Principles of Geriatric

Drug Therapy

Prof. Anita Ocampo - So, MD, DPBA, FPSA, FPSP, MHA

Pamantasan ng Lungsod ng Maynila, College of Medicine
Objectives
1. Understand the principles of Geriatric drug therapy
2. Discuss and review
• predictors for adverse drug events in the elderly.
• pharmacodynamics and the effects of aging.
• criteria for appropriate prescribing in the elderly.
RATIONAL DRUG USE
Rational use of medicines requires that “patients receive medications
appropriate to the clinical needs, in doses that meet their own
individual requirements, for an adequate period of time, and the lowest
cost to them and their community”
World Health Organization
RATIONAL MEDICATION
• Rational medication prescribing dictates that the fewest medications
be used to achieve the therapeutic goals as determined by the
clinician and patient
Taskem,M.,Teal.
J Drug Del. & Therap.
OPTIMAL PHARMACOLOGY
Balance between over prescribing and under prescribing.
• Correct drug
• Correct dose
• Targets appropriate condition
• Is appropriate for the patient
• Avoid “A pill for every ill”
• Always consider non-pharmacologic therapy
Definition
1. Senior
2. Elderly
3. Geriatrics
Predictors of Adverse Drug Events

• > 4 prescription medications

• Length of stay in hospital > 14 days
• > 4 active medical problems
• Admission to general medical unit
• History of alcohol use
• Lower mean MMSE score
• 2-4 new medications added during hospitalization
Pharmacokinetics and Aging

• Behavior of drugs in the body

• Absorption, distribution, metabolism, elimination

• Removal of drugs from the body is slowed

Absorption
• Increased GI pH
• Calcium carbonate, this is bought OTC by the patients

• Slower gastric motility/emptying

• Increased fat/decreased muscle

• Transdermal, IM, SQ

• Dysphagia may potentially alter absorption

Overall, extent or rate of absorption not significantly altered

Distribution

• Increased Vd for water soluble drugs

• in body fat

•  in serum proteins
Metabolism

• Drugs with a high extraction ratio (ER)

• Decreased clearance:
• reduced hepatic blood flow
• reduced liver mass
High Extraction
• Examples of high ER drugs with decreased clearance:

• Meperidine, morphine
• Metoprolol, propranolol
• Amitriptyline, nortriptyline
• Verapamil
Metabolism
• Decreased oxidative (phase I, P-450) metabolism
due to reduced liver volume and perfusion.

• Diazepam, piroxicam, theophylline,

quinidine
• Confounded by smoking, diet, drug
interactions, race, sex, and frailty
Renal Elimination

• Identify the drug below that is renally excreted

more slowly in elderly adults than in young adults.

• Celecoxib
• Gabapentin
• Morphine
• Sertraline
Renal Elimination
Decrease in:

• Kidney mass
• Nephron size and number
• Renal blood flow
• Tubular secretion
• Glomerular filtration rate
Pharmacodynamics and Aging
• Some effects are increased
• alcohol increases drowsiness and lateral sway
• e.g. diazepam, morphine, theophylline

• Some effects are decreased

• diminished HR response to b-blockers
Risk Factors for Drug Related Problems in the Elderly

• Suboptimal prescribing

• Medication Errors

• Medication none adherence

Medication Appropriateness Index
1. Is there an indication?
2. Is the medication effective for the condition?
3. Is the dosage correct?
4. Are the directions correct?
5. Are the directions practical?
6. Are there clinically significant drug-drug interactions?
7. Are there clinically significant drug-disease interactions?
8. Is there unnecessary duplication?
9. Is the duration of therapy acceptable?
10. Is this drug the least expensive alternative?
Additional Criteria for Drug Use
• Compatible safety and side effect profile

• Low risk of drug/nutrient interactions

• T1/2 < 24h with no active metabolites

• No adjustments for renal/hepatic function

• Strength/dosage form match recommendations for

older adults
Newer Drugs
• What is unique about the new drug?
• Is clinical data available?
• How does it compare with traditional therapy?
• Cost?
• Coverage by third party payers?
• Does potential advantage justify risk of new drug?
How to Prescribe Appropriately
1. Obtain complete drug history
2. Avoid prescribing prior to diagnosis
3. Review medications regularly
4. Know actions, adverse effects, toxicity
5. Start at low dose and titrate
6. Try not to start two drugs at the same time
7. Reach therapeutic dose before switching/adding
8. Consider non-pharmacological alternatives
How to Prescribe Appropriately
9. Educate patient/caregiver
10. Use one drug to treat two conditions
11. Keep regimen as simple as possible
12. Caution with combination products
13. Communicate with other prescribers
14. Avoid drugs from same class/similar actions
15. Avoid one drug to treat side effect of another
Drug 1

Adverse drug effect

misinterpreted as new
medical condition

Drug 2

Adverse Drug
Effect

Prescribing Cascade
 Underprescribing

Overprescribing

Optimize Drug Therapy

Drug-Food Interactions
• Warfarin and vitamin K
• Methotrexate and folate
• Phenytoin and vitamin D metabolism
• Impact on appetite
• taste alteration
• decreased saliva production
NSAIDs
• Side effects
• GI hemorrhage
• Decline in GFR

• Decreased effectiveness of diuretics and

antihypertensives

• For mild OA, use acetaminophen

Anticipate Side Effects
• Narcotics
• begin stimulant laxative
• Steroids
• osteoporosis prevention
• hyperglycemia
Potential Barriers to improving Adherence
• Poor attitude • Denial
• Memory deficits • Fear or
• Language embarrassment
• Literacy • Side effects
• Cultural beliefs • Religious beliefs
• Alternative health • Unable to “see”
beliefs results of drug therapy
• Poor support • Lack of choices
• Pride • Cost

Vermiere E, et al. J Clin Pharm Ther. 2001;26:331-342.

Factors Influencing Ability to Comply
•  3 chronic conditions
• > 5 prescription medications
•  12 medication dosages per day
• Regimen changed  4 times in past 12 months
•  3 prescribers
• Significant cognitive or physical impairment
• Living alone in community
• Recently discharged from hospital
• Reliance on caregiver
• Low literacy Medication cost
• Demonstrated poor compliance history
OTC’s
• Elderly takes an average of 2-4 OTC drugs every day

• Laxatives used in 1/3 to 1/2

• NSAIDs, antihistamines, H2 blockers

ALL CAN CAUSE SIDE EFFECTS!

Strategies to Ensure Adherence
• Find out about patient/family expectations; explain
why some may not be met

• Provide information on illness / consequences of

none adherence

• Use a behavioral contract

• Increase motivation by enlisting patient/family in

decision-making process
Strategies to Ensure Adherence
• Ask patient/family to repeat instructions

• Keep directions / labels simple and use lay terms

• Give clear instructions on drug regimen, preferably in

writing

• Emphasize importance of adherence at each visit

• Involve patient’s spouse or partner

MAJOR DRUG GROUPS
A. CNS Drugs
1. Sedative - Hypnotics
2. Analgesics
3. Antipsychotics and Antidepressant Drugs
4. Drugs used in Alzheimer’s Disease
B. CARDIOVASCULAR DRUGS
1. Antihypertensive Drugs
• Hypertension before was treated conservatively but now it is dealt with more vigorously.
• Non-pharmacologic regimen encouraged = life style changes
2. Positive Inotropic agents
• Digoxin – half life is increased by 50% or even more
3. Anti arrhythmic drugs
• Disopyramide should be avoided
• Local anesthetics
C. ANTIMICROBIALS
guiding principles: there is decrease in renal function
and a decrease in liver blood flow and function

D. ANT- INFLAMMATORY DRUGS

1) NSAIDs
2) Corticosteroids
3) Bisphosphonates
E. OPHTHALMIC DRUGS
1) Glaucoma
2) Macular degeneration

E. ANESTHETIC DRUGS
• Lower the dose by one third
The Ten Commandments in Prescribing for the
Elderly
1) Know the pharmacology of the drug to be prescribed, its route of
metabolism and excretion.
2) Use the drug for the correct and absolute indication and only when
necessary for treatment.
3) Simplify the medication regimen to improve compliance and
reduce the likelihood of interactions.
4) Use the lowest possible effective dose.
5) Reduce the number of drugs to be prescribed.
The Ten Commandments in Prescribing for the
Elderly
6) Discontinue all other unnecessary drugs.
7) Inform the patient and responsible companion on the purpose of
the drug, its expected and desired effects and important side-
effects.
8) Write dosage instructions about the prescribed drug/s in legible
print and provide the patient with a copy.
9) Have the patient demonstrate that he/she is able to open the
medication container.
10) NEVER, EVER withhold medication for the simple reason that the
patient is old.
Patient Case
An 82 year old white woman has been having
anxiety due to the anniversary of her husband’s
death. Which one of the following would be the
safest pharmacologic treatment for her anxiety?

• Alprazolam
• Chlordiazepoxide
• Diazepam
• Lorazepam
Renal Elimination

• Identify the drug below that is renally excreted

more slowly in elderly adults than in young adults.

Celecoxib
Gabapentin
Morphine
Sertraline