GENERAL PRESCRIBING

GUIDELINES FOR
GERIATRIC PATIENTS….

PRESENTED BY : ASHITHA GOWDA M S

OBJECTIVES

• INTRODUCTION
• EPIDEMIOLOGY OF AGING
• HUMAN AGING
• PHARMACOKINETICS DRUG CHANGES
• PHARMACODYNAMICS DRUG CHANGES
• CLINICAL GERIATRICS
• DRUG RELATED PROBLEMS
• PROVISION OF COMPREHENSIVE
• CONCLUSION
 INTRODUCTION

• Older patients have a higher prevalence of chronic and multiple illness and
physiological changes associated with ageing may act as illness.
• They are more likely to be prescribed medication by their doctors and to take
multiple agents .
EPIDEMIOLOGY OF AGING

• The older American population is very diverse and heterogenous with respect to health status .
The demographics and health characteristics of persons aged 65 to 74 years are different from
those of persons 85years of age and older.
• It is teasing apart the various threads of wellness and illness, independence and dependence,
and function and dysfunction that makes the available demographic and health status data
relevant for clinical practice.
• Understanding this diversity and growth of the older population will allow society to plan for
training, research, and resource needs necessary for future clinical practice and adequate health
care.
EPIDEMIOLOGY OF AGING

• In 2000, persons aged 65 or older accounted for 12.4% (35 million) of the total U.S
population. Of those over 65years of age, women outnumbered men and accounted
for 58% of this segment of the population.
• However, the number of persons aged 85 years and older will further increase by
2050 to 5% (19 million ) of the total U.S population.
• The increase in the number of older persons is not just due to the post World War II
birth rate but also to a declining mortality rate and overall better health among
elders.
EPIDEMIOLOGY OF AGING

• The decline in early death and better health of older adults arise for a variety of
reasons :
1. Public health measures affecting all age groups. Ex: ( immunizations, prenatal
care)
2. Advances in medical procedures and drugs.
3. Promotion of a healthy lifestyle, and
4. Improvements in social living conditions .
EPIDEMIOLOGY OF AGING

• In 2000, white women 65 years of age can expect an average additional 19.2
years of life ; black women, 17.4 years ; white men, 16.3 years ; and black
men, 14.5 years.
• Today, if a person survives to age 85 , he can expect to live another 5-6 years
and she 6-7 years.
EPIDEMIOLOGY OF AGING

• An important goal in care of older adults is to maintain independence and avoid

the need for institutionalization for as long as possible.
• Functional loss or disability is often a final common pathway of most clinical
problems in older persons, especially in those over 75.
• A chronic conditions , defined as an illness or impairment that cannot be cured, is
often the cause of disability in the elderly. The older population compared with
younger persons is more affected by chronic conditions for several reasons.
EPIDEMIOLOGY OF AGING

1. The types of chronic conditions common among older persons tend to be

more disabling (ex: arthritis, heart disease).
2. The conditions become more severe with aging and
3. Several conditions are likely to be present.
HUMAN AGING

• There is a progressive functional decline in many organ system with advancing age.
• Age-associated physiologic changes may cause reductions in functional reverse
capacity (the ability to respond to physiologic challenges or stresses) and the ability
to preserve homeostasis, thus making an elder susceptible to decomposition in a
stressful situation.
• A number of age related physiologic changes occur that potentially could affect drug
pharmacokinetics and pharmacodynamics
ORGAN SYSTEM MANIFESTATION
Body compostion Decrease in total body water
Decrease in lean body mass
Increase in body fat
Decrease in serum albumin
Increase in alpha1-acid glycoprotein (increased by
several disease states)
Cardiovascular Decrease in myocardial sensitivity to beta-
adrenergic stimulation
Decrease in baroreceptor
Decrease in cardiac out put
Increase in total peripheral resistance
Central nervous system Decrease in weight and volume of the brain
Alterations in several aspects of cognition
Endocrine Thyroid gland atrophies with age
Increase in incidence of DM, thyroid disease
menopause
Gastrointestinal Increase in gastric pH
Decrease in GI blood flow
Delayed gastric emptying
Slowed instetinal transit
Genitourinary Atrophy of the vagina due to decreased estrogen
Prostatic hypertrophy due to androgenic hormonal
changes
Age-related changes may predispose to
incontinence
Immune Decrease in cell mediated immunity

