Principles of Drug Therapy for the Elderly.

Aging problems:
The elderly population has a higher prevalence of chronic and multiple diseases They are vulnerable to adverse health outcome because of advanced age, compromised functional status, frailty, and diseases. Social or economic factors, health habit, and lack of access to care can exacerbate their illnesses In elderly persons, the risk is greater for an adverse drug reaction.

Factors That Interfere with Safe and Successful Drug Therapy in the Elderly
Barriers to the recognition of the need to obtain care (cultural, economic, physical, psychological) Atypical presentation of illness Multiple illnesses Dementia. Diminish vision or hearing Impairment to compliance (cultural, economic, physical, physiologic) Polypharmacy Increased susceptibility to adverse drug events. Age-related change in pharmacology (ADME)

Impaired organ functions

Aging

Multiple diseases Multiple physicians Polypharmacy

Altered drug concentration

Altered organ function

Decreased homeostatis

Adverse drug reaction

Altered compliance

Interactions of Many Factors That Contribute to Adverse Health Outcomes in the Vulnerable Elders:

Drug-aging interactions Drug-disease interactions Drug-drug interactions

Inappropriate Polypharmacy in the Elderly:

Polypharmacy may be inappropriate if more drugs are prescribed than necessary, prescription of drugs with unacceptable side effects, coprescription of drugs with harmful drug-drug and drug-disease interactions. A major concern about polypharmacy is the potential for adverse drug reactions and interactions.

Inappropriate Polypharmacy in the Elderly

Non-adherence, increased risk of hospitalizations, medication errors, and increased cost resulting from treatment of adverse events or other potential problems with inappropriate polypharmacy. As the number of medications used by patient increases, the incidence of ADRs increases exponentially

Inappropriate Polypharmacy in the Elderly

The potential for an ADR is estimated at 6% when 2 drugs are taken, at 50% when 5 drugs are taken, and at nearly 100% when 8 or more drug are taken. The risk of a serious ADR also increases with age; it is 18.5% in adults aged 55-64 years, 30.1% in those 75-84, and 41.8 in those 85 and older. Physicians may contribute to polypharmacy by excessive or inappropriate prescribing practice or through lack knowledge about drug actions and interactions.

Effects of Aging on Pharmacokinetics:

Absorption: - GI motility and blood flow decrease; drug absorption rate decreases, pH decreases, intestinal motility decreases. Therefore drug absorption is quantitatively unaffected by aging Distribution: - Vd of water soluble drugs decreases; loading dose should be decreased. - Vd of fat soluble drugs increases; t1/2 increases. - Free drug concentration in plasma increases.

Effects of Aging on Pharmacokinetics:

Metabolism: - Phase I drug metabolism declines; liver size and hepatic blood flow decrease. Dosage of hepatically metabolized drugs should be reduced in elderly Excretion: - Half-life of drugs undergoing renal elimination prolongs; the daily dose should be based on creatinine clearance. The following formula is useful in estimating CLcr: CLcr=(140-Age)xBW/72xCr. 0.85 is a correction factor for women.

Effects of Aging on Pharmacodynamics

Homeostatic control mechanisms are blunted, response to drugs may change the intensity of response. For example, blood pressure goes up with age, but the incidence of orthostatic hypotension also increase markedly. Polypharmacy is associated with an increased fall risk. Use of diuretics, hypnotic-sedatives, 1st antihistamines, anticholinergics, is associated with increased falling.

Principles of Geriatric Prescribing

Evaluate the need for drug therapy. Take a careful history of habits and drug use. Know the pharmacology of drug prescribed. Begin therapy with small doses. Titrate the dosage with patient response. Simplify the regimen and encourage compliance. Regularly review the treatment plan, discontinue drugs no longer needed. Remember that drugs may cause new problems or exacerbate chronic problems.

10 Steps to Prudent Use of Drugs in the Elderly:

Disclosing all medications. Identifying drugs by generic name and class. Using the right drug for the right indication. Knowing the side effect profile of the drug being prescribed. Understand how drug kinetics and dynamics increase the risk of ADE Stop any drug without known benefit. Stop any drug without a clinical indication. Attempt to substitute a less toxic drug. Be aware of prescribing cascade. As much as possible, use the motto, one disease, one drug, once-a-day.

Common Drugs with Adverse Events in the Elderly

NSAIDs Aminoglycosides. Anticholinergics Anticoagulants Antidepressants Antipsychotics Beta blockers Digoxin Insulin, OAD Narcotics Sedative hypnotics Muscle relaxants 1st antihistamines Methyldopa and reserpine. Negativeinotropic antiarrythmias