Drugs In The Elderly Flashcards
Definition of elderly
- Young elderly (60-74): retired, good social network
- Elderly (75-84): independent, living with some support
- Very elderly (>85): widowed, disabled, need reg support
UK population data
DONT BOTHER LEARNING
- Life expectancy: male (86.2); female (88)
- There are approx 14.92 million people aged 60+ (23.1% of UK population- world average of 12.4%)
- By 2035, 60 in UK, 21.35 million- 29.4%
- There are 1.5 million people aged 85+ (2.32% of UK population- world average of 0.75%)
- By 2035, 85+ in UK, 3.47 mill- 4.78%
An ageing world
- By 2047, it is predicted that for the first time in human history, there will be more older people (60+) than children (<16)
- The number of people aged 80+ is projected to more than triple by 2050 and increased more than 7 fold by 2100
- By 2050, all major area of the world, except Africa will have nearly a quarter or more of their populations aged 60 and over
- Even Africa life expectancy is rapidly increasing
Concomitant diseases (These are conditions that you get while having another disease that are common)
- Constipation- opioid
- Incontinence-
- Cancer
- Neurological disease (Parkinson’s)
- UTI
- Benign prostatic hypertrophy
- Osteoporosis; osteoarthritis
- Hypertension
- CHF
- Respiratory disease
- Diabetes
- Respiratory infections (Pneumonia)
Frailty
- A state of increased vulnerability resulting from ageing and associated decline in the body’s physical and physiological reserves
- Approx 10% of people aged >65 yrs have frailty, rising between 25-50% over age 85 yrs
- Older people living with frailty are at risk of adverse effects e.g. their physical and mental well-being after a minor event
- Frailty is distinct from living with one or more long term conditions and or/disability, though there may be overlaps in managements
Frailty 2
The 2 broad models of frailty use changes in a persons weight, muscle strength etc or identification of sensory loss or dementia
Triggers to consider: falls; immobility; delirium; incontinence; susceptibility to side effects of medicines
Frailty is broader than the phenotype approach, encompassing co-morbidity and disability as well as cognitive, psychological and social factors
Being elderly in the UK today
61% of today’s over 65 year olds worry about losing independence. 53% find loss of independence a difficult subject to discuss
Older people living with frailty represent a group of people who are amongst the most vulnerable in society and who often let down by the services and communities they rely on
Where do the elderly live
- Independently at Home
- With family at home
- At hoe with carers
- Sheltered housing
- Care homes (1.5% of over 65s and 20% of over 80s)
-Temporarily: hospital; -intermediate care
Older people on a drugs cocktail
45% of medication prescribed in UK are for people 65+
90% of >65s take at least 1 prescription item
Nearly half of over 65 are taking 5 or more prescribed drugs
12% of older people are taking 10 or more prescribed drugs
As many as 50% of older people on prescribed medication may not be taking their prescribed medication as instructed
Transfer of care between healthcare professionals
Most older people will have at least 1 chronic condition, take multiple medicines, have more than 1 community pharmacy
Between 30-70% of patients experience a medication error or unintended change to their medicine when they move between healthcare settings
Effective communication is the key
The fewer prescribers the better
Pharmacodynamic changes of ageing
- Receptors, altered number/-affinity
- Homeostasis (postural hypotension)
- Increased susceptibility to confusion
- May result in difficulty distinguishing between disease and drug effects
Pharmacokinetic of ageing: drug absorption
- Reduced saliva (solid buccal formulation)
- Increased gastric pH (effect absorption and action of drug)
- Decreased GI motility (Take longer for absorption/to reach the target area)
- Decreased GI and regional blood supply
Pharmacokinetic of ageing: drug metabolism
- Reduced hepatic blood flow, resulting in reduced 1st past metabolism and greater drug effect
- Reduced metabolic clearance, resulting in increased levels or duration of action of drugs extensively metabolised
- Pro-drugs may be less effective
Pharmacokinetic of ageing: drug excretion
- Kidney size decreased
- Loss of functional glomeruli, leading to decreased GFR
- Use Cockroft-Gault equation to estimate GFR
- Risk of renal disease or drug induced renal damage increased (ACEI, NSAIDs)
Drugs to look closely at
Analgesics (opioid and NSAID)
Digoxin (narrow INR, kidney clearance)
Diuretics (esp loop cause electrolyte imbalance e.g. hypokalaemia)
Warfarin (narrow INR)
ACEI (renotoxic)
Beta blocker
Benzodiazepines (Drowsiness)
Phenothiazine (Drowsiness, Parkinson like symptoms)
Anti-Parkinson drugs (psychiatric side effects)
Medication review
Why is it prescribed Is it appropriate Is it still required Is the dose and frequency appropriate Is the patient experiencing side effects Is it still working Are there interactions of clinical significance Can the patient manage the dosage form
Difficulties the elderly
- Visual impairment (mistake drugs, different colour)
- Hearing impairment (may not hear when counselling)
- Swallowing difficulties (large quantities, sugar, bad taste, sorbitol)
- Mobility
- Manual dexterity
- Cognitive impairment
Dosage forms and adherence
- Avoid poly pharmacy
- Blister packs and bottle tops
- Liquids and measuring
- Sublingual tablets and dry mouths
- Functional capacity
Cost of FALLS
30% of >65 fall in the community each year: 1/10 lead to fractures, 1/5 need medical attention
Falls and fractures in 65+ for 4 mill bed days in England each year
Costs £2 billion a year
Injurious falls are the top accident relate mortality
After falling, 50% chance of their mobility be impaired and 10% chance of death within a year
Lead to a lack of independence and confidence
pharmacokinetics of ageing: Distribution
- Increased mass adipose tissue by 14-35%; increasing Vd of lipid soluble drugs
- Decrease in lean muscle mass by 12-19% (e.g. lower doses of digoxin required)
- Decrease in total body water, decreasing Vd for water soluble drugs
- Reduced serum albumin levels (many drugs phenytoin carried by albumin)
Medication review: reducing risk of fall
- Rationalise IF possible
- Change to alternative drug
- Reduce the dose
- Change timing so adverse effects in the evening night
- Spread dose out throughout the day (side effects from peak drug conc)
- Use slow release preparations
- Need to personalise regimen to the individual
NICE 2013: Multifactorial falls risk assessment
- Identification of fall history
- Assessment of gait, balance and mobility and muscle weakness
- Assessment of osteoporosis risk
- Assessment of the older persons perceived functional ability and fear relating to falling
- Assessment of visual impairment
- Assessment of cognitive impairment and neurological examination
- Assessment of urinary incontinence
- Assessment of home hazards
- Cardiovascular examination and medication review
Conclusion
- Ageing population
- Long term conditions
- Polypharmacy
- Altered drug handling and response to drugs
- Need for regular medication reviews