Liver Decrease in liver size

Decrease in liver blood flow
Oral Altered dentition
Decrease in ability to taste sweetness, sourness, and
bitterness
Pulmonary Decrease in muscle strength, chest wall
compliance, total alveolar surface, vital capacity,
maximal breathing capacity.
Renal Decrease in GFR, renal blood flow, renal mass,
tubular secretion function.
Increase in filteration fraction
Sensory Decrease in accommodation of the lens of the eye,
causing farsightedness presbycusis ( loss of
auditory acuity)
Decrease in conduction velocity

Skeletal Loss of skeletal bone mass (osteopenia)

Skin / hair Skin dryness, wrinkling, and changes in

pigmentation, epithelial thinning, loss of dermal
thickness
Decrease in number of hair follicles and
melanocytes in the hair bulbs
ALTERED PHARMACOKINETICS
• ABSORPTION
I. Most of the drugs are given orally, and thus a number of the age related changes in GI physiology potentially could
affect the absorption of medications.
II. Fortunately, most drugs are absorbed via passive diffusion, and age –related physiologic changes appear to have little
influence on drug bioavailability.
III. Few drugs require active transport for their absorption, and thus their bioavailability may be reduced (ex: calcium in
the setting of hypochlorhydria).
IV. However, there is a evidence for a decreased first pass effect on hepatic or gut wall metabolism that results in
increased bioavailability and higher plasma concentrations of drugs such as propranolol and morphine.
V. increased drug bioavailability also may be seen with the concurrent ingestion of grapefruit juice. constituents of this
product inhibit cytochrome P450 isoenzyme 3A4, thus decreasing in first pass metabolism and resulting in
exaggerated pharmacologic effects.
• DISTRIBUTION
a. The distribution of medications in the body mainly depends on factors such as
blood flow, plasma protein binding, and body composition, each of which may be
altered with age.
b. The major plasma proteins to which medications can bind are albumin and alpha1-
acid glycoprotien (AAG), and concentrations of these proteins may change with
concurrent pathologies seen with increasing age.
c. For acidic drugs such as naproxen, phenytoin, tolbutamide,and warfarin, decreased
serum albumin may lead to an increase in free fraction.
d. An increase in AAG induced by burns, cancer, inflammatory disease or trauma may
lead to a decreased free fraction of basic drugs such as lidocaine, propranolol,
quinidine, and imipramine.
• METABOLISM
• The liver is the major organ responsible for the drug metabolism including phase I and phase II
reactions.
• The most remarkable characteristics of liver function in the elderly is the increase in the
interindividually variability compared with other age groups.
• Recent data suggest that age-related declines in phase I metabolism (hydroxylation, dealkylation) are
more likely the result of reduced liver volume rather than reduced hepatic enzymatic activity. Decreased
phase I metabolism producing decreased drug clearance and increased terminal disposition half-life has
been reported in elders for medications such as diazepam, piroxiam, theophylline, and quinidine.
• Phase II metabolism (ex: glucuronidation, acetylation) of medications such as lorazepam and oxazepam
appear to be relatively unaffected by advancing age.
• Hepatic enzyme induction (ex: by rifampin, phenytoin) or induction (ex: by fluoroquinolone and
macrolide antimicrobials, cimetidine) does not appear to be affected by aging process.
ELIMINATION
Renal excretion is the final route of elimination for many drugs.
Although age-related reductions in GF are well documented,the normal elder people have no reduction, as measured
by creatinine clearance.
The estimation of creatinine clearance , although not entirely accurate in individuals, can serve as a useful screening
approximation.one of the most commonly used equations is ,
creatinine clearance= (140-age in yrs) (actual body weight in kg) /
72 (serum creatinine in mg/dl)
For females, multiply this result by 0.85.
Medications for which there is evidence of age-related reduction in renal and total body clearance include :
amantadine, aminoglycosides, atenolol, captopril, digoxin.
Some hepatically metabolised medications are N-acetyprocainamide, normeperinide, and morphine-6-glucuronide,
which can accumulate with advancing age owning to reduced renal function
AGE RELATED CHANGES IN DRUG PHARMACOKINETICS

