10th Annual Mini Medical School

GERIATRICS

Caring for our Aging Population

Pharmacology Considerations in
the Elderly
Common Concerns with the use
of Medications
Roger Hefflinger, Pharm.D.
Associate Professor
Idaho State University
College of Pharmacy
Family Medicine Residency of Idaho

Disclosure
I have no fiscal connections to disclose with
any of the manufactures of medications
discussed during this presentation

Objectives:
Upon completion of this presentation the
audience member shall be expected to:
Recognize changes in the elderly that may
contribute to medication adverse events
Identify classes of medications that are more likely
to have adverse events in the elderly
Organize therapy plans for appropriate
management of various disease states in the
elderly
Modify existing therapy plans for more effective
and potentially safer disease state management

The Life-Span
Fetal Development
First Trimester
Second Trimester
Third Trimester

Gestational Issues
Perinatal Issues
Infant
Toddler
Adolescent

Puberty
Adult
Organ System Failure
Renal
Liver

Geriatrics
End of Life
Hospice Care

What Factors Most Affected

Pharmacokinetics of Medications:
Dissolution
Stomach acid, motility, affect product delivery

Absorption
Stomach acid inc/dec effect, concurrent medications

First Pass Metabolism

Genetic inc/dec, enzyme inducers, enzyme inhibitors

Distribution
Protein binding, albumin stores, fat stores

Elimination
Gut, liver, renal function

What are realistic goals of

medication administration
Stop the disease process
Cancer chemotherapy, Antibiotics

Slow the progression of the disease

High blood pressure, Diabetes, Depression

Minimize the symptoms of the disease

COPD, Pain,

Minimum amount of side effects

In the most cost effective manner

What is Acceptable Risk

Food and Drug
Administration
Phase 1 drug trials
Phase 2 drug trials
Phase 3 drug trials
Drug approval
Drug release
Post marketing adverse
event reporting

Side Effects:
Pick an organ system
Central Nervous System
Cardiovascular System
Heart, Blood vessels

Respiratory System
Hepatic (Liver)
Renal (Kidney)
Gastrointestinal
Skin
Bone Marrow

Central Nervous System

Drowsiness
Dizziness
Ringing in ears
Confusion
Depression
Psychosis

Elderly:
Altered sleep patterns
More easily sedated
More likely to get
dizziness
Underlying vertigo

Changes in brain wire

chemistry as age
Decrease in brain mass
as age
Cerebral atrophy

Cardiovascular System

Heart block
Elderly more likely to:
Have more medications
Arrhythmias
that can become
High blood pressure
additive in CV SE
Low blood pressure
Heart becomes more
sensitive to ischemia
Angina
Beta receptors decrease
Heart Failure
in elderly
Edema
Altered sympathetic
nervous system tone

Respiratory System
Shortness of breath Elderly more likely to:
Pulmonary scaring
Have either long
Pulmonary fibrosis

standing asthma or if
smoking history COPD
May also have anemia
Decrease in red blood
cells = carry oxygen
around the body
More sensitive to
decrease in oxygen drops

Altered Organ System Function

Liver dysfunction
Much more to follow

Long standing alcohol

may affect livers ability
to metabolize and clear
medications

Renal dysfunction
It is a normal part of
aging to have a gradual
decline in the kidneys
ability to filter and
excrete
Many drugs are
eliminated in the urine
Many drugs affect the
ability to urinate

Gastrointestinal System

Nausea
Vomiting
Diarrhea
Constipation
Abdominal Cramping
Peptic ulcer disease

Elderly more likely to:

Have less protective
mucus in stomach
More sensitivity to
medications

Less nerve innervation of

the intestinal tract
= more diarrhea or more
common more
constipation

More SE if on
medications and get viral
infections

Adult Medicine
All medications are formulated for effective
dosing in the Normal adult population
Very general rule- Lower tablet strengths
availability is/are generally acceptable starting
dose for desired action
Citalopram: 10,20, 40 mg- 10 mg HS good start
HCTZ: 12.5, 25, 50 mg- 12.5 mg q d good start

At what individual risk?

Every patient has the right to refuse a
medication if they feel the risk is too great
Back to goals of therapy
If you are going to refuse all medications that are
offered why are you here?- rgh

Example Package Insert

Adult Medicine
Drugs with a Narrow Therapeutic Window
deserve to be monitored.
Digoxin Lanoxin
Levothyroxine Synthroid, Levoxyl
Warfarin Coumadin
Sodium channel blocker for seizure disorder
Enzyme inducers and inhibitors- look for interactions!
Birth Control lose of efficacy

Monitor for established drug levels

For Bipolar?, Migraine?, Depression?, Psychosis?

