7 - Geriatric Pharmacotherapy

Question 1

What is the problem with the increase in chronic conditions in the elderly?

Answer 1

People are living longer, having more diseases, and having more meds. These factors result in many drug interactions.

Question 2

What percent of elderly patients are taking at least one Rx medication?

Answer 2

80%

Question 3

What are important factors to think about when discussing meds with elderly patients?

Answer 3

• Make sure that you ask if they are actually taking their meds
• Tell them they can contact you if they are having trouble with the meds before they stop them.
• Think about what meds you can stop because they no longer need them or they are not effective
• Cost

Question 4

True/False

One in six hospital admissions is due to an adverse drug event.

Answer 4

True!

Question 5

What are the most common medications that result in an adverse drug event in an elderly patient?

Answer 5

Anti-thrombotics, diuretics, NSAIDs, and

anti-diabetic agents

Question 6

What factors should you consider for therapeutic goals?

Answer 6

What are the patient’s goals?
What are your goals for the patient?

Independence
Physical function
Mobility
Activities of daily living
Instrumental activities of daily living
Health-related quality of life (HRQOL)
Patient’s perception of how health impacts their physical, social, and psychologic functioning and well-being 
Longevity

Question 7

Define Pharmacokinetics (PK).

Answer 7

“What the body does to the drug”

Absorption, Distribution, Metabolism, and Elimination (ADME)

Question 8

True/False

Due to age-related changes PK parameters can change dramatically for some drugs.

Answer 8

True

Question 9

What is likely the most important factor in the age related change in PK?

Answer 9

Reduced renal function is likely the most relevant

Question 10

How does absorption change in the elderly?

Answer 10

Unchanged passive diffusion (most drugs)
↓ active transport, ↓ bioavailability (some drugs)
↓ first-pass metabolism, ↑ bioavailability (some drugs)

Question 11

How does distribution change in the elderly?

Answer 11

Water-soluble: ↓ Vd and ↑ plasma concentration

Lipid-soluble: ↑ Vd and ↑ t ½

Question 12

How does metabolism change in the elderly?

Answer 12

↓ hepatic metabolism and ↑ t ½ (some drugs)

Question 13

How does elimination change in the elderly?

Answer 13

↓ clearance and ↑ t ½ of renally eliminated drugs and/or active metabolites (many drugs)

Question 14

What is the Cockcroft-Gault Equation used for?

Answer 14

Assessing renal function (GFR)

look at this slide

Question 15

What is the MDRD Equation used for?

Answer 15

Assessing renal function (GFR)

Takes into account age, SCr, gender, ethnicity, BUN, albumin, and body surface area
Need more lab values, equation is much more complex
May be more accurate than Cockcroft-Gault

Question 16

Define Pharmacodynamics.

Answer 16

What the drug does to the body

• Both therapeutic effects and side effects
• Ex: Anticoagulants, antiplatelets, sedatives, antihypertensives, antidiabetics, etc.

** Remember: Elderly may be more sensitive to the effects of medications

Question 17

Why do we “start low, go slow”? What does it mean?

Answer 17

Start at a lower dose and titrate up slowly

Can help mitigate the consequences of PK and PD changes

Question 18

Define Polypharmacy.

Answer 18

Use of multiple drugs or the administration of more medications than are indicated clinically

Question 19

Polypharmacy occurs in ___% of older patients.

Answer 19

Approximately 50-60% of older outpatients

Question 20

What are complications of polypharmacy?

Answer 20

May lead to drug-drug and/or drug-disease interactions:
Increase risk for side effects
Multiple providers
OTCs

Question 21

How can we help prevent/decrease polypharmacy?

Answer 21

Avoid treating side effects with another drug

Ask about dietary supplements because they increase polypharmacy:
Vitamins, minerals, and herbal products (often not included on medication records)

Question 22

Define Underuse.

Answer 22

Omission of drug therapy that is indicated for the treatment or prevention of a disease and/or condition
“Gap(s) in therapy”
Consider non-adherence as potential source for underuse

Question 23

What are some drugs that are commonly underused?

Answer 23

Commonly include bisphosphonates, anticoagulants, antiplatelets, antihypertensives, statins
Highly dependent on comorbid disease states and PMH
Consider rescue medications as well (albuterol, nitroglycerin, etc.)

Question 24

Define Inappropriate use.

What are the problems that arise?

Answer 24

Prescribing medications outside the bounds of acceptable medical standards

• Different than “off-label use”
• Inappropriate drug, dose, or duration

Can lead to drug-drug or drug-disease interactions
Consider renal dose adjustments

Question 25

How can we help decrease inappropriate use? What are some tools we can use?

Answer 25

Beers List and STOPP/START may help guide selection of appropriate agents

Assess OTC, herbal, and other potential sources of medications

Question 26

What should you think about when doing a medication assessment?

Answer 26

Determine tx goals first!
Patient’s age and renal status
drug/drug interactions (including supp/OTC)
drug/disease interactions
Accurate and complete PMH and medication list
Allergies
Compliance (find out why if it is an issue)

**Counsel patient and reassess often!

Question 27

Describe drug-drug interactions:

Answer 27

Can increase/decrease therapeutic effects or side effects

Can occur between prescription drugs and OTC products

Additive or synergistic

Question 28

Describe drug-disease interactions:

Answer 28

Side effect/therapeutic effect of one drug may worsen another disease

Most interactions are due to the therapeutic effects as opposed to rare side effects

Question 29

What is the BEERS List?

Answer 29

A guide for practitioners when choosing medications for patients.

Three categories of recommendations:
Medications to avoid regardless of indication
Medications to be avoided if certain disease(s) are present
Medications to be used cautiously in older adults

Question 30

What drugs should be avoided in elderly people if at all possible? Why?

(think of the ones we talked about a lot!)

Answer 30

Drugs with anticholinergic burden

Can cause sedation, confusion, mental clouding, delirium, memory problems, difficulty concentrating, urinary retention, constipation, dry-mouth, tachycardia, falls

• Elderly tend to be more sensitive to these effects
• If use cannot be avoided, limit use of other potential problem agents

Question 31

What are some other medications to be avoided (according to the Beers criteria)?

Answer 31

Digoxin
Antispasmotics
Alpha1 blockers 
Central alpha blockers 
Tertiary TCAs
Antipsychotics
Barbituates
Benzodiazepines 
Non-benzodiaz-epine hypnotics
Insulin - sliding scale
Sulfonylureas, long-acting
NSAIDS
Muscle relaxants

Question 32

What are some other medications to be used cautiously (according to the Beers criteria)?

Answer 32

Aspirin for primary prevention of cardiac events
Prasugrel
Dabigatran
Antipsychotics 
Vasodilators

Question 33

Beers vs. STOP/START

just review

Answer 33

Both offer advantages:
Medications to avoid (both)
START/STOPP also recommend alternatives
Both relatively evidenced-based
STOPP may better identify avoidable problems
Beers List only requires medication review; START/STOPP also require lab values

Both have disadvantages:
Neither has proven to improve overall outcomes (mortality)
Neither discuss appropriate medications used inappropriately

Question 34

True/False

Use of combination tablets and long-acting formulations is not recommended for elderly patients.

Answer 34

False

Use of combination tablets and long-acting formulations may overcome some compliance issues.

Question 35

What is a resource you can refer to in addition to Beers and START/STOP criteria that is especially helpful in managing elderly medications?

Answer 35

Your local pharmacist!!

Question 36

Done! Rocked it!

Answer 36

I cut out material that went beyond our objectives =)