Pharmacokinetic phase Pharmacokinetic parameters

GI absorption Unchanged passive diffusion and no change in
bioavailability for most drugs
Decrease in active transport and increase in
bioavailability for some drugs
decrease in first pass extraction and increase in
bioavailability for some drugs

Distribution Decrease in V of distribution, increase in plasma

concentration of water soluble drugs
Increase in volume of distribution, increase in
terminal deposition of t ½ for fat soluble drugs
Hepatic metabolism Decrease in clearance and increase in t ½ for some
oxidatively metabolized drugs and of drugs with
high hepatic extraction ratios.
Renal excreation Decrease in clearance and increase in t ½ of renally
eliminated drugs and active metabolites
 ALTERED PHARMACODYNAMICS
• There is some evidence in the elderly of the altered drug response or sensitivity.
• 4 possible mechanisms have been suggested, they are :
1. Changes in receptor number
2. Changes in receptor affinity
3. Postreceptor alterations
4. Age-related impairment of homeostatic mechanisms.
For example, muscarinic, parathyroid hormones, beta-adrenergic, and alpha-1 adrenergic receptors exhibit reduced density
with increasing age.
• Independent of pharmacokinetics alterations, the elderly are more sensitive to the CNS effects of benzodiazepines.
• The elderly also exhibit a greater analgesic responsiveness to opiods when compared with their younger counterparts.
• In addition, the elderly demonstrate an enhanced responsiveness to anticoagulants such as warfarin and heparin and also
thrombolytic therapy.
• In contrast, the elderly exhibit decreased responsiveness to certain drugs like antagonists.
• For some drugs like calcium channel blockers , enhanced responsiveness as demonstrated by greater reduction in BP and
decreased responsiveness as demonstrated by reduced atrioventricular nodal blockade ; can occur simultaneously in elder.
 CLINICAL GERIATRICS
• Maintenance of independence and prevention of disability are primary goals in the
clinical care of persons 65 years of age or older.
• To achieve these goals, it is necessary that all health care professionals understand the
concept of functional status.
• ADLs [ activities of daily living ] and IADLs [ instrumental activities of daily living ].
• One of the challenges of maintaining and improving functional status in geriatric
individuals is recognising and managing conditions frequently seen in older adults.
• Problems found more commonly in older persons sometimes referred to as the ‘I’s of
geriatrics.
The ‘i’s of geriatrics : common problems in the
elderly
Immobility Instability

Isolation Intellectual impairment

Incontinence Impotence

Infection Immuno deficiency

Inanition Insomnia

Impaction Iatrogenesis

Impaired sense
• Another factor contributing to the challenge of clinical geriatrics is that
approximately 50% of older patients present with atypical symptoms or
complaints, making it difficult to use the classic medical model for diagnosis.
• Multiple coexisting chronic illnesses are another common threat to independence
that distinguishes the elderly from younger patients . It is not unusual for elderly
patients to have multiple comorbidities such as osteoarthritis, heart disease and
diabetes. Although multiple comorbidities can have a substantial impact on a
patient’s functional status, the mere existence of multiple diseases alone does not
determine functional impairment.
Atypical Disease Presentation In the Elderly

Disease Presentation

Acute myocardial Only about 50% present with chest pain. In general, the elderly present with
infarction weakness, confusion, syncope, and abdominal pain; however,
electrocardiographic findings are similar to younger patients.

Congestive heart failure Instead of dyspnea, the older patient may present with hypoxic symptoms,
lethargy, restlessness, and confusion.

Gastrointestinal bleed Although the mortality rate is about 10%, presenting symptoms are
nonspecific, ranging from mental status change to syncope with
hemodynamic collapse. Abdominal pain is often absent.
Disease Presentation

Upper respiratory Older patients typically present with lethargy, confusion, anorexia, and
infection decompensation of a preexisting medical condition. Fever, chills, and a
productive cough may or may not be present.

