PRINCIPLES OF GERIATRICS

PHARMACOTHERAPY

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• Outline
– Epidemiology of aging;
– Physiologic changes associated with aging,
– Clinical conditions commonly seen in older
adult patients;
– Epidemiology of drug-related problems in
older adults; and an approach to reducing
drug-related problems.

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 Geriatrics
• The population of persons aged 65 years and older
• Their proportion is increasing.
• Pharmacotherapy for older adults can cure or palliate
disease as well as enhance health-related quality of life
(HRQO)
• Despite the benefits of pharmacotherapy, HRQOL can be
compromised by drug-related problems
• The prevention of drug-related adverse consequences in
older adults requires knowledge about a number of age-
specific issues.
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 EPIDEMIOLOGY OF AGING
• In 2000, persons aged 65 and older accounted for 12.4% of
which women accounted for 58.8%
• By 2030, the older population is projected to double in size
relative to the year 2000, with one in five (20%) Americans
older than 65 years.
• The proportion of the oldest old (>85 years) will continue to
grow and will double in 2050.
• Why ?
a) Public health measures affecting all age groups (e.g.,
immunizations),
b) Advances in medical technology,
c) Promotion of a healthy lifestyle, and
d) Improvements in living conditions
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 Epidemiology….
• Chronic diseases or impairments, such as heart disease, stroke,
and diabetes, are major causes of disability in older adults.
– An estimated 80% of older adults have at least one chronic
health condition, and more than half have at least two
concomitant conditions.
– Many chronic conditions can be prevented or improved with
behavioral modification, such as diet and physical activity
– Chronic diseases are the primary cause of death in older
adults
• Sensory impairments are common in older adults and pose
challenges
• Memory impairment
• Older adults are devoted consumers of medical and
prescription drug resources.
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• Examples of conditions associated with age
– Osteoarthritis
– Osteoporosis
– Foot deformities
– Atherosclerosis
– Cerebral ischaemia
– Myocardial infarction
– Alzheimer’s disease
– Parkinsonism.

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• Problems in the elderly that may interfere with
drug therapy and disease progression
– Mental confusion
– Incontinence
– Postural instability
– Immobility
– Skin and muscle wasting.

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• Factors responsible for increased incidence of
adverse drug reactions in the elderly
– Multiple disease states
– Increased use of medicines
– Over-prescribing
– Alterations in drug handling by the body
– Increased sensitivity to the effects of some drugs.

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 Physiologic Changes with Aging
• Body composition
• ↓ Total body water
• ↓ Lean body mass
• ↑ Body fat
• ↔ or ↓ Serum albumin
• ↑ α1-Acid glycoprotein (↔ or ↑ by several disease
states)
• Cardiovascular
• ↓ Myocardial sensitivity to β-adrenergic stimulation
• ↓ Baroreceptor activity
• ↓ Cardiac output
• ↑ Total peripheral resistance
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 Physiologic Changes….
• Central nervous system
– ↓ Weight and volume of the brain
– Alterations in several aspects of cognition
• Endocrine
– Thyroid gland atrophies with age
– Increased incidence of diabetes mellitus, thyroid disease
– Menopause
• Gastrointestinal
– ↑ Gastric pH
– ↓ Gastrointestinal blood flow
– Delayed gastric emptying
– Slowed intestinal transit

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 Physiologic Changes….
• Genitourinary
– Atrophy of the vagina due to decreased estrogen
– Prostatic hypertrophy due to androgenic hormonal changes
– Age-related changes may predispose to incontinence
• Immune
– ↓ Cell-mediated immunity
• Liver
– ↓ Hepatic size
– ↓ Hepatic blood flow
• Oral
– Altered dentition
– ↓ Ability to taste sweetness, sourness, bitterness.

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 Physiologic Changes….
• Pulmonary
– ↓ Respiratory muscle strength
– ↓ Chest wall compliance
– ↓ Total alveolar surface
– ↓ Vital capacity
– ↓ Maximal breathing capacity
• Renal
– ↓ Glomerular filtration rate
– ↓ Renal blood flow
– ↑ Filtration fraction
– ↓ Tubular secretory function
– ↓ Renal mass.

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 Physiologic Changes….
• Sensory
– ↓ Accommodation of the lens of the eye, causing
– farsightedness
– Presbycusis (loss of auditory acuity)
– ↓ Conduction velocity
• Skeletal
– Loss of skeletal bone mass (osteopenia)
• Skin/hair
– Skin dryness, wrinkling, changes in pigmentation,
epithelial thinning, loss of dermal thickness
– ↓ Number of hair follicles
– ↓ Number of melanocytes in hair bulbs

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 Age-Related Changes in Drug
Pharmacokinetics
• Gastrointestinal absorption
– Unchanged passive diffusion and no change in
bioavailability for most drugs
– ↓ Active transport and ↓ bioavailability for some drugs
– ↓ First-pass extraction and ↑ bioavailability for some drugs
• Distribution
– ↓ Volume of distribution and ↑ plasma concentration of
water-soluble drugs
– ↑ Volume of distribution and ↑ terminal disposition half-life
(t1/2) for fat-soluble drugs
– ↑ or ↓ Free fraction of highly plasma protein bound drugs.
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 Age-Related Changes in PK….

