_Therapeutics:_ ‘The medical treatment of disease.’ ‘The branch of medicine concerned with the treatment of disease.’ ‘The branch of medicine concerned with the use of remedies to treat disease.’ ’……the science or art of healing.’

‘The medical treatment of disease.’ ‘The branch of medicine concerned with the treatment of disease.’ ‘The branch of medicine concerned with the use of remedies to treat disease.’ ’……the science or art of healing.’

_Polypharmacy - appropriate vs problematic (elderly)_ Appropriate: prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence Problematic: prescribing of multiple medications inappropriately or where intended benefit is not realised e.g. treatments not evidence based, risk of harm outweighs benefits, medicines interactions present, unacceptable pill burden etc.

Appropriate: prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence Problematic: prescribing of multiple medications inappropriately or where intended benefit is not realised e.g. treatments not evidence based, risk of harm outweighs benefits, medicines interactions present, unacceptable pill burden etc.

_Dangers of Polypharmacy:_ ... effects Drug-drug ... ... of drug therapy Poor ... C... Decreased ... of ...

Adverse effects Drug-drug interactions Duplication of drug therapy Poor adherence Cost Decreased quality of life

_Challenges for prescribing in the elderly:_ Multiple medical ... Multiple ... Multiple P... Different M... and R... Lack of ... for use in the elderly A... and cost

Multiple medical conditions Multiple medications Multiple prescribers Different metabolisms and responses Lack of evidence for use in the elderly Adherence and cost

Therapeutics in the Older Patient Flashcards by Chrissy Taaffe

Therapeutics:

‘The medical treatment of disease.’
‘The branch of medicine concerned with the treatment of disease.’
‘The branch of medicine concerned with the use of remedies to treat disease.’
’……the science or art of healing.’

‘The medical treatment of disease.’
‘The branch of medicine concerned with the treatment of disease.’
‘The branch of medicine concerned with the use of remedies to treat disease.’
’……the science or art of healing.’

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1 in … people (…%) born in the UK* in 2012 will live until they are 100 years of age…. - dependent on postcode

1 in 5 people (20%) born in the UK* in 2012 will live until they are 100 years of age…. - dependent on postcode

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Pharmacological Treatment - Elderly

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Polypharmacy: elderly

How much is enough?* How many is too many?

* “Some is plenty, enough is too much.”

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What is polypharmacy?

•The use of at least four to five medicines

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Polypharmacy - appropriate vs problematic (elderly)

Appropriate: prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence
Problematic: prescribing of multiple medications inappropriately or where intended benefit is not realised e.g. treatments not evidence based, risk of harm outweighs benefits, medicines interactions present, unacceptable pill burden etc.

Appropriate: prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence
Problematic: prescribing of multiple medications inappropriately or where intended benefit is not realised e.g. treatments not evidence based, risk of harm outweighs benefits, medicines interactions present, unacceptable pill burden etc.

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Polypharmacy – Facts and Figures

By 2018 3 million people in the UK will have a long-term condition managed by polypharmacy
2 million prescriptions are issued each day in England.
The number of prescriptions issued has increased by 55.2% since 2004.
Approximately …%of prescriptions are issued to people aged 60 years and over.
A person taking ten or more medicines is ….% more likely to be admitted to hospital.
A … of people aged 75 years and over are taking at least six medicines.
- Source: CPPE Polypharmacy DLP 2016

By 2018 3 million people in the UK will have a long-term condition managed by polypharmacy
2 million prescriptions are issued each day in England.
The number of prescriptions issued has increased by 55.2% since 2004.
Approximately 60%of prescriptions are issued to people aged 60 years and over.
A person taking ten or more medicines is 300% more likely to be admitted to hospital.
A third of people aged 75 years and over are taking at least six medicines.
- Source: CPPE Polypharmacy DLP 2016

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By 2018 … million people in the UK will have a long-term condition managed by polypharmacy

By 2018 3 million people in the UK will have a long-term condition managed by polypharmacy

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… million prescriptions are issued each day in England.

2 million prescriptions are issued each day in England.

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The number of prescriptions issued has increased by …% since 2004. (2016)

The number of prescriptions issued has increased by 55.2% since 2004. (2016)

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Approximately …% of prescriptions are issued to people aged 60 years and over.

Approximately 60%of prescriptions are issued to people aged 60 years and over.

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A third of people aged 75 years and over are taking at least … medicines.

A third of people aged 75 years and over are taking at least six medicines.

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Dangers of Polypharmacy:

… effects
Drug-drug …
… of drug therapy
Poor …
C…
Decreased … of …

Adverse effects
Drug-drug interactions
Duplication of drug therapy
Poor adherence
Cost
Decreased quality of life

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Challenges for prescribing in the elderly:

Multiple medical …
Multiple …
Multiple P…
Different M… and R…
Lack of … for use in the elderly
A… and cost

Multiple medical conditions
Multiple medications
Multiple prescribers
Different metabolisms and responses
Lack of evidence for use in the elderly
Adherence and cost

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‘Guideline medicine’ often won’t help (Polypharmacy - elderly)

If you follow NICE Guidance
Patient with
- Type 2 diabetes (23 drugs recommended)
- Depression (13 drugs recommended)
- Heart failure (11 drugs recommended)
Study looked at how many interactions there would be with 11 other common conditions e.g. CKD, Osteoarthritis, Hypertension, COPD
If NICE guidelines followed
- 133 drug-drug interactions with Diabetes guidelines
- 89 for Depression guidelines
- 111 for heart failure

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Challenges for prescribing in the elderly:

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Meet ‘Mrs Anderson’

87 year old lady, presented to A&E via ambulance from nursing home
Found on floor at 0730 - unable to recall events. NH staff reports that patient was put to bed at 2130 and, when checked at 2330, was asleep in bed.
PC: Right hip and back pain, agitated - says “yes” when asked if she is in pain.
PMH - Type 2 Diabetes - on s/c insulin, Peripheral Neuropathy, Anaemia, COPD, Parkinson‘s Disease (2014), Recurrent UTI’s
Drug History: AS SHOWN
Why is Mrs Anderson at Risk?

87 year old lady, presented to A&E via ambulance from nursing home
Found on floor at 0730 - unable to recall events. NH staff reports that patient was put to bed at 2130 and, when checked at 2330, was asleep in bed.
PC: Right hip and back pain, agitated - says “yes” when asked if she is in pain.
PMH - Type 2 Diabetes - on s/c insulin, Peripheral Neuropathy, Anaemia, COPD, Parkinson‘s Disease (2014), Recurrent UTI’s
Drug History: AS SHOWN
RISK FACTORS - Multiple Drugs:, Risk of ADE is proportional to number of drugs, Increased probability of drug-drug interactions, Physiological Changes:, Associated with disease state, Associated with normal ageing

Physiological changes associated with disease states:

Cardiac disease:
- Impaired cardiac output (decreased absorption, metabolism, clearance)
- Greater … to cardiac adverse effects
Kidney and Liver diseases:
- … drug clearance, metabolism changes
Neurological diseases:
- … neurotransmitter levels
- … cerebral blood flow
- Greater … to neurological effects

Cardiac disease:
- Impaired cardiac output (decreased absorption, metabolism, clearance)
- Greater susceptibility to cardiac adverse effects
Kidney and Liver diseases:
- Decreased drug clearance, metabolism changes
Neurological diseases:
- Reduced neurotransmitter levels
- Impaired cerebral blood flow
- Greater sensitivity to neurological effects

Physiological changes associated with disease states:

Cardiac disease:
- Impaired cardiac output (… absorption, metabolism