Urinary tract infection Dysuria, fever, and flank pain may be absent. More commonly, the elderly
present with incontinence, confusion, abdominal pain, nausea/vomiting,
and azotemia.
DRUG RELATED PROBLEMS IN THE ELDERLY

• Although medications used by the elderly can lead to improvement in HRQOL, negative
outcomes owing to drug-related problems are considerable. Three important and
potentially preventable negative outcomes owing to drug-related problems that can occur
in the elderly are adverse drug withdrawal events (ADWEs), which are clinically
significant sets of symptoms or signs caused by the removal of a drug ; therapeutic failure
(inadequate or inappropriate drug therapy and not related to the natural progression of
disease); and adverse drug reactions (ADRs), defined as a reaction that is noxious and
unintended and which occurs at dosages normally used in humans for prophylaxis,
diagnosis, or therapy
RISK FACTORS

• A number of factors are believed to increase the risk of drug related problems
in the elderly, including suboptimal prescribing (e.g., overuse of medications
or polypharmacy, inappropriate use, and underuse), medication errors (both
dispensing and administration problems), and patient medication
nonadherence (both intentional and unintentional). The following subsections
address suboptimal prescribing and medication nonadherence, the most
common problems.
1.OVERUSE

• Polypharmacy can be defined as either the concomitant use of multiple drugs

or the administration of more medications than are indicated
clinically.Polypharmacy is common and increasing among the elderly.
Multiple medication use has been strongly associated with ADRs.
Polypharmacy is also problematic for elderly patients because it may
increase the risk of geriatric syndromes (e.g., falls, cognitive impairment),
diminished functional status, and health care costs.
2. INAPPROPRIATE PRESCRIBING

• Inappropriate prescribing can be defined as prescribing of medications outside the

bounds of accepted medical standards.This phenomenon occurs commonly in elderly
outpatients, as exemplified by one study in which 74% of drugs had atleast one
inappropriate rating based on clinical review applying explicit criteria. Studies using
explicit drug-use review criteria have found that between 7% and 53% of community-
dwelling elders take one or more medications that have a dose, duration, duplication, or
drug-interaction problem. Alternatively, inappropriate prescribing can be defined as
prescribing of drugs whose use should be avoided because their risk out weighs their
potential benefit.
3. UNDERUSE

• An important and increasingly recognized problem in elders is underuse,

defined as the omission of drug therapy that is indicated for the treatment or
prevention of a disease or condition. Underuse may have an important
relationship with negative health outcomes in the elderly, including functional
disability, death, and health services use.The risk from underuse of medication
in general owing to limiting Medicaid patients’ access to medications resulted
in a more than doubling of the risk of admission to a nursing home.
4. MEDICATION NONADHERENCE

• Medication no adherence is a common problem in the elderly.80−82 The

prevalence rate ranges from 40% to 80% of patients (mean of
approximately50%).Overall,the elderly are adherent with about 75% of their
medications.80−82 The elderly have similar adherence to younger patients
when the number of drugs taken by both groups is similar.Infact,there is some
evidence that adherence may be better in elders for some conditions.Gurwitz
and colleagues found that 21% of preventable ADRs in elderly outpatients
were due to errors in patient adherence.
PROVISION ON COMPREHENSIVE
GERIATRIC ASSESSMENT.