Adult Medicine Drug Interactions

Substrates- metabolized this route

Adult Medicine Drug Interactions

Inhibitors- Stop the metabolism

Adult Medicine Hepatic Impairment

You need to destroy 95% of your hepatocyte
function before you start to lose medication
clearing ability
Transaminitis:
AST/ALT elevations- Most drugs with transiently
elevate

Liver Function INR- synthetic marker of clotting factor production

Auto anticoagulated- other drugs contribute bleed risk?

Albumin- synthetic
Alter distribution of protein bound medications

Potentially Clinically Significant

Benzodiazepines for etoh withdrawal
Short Acting:
Lorazepam
Ativan
Oxazepam
Serax
Alprazolam
Xanax

Adult Medicine Renal Impairment

Cockcroft and Gault
Normal GFR
100-130

Obligated to look GFR

Metformin
Contraindication:
SrCr > 1.5 men
SrCr> 1.4 Women
CrCl <60

60

Most drugs need GFR dosing adjustment

30

Most All drugs need renal dosing

15

Adult Medicine Significant

Interactions
Lithium
Very effective under
used
Short yet significant list

NSAIDs
Diuretics
ACEs, ARBs,
Lithium toxicity may be
fatal

MAO-Inhibitors
Parkinsons
Selegiline Eldepryl
Transdermal Emsam
Rasagiline Azilect

REFRACTORY Depression
Parnate
Nardil
Marplan

Anti- MRSA antibiotic

Linezolid Zyvox

Geriatric Medicine
Lean mass declines
Sarcopenia, decrease
strength, mass
Andropause?
Androgen replacement
therapy males?

Fat deposits increase

Alterations of fat
deposited medications
Lipophilicity
Altered loading doses

Gastrointestinal PH
changes

B-12 deficiency
Folate deficiency
Iron deficiency
Drug induced?
PPI

Albumin decreases
Less protein binding
More free drug = toxicity

Less balance
Falls- drug induced dizzy

Geriatric Medicine Beers List

http://www.fmda.org/beers.pdf
Comprehensive list of every medication that may
cause ADR in elderly patients

Collective Overconsumptionrgh
2 Distinct different phenomenon
#1- Tipping over the edge
Poly-pharmacy and the latest dosage change of
medication addition causes the patient adverse
events
Make small dosing changes and only 1 drug
change at a time

#2- Oh my goodness- Loved one is on TOO

MANY medications
When you break it down individually- they are not

Geriatric Medicine
Fixed income concerns:
If you have a sample in your office- it is not
inexpensive
Co-pay waivers
Actual costs health plan

What disease can you not manage

generically?
Price matching education
Every chain will price match if the PATIENT asks
Does not work if they have insurance
Less than co-pay?

Elderly Medicine: Bone Health

Bisphosphonates
Alendronate
Fosamax PO

Abandronate
Boniva PO

Risedronate
Actonel PO

Zoledronic Acid
Reclast IV

Women are 4 times

more likely to develop
osteoporosis than men
77% of women who are
osteoporotic are
undiagnosed

1 in 3 women will
develop a fracture
1 in 8 men will develop
a fracture
Dont forget the Calcium 1500 mg a day
And the Vitamin D- 400-800 units a day!

Elderly Medicine Arthritis = Pain

Osteoarthritis

Rheumatoid Arthritis
Wear and tear
Inflammatory disorder
Knees, Hips, Feet
characterized by the body
Decrease in the
attacking itself and eating
softness of the
up the meniscus, cartilage,
meniscus resulting in
and eventually bone
thinning, tearing of
Treatment:
tissue
Analgesics
Treatment:
Disease Modifying Agents
Analgesics

Immune modulating agents

How do we measure efficacy?