• Hepatic metabolism
– ↓ Clearance and ↑ t1/2 for some oxidatively metabolized
drugs

– ↓ Clearance and ↑ t1/2 for drugs with high hepatic

extraction ratios

• Renal excretion
– ↓ Clearance and ↑ t1/2 for renally eliminated drugs and
active metabolites.

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 ALTERED PHARMACODYNAMICS
• Four possible mechanisms have been suggested:
a) Changes in receptor numbers,

b) Changes in receptor affinity,

c) Postreceptor alterations, and

d) Age-related impairment of homeostatic

mechanisms.

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• Pharmacodynamic changes
– Changes in receptor sensitivity (e.g. decreased
responsiveness to agonists and antagonists at beta-
adrenoceptors)
– Increased sensitivity to drug effects (e.g. anticoagulant
effects of warfarin)
– Decline in some pathways: decreased cholinergic
neurons in areas of the brain lead to a higher risk of
drugs with anticholinergic properties (e.g. benzatropine,
trihexyphenidyl, sedating antihistamines, tricyclic
antidepressants, neuroleptics) inducing mental
confusion
– Orthostatic hypotension: may be aggravated by alpha-
adrenergic blocking drugs, diuretics, nitrates,
phenothiazines, tricyclic antidepressants.
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 CLINICAL GERIATRICS
• Maintenance of independence and prevention of disability
are primary goals in the clinical care of persons 65 years
of age and older
The I’s of geriatrics: common problems in older adults

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 Identifying drug-related problems
• Discuss with patient medications used and health related
issues to identify any drug-related problems.
• Problems with dispensed • Problems associated with
medication formulation
❖Illegible and unclear ✓ Swallowing tablets
label
✓ Measuring suspensions
❖Formulation
✓ Using inhalers
❖Packaging
✓ Instilling eye drops
❖Side-effects
✓ Using suppositories
❖Use of non-prescription
✓ Applying creams.
medicines.

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 DRUG-RELATED PROBLEMS IN OLDER
ADULTS
• Medications used by older adults can lead to improvement
in HRQOL,
• Negative outcomes due to drug-related problems are
considerable
• Three important and potentially preventable negative
outcomes due to drug-related problems :
– Adverse drug withdrawal events (ADWEs),
– Therapeutic failure (inadequate or inappropriate drug
therapy and not related to the natural progression of disease)
– Adverse drug reactions (ADRs),
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 RISK FACTORS
• Overuse
– Polypharmacy can be defined as either the concomitant
use of multiple drugs or the administration of more
medications than are indicated clinically.
• Inappropriate Prescribing
– Can be defined as prescribing medications outside the
bounds of accepted medical standards
– Also it can be defined as prescribing drugs whose use
should be avoided because their risk outweighs their
potential benefit.
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 Risk Factors….
• Underuse

– Defined as the omission of drug therapy that is

indicated for treatment or prevention of a disease
or condition
• Medication Nonadherence

– The prevalence rate of medication nonadherence in

older adults ranges from 40% to 80%

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 Falls in older people
• Common, devastating problem
• Associated with identifiable risk factors: weakness, gait,
confusion, medications
• Fall prevention: assessment of fall risks by identifying risk
factors and preparing a riskreduction strategy which includes
patient support and home help
• Fall management: in addition to looking into the physical
damage, when falls in older people occur: pharmacist review
of medications, physiotherapists to support patient in physical
movements, social worker to assess patient needs at home.

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• Drugs and falls
– Drugs causing hypotension (e.g. antihypertensives)

– Drugs causing hypovolaemia (e.g. diuretics)

– Drugs causing incontinence (e.g. diuretics)

– Drugs causing undue sedation (e.g.

benzodiazepines, antidepressants).

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COMPREHENSIVE GERIATRIC ASSESSMENT
1. Hx taking
– Difficulties include:
a) Communication problems (impaired hearing and
vision),
b) Underreporting (e.g., health beliefs, cognitive
impairment),
c) Reporting of vague or nonspecific symptoms (altered
presentation),
d) Coexistence of multiple diseases and/or use of
multiple medications,
e) Reliance on a caregiver for the history, and
f) Lack of medical records to confirm findings.
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 GERIATRIC ASSESSMENT…...
2. Assessing and monitoring drug therapy
3. Documenting problems and formulating a therapeutic
plan.
4. Consulting the physician regarding problems and
concerns
5. Counseling and adherence aids
6. Documenting interventions and monitoring patient
progress
7. Targeting high-risk older adults

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Thank You!!!

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