure appropriate doses
• Identify ADRs
• Simplify drug regimens
• Avoid sudden withdrawal of sedating medications
• Recommend low dose heparin for DVT
• Short term use of laxatives for those prescribed with opioids

23. GUIDELINES FOR PRESCRIBING FOR ELDER PEOPLE
Start low, Go slow
• Appropriate treatment requires adequate clinical assessment and accurate
diagnosis
• Problem oriented prescribing i.e., treat only the disorder that need to be
treated
• Keep drug regimens as simple as possible
• Where possible predetermine the duration of treatment and communicate
this to the patient
• Use low doses and increase slowly
• Avoid polypharmacy

24. • Consider potential drug interactions
• Provide patients with clear instructions both verbal and in writing
• Review patients and their medications regularly
• If in doubt, don’t prescribe
• Regularly review patient’s medications and cease those not required
• Regularly review patient’s medication adherence

25. Conclusion:
• Successful pharmacotherapy means using the correct drug at the correct
dose for the correct indication in an individual patient.
• Age alters PK & PD.
• Polypharmacy is prescribing more than 5 drugs at the same time.
• ADRs and Drug interactions are common among the elderly because of
polypharmacy.
• These can be minimized by appropriate prescribing and avoid
polypharmacy.

26. References:
1. Dipiro JT, Talbert RL, Yee GC. Pharmacotherapy: a pathophysiologic approach
Seventh Edition, Chapter: Geriatrics Pg.no:57
2. Milton JC, Hill-Smith I, Jackson SH. Prescribing for older people. BMJ. 2008
Mar 15;336(7644):606-9.
3. Holbeach, Edwina & Yates, Paul. (2010). Prescribing in the elderly. Australian
family physician. 39. 728-33.
4. https://www.slideshare.net/drshama65/geriatric-medicine
5. https://www.slideshare.net/drdhriti/prescribing-medications-in-the-elderly

27. Thank you for your kind listening…