Drug A Better than Drug B

TOPAR
Total Pain Reduction 4 hours, 8 hours, 12 hours

How do we measure functionality

Range of motion
With or without pain

Specific disease state

assessments

RA
Osteoarthritis
Back Pain
Neuropathic

Quality of Life

First Line Therapy:

Acetaminophen
= Tylenol
Scheduled improves
pain
Does not relieve
swelling

Hepatic Toxin
NMT 4 Grams Total/day
Blood Pressure?
Overdose

 Propionic Acid
Ibuprofen

Clinoril

Motrin et al

Fenprofen

Indocin

Ketoprofen

Tolectin

Voltaren,
Arthrotec

Anaprox RR
Naprelen SR
Ansaid

Oxaprosin Daypro

Phenylacetic acids
Diclofenac Sodium

Naproxen Sodium

Flurbiprofen

Pyrole acetic acid

Tolmentin

Naproxen HCL
Naprosyn
EC Naprosyn

Indole acetic acid

Indomethacin

Nalfon
Orudis
Oruvail

Indene acetic acid

Sulindac

Diclofenac Potassium

Cataflam

Miscellaneous
Ketorolac Toradol

Fenamates:
Mefanamic Acid
Ponstel

Meclofenamate
Meclomen

Oxicams:
Piroxicam
Feldane

Meloxicam Mobic
Pyranocarboxylics
Etodolac
Lodine
Etodolac XR

Napthylakanones:
Nabumetone
Relafen

COX-2 Inhibitors Pain

Rofecoxib: Vioxx
Osteoarthritis:
12.5-25 mg q day

Acute Pain:
25-50 mg q day
> Celecoxib
= to Ibuprofen

Celecoxib:

Celebrex

Osteoarthritis:
100-200 mg q day

Rheumatoid Arthritis:
100-200 BID
(400 BID)

Meloxicam: Mobic
Osteoarthritis:
7.5-15 mg q day

Is it selective?

Valdicoxib Bextra
10 mg
20 mg

Additional Options of Analgesia

Acetaminophen = Tylenol Tramadol
Tramadol plus APAP
NSAIDS:
Muscle Relaxants:
Cox-1 vs Cox-2
Topical agents
Steroids:
Opioids
C-II law

Opioids plus APAP

Dozens
Increase Usage

Opioids plus NSAIDS

Empirin, Vicoprofen

Caine anesthetics
Capsacian
Menthol Camphor

Adjunctive
medications
Anti-depressants
Membrane
Stabilizers

Geriatric Medicine:
Parkinsons Disease
Disease that is a functional decline in the
balance between 2 nervous system
transmitters- Dopamine and Acetylcholine

Presenting Symptoms:
Initial:
aches, pains, parasthesias,
numbness coldness

Classic:
Temor:
Pill rolling, thumb finger,
feet
At rest
Stress makes worse
Usually initial presenting
symptoms

Bradykinesia:
Slowing of movements
Hypokinesia
decreased ability to move

Masked Facies
Emotionless
Walking difficulties

Ridgidity:
Cog wheeling
Coordination difficulties
Walking difficulties

Options of Medication
Management:

1. Replace the deficient chemical

2. Normalize relative imbalance of chemicals
3. Stimulate the receptor
4. Stop the normal breakdown of the chemical
5. Stimulate the release remaining chemicals
6. Increase the numbers or sensitivity of
remaining receptors

Therapy for Parkinsons

Anticholiniergics:
Diphenhydramine
Benadryl
Trihexylphenadyl Artane
Benztropine Cogentin

Increase Dopamine
Carbidopa/Levodopa
Sinemet

Stimulate DA receptor
Ammantadine
Pramipaxole Mirapex
Ropinerole Requip

Stop the breakdown

Selegiline Eldepryl
Rasagaline Azilect
Tolcalpone Tasmar
Entacapone Comtan

Other increasing elderly disorders

Depression

Psychosis

Weight loss

Dementia

Weight gain

Delirium

Anxiety

Sun Downing

End of Life Issues

Can the elderly make decisions for
themselves?
Power of attorney

TALK about it BEFORE elderly is very sick

Get ALL family members on the same page

Hospice Concerns
Die with dignity
Treat pain appropriately
Morphine High dose
Morphine 3 Glucuronide is INACTIVE
95% of MSO4 metabolite

Morphine 6 Glucuronide is ACTIVE

M3G ANTAGONIZES M6G and MSO4

May be worth your while to switch to another

phenanthrene opioid

Hospice Concerns
The death rattles
Air hunger
Inhaled morphine effective
Injectable and oral opioids effective

Constipation
Softeners at minimum, senna, stimulates, Mirilax

Hypersecretions:
Glycopyralate Robinul
1-2 mg PO TID-QID, IM or IV 0.1 mg Q 3-4 hours

Summary The Life-Span

Fetal Development
First Trimester
Second Trimester
Third Trimester

Gestational Issues
Perinatal Issues
Infant
Toddler
Adolescent

Puberty
Adult
Organ System Failure
Renal
Liver

Geriatrics
End of Life
Hospice Care

Questions?

roger@otc.isu.edu