• The term comprehensive geriatric assessment has been applied to geriatric

evaluation and management (GEM), in which GEM clinicians manage the
patient, and to consultative geriatric assessment, in which the geriatric
multidisciplinary team makes recommendations to other clinicians for
management of the patient. The following subsections provide an approach
to how pharmacists in any practice setting can optimize medication use
through the provision of comprehensive geriatric assessment.
History taking
Assessing and monitoring drug therapy
Documenting problems and formulating a therapeutic plan
Consulting the physicians regarding problems and concerns
Counselling and adherence aids
Documenting interventions and monitoring patients
progress
Targeting High-risk elderly
1. HISTORY TAKING
• Several potential difficulties may occur while taking medication
histories from the elderly. They include
• communication problems (impaired hearing and vision),
• underreporting(health beliefs, cognitive impairment),
• vague or nonspecific symptoms (altered presentation),
• multiple diseases and medications,
• reliance on a caregiver for the history, and
• lack of medical records to confirm finding
2. ASSESSING AND MONITORING DRUG THERAPY
• The appropriateness of each prescribed medication should be assessed using a
variety of methods. One standardized measure that has demonstrated reliability and
validity is the Medication Appropriateness Index (MAI).
(1) suboptimal medication choice (based on effectiveness, safety, cost, and effects on
HRQOL),
(2) allergy (especially for new prescriptions),
(3) under treatment, and
(4 ) drug interactions with food or laboratory tests.
Some additional factors to consider during drug regimen review include adherence,
medication storage problems, laboratory monitoring, therapeutic end points, and ADRs.
3. DOCUMENTING PROBLEMS AND FORMULATING A
THERAPEUTIC PLAN
• The clinician must document the problems that have been detected,
develop a therapeutic plan to resolve them, and establish reasonable
therapeutic end points if these have not been set already. An important
point to remember is that what may be a reasonable end point for a 40-
year-old patient may not be as reasonable for an 80-year-old person.
• when comorbidities, functional status, and life expectancy are taken into
consideration.
4. CONSULTING THE PHYSICIAN REGARDING PROBLEMS AND
CONCERNS
• In some cases, the pharmacist or other health care professional must contact a
patient’s physician regarding problems and concerns that have been detected
and documented. In discussing the patient in this context, the importance of
optimizing the prescribing for elderly patients before implementing strategies to
enhance their adherence cannot be overstressed. Otherwise, the adherence
intervention, if effective,may result in patient harm. Similarly, in institutional
settings, strategies to reduce medication administration errors may not improve
patient outcomes if prescribing is not improved before hand.
5. COUNSELING AND ADHERENCE AIDS
• Some general factors to consider, before medication dispensing, to enhance adherence in the
elderly include modifying medication schedules to fit patients’ lifestyles, considering generic
agents to reduce costs, using easy-to-open bottles and easy-to-swallow dosage forms, and using
larger-type direction labels and auxiliary labels. When dispensing medications (in particular, new
medications or old ones that have changed in appearance or directions for use), both written and
oral drug information should be provided to the patient and caregiver. To improve the likelihood of
adherence, the health care professional also should recruit active patient and caregiver
involvement, stress the importance of adherence, and consider the use of adherence enhancing aids
(e.g., special packaging, a medication record, a drug calendar, medication boxes, magnification for
insulin syringes, dose measuring devices, and spacers for metered-dose inhalers). In institutional
settings, discussion of special considerations (e.g., medications that can be crushed and given via
feeding tube) with health care professionals responsible for medication administration is also
prudent.
6. DOCUMENTING INTERVENTIONS AND MONITORING PATIENT
PROGRESS
• All interventions must be documented, and the steps just outlined must be
repeated overtime with elderly patients. During follow-up contacts,
minimum inquiry should include questions as to whether the patient has any
questions or concerns regarding medicines and determining whether the
therapeutic end points previously established have been achieved. Moreover,
ask patients whether they are or have recently experienced any side effects,
unwanted reactions, or other problems with their medications to assess
potential ADRs.
7. TARGETING HIGH-RISK ELDERLY
• In busy practices, the approach outlined here may not be feasible for every patient. Therefore,
practitioners may consider targeting these activities to patients at high risk for developing drug-related
problems. Geriatric experts have identified 18risk factors for drug-related problems in elderly nursing
home patients. These include the following medication-related factors:
(1) polypharmacy(e.g.,9 or more medications or 12 or more doses per day),
(2) taking specific high-risk drugs (e.g., intermediate- and long-half-life benzodiazepines, sedative hypnotic
agents, antipsychotic drugs, anticholinergic medications, opioid analgesics, and chlorpropamide),
(3) certain patient characteristics (e.g., low body weight, age 85 years or older, and decreased renal
function),
(4) use of narrow-therapeutic-range drugs(e.g.,lithium, digoxin, warfarin, and anticonvulsants), (5) a
history of a prior ADR, and
(6) presence of six or more illnesses. The applicability of these criteria to elderly persons in other care
settings and the relationship between identification of elderly patients with these potential risk factors and
actual health outcomes remain to be determined.
 CONCLUSION
• The number of people older than age 65 years is growing in the United States and around
the world, and the fastest growing segment of the American populationis those over age 85.
• A number of physiologic changes with age affect pharmacokinetics and pharmacodynamics
of drugs, especially hepatic metabolism and renal excretion.
• Improving and maintaining functional status and managing comorbiditiesare hallmarks of
clinical geriatrics.
• Certain medical conditions are restricted to the elderly, and drug-related problems represent
a major concern for this group.
• Innovative approaches, such as the provision of comprehensive geriatric assessment by
pharmacists and other health care professionals,are needed to decrease the occurrence of
these drug-related problems.
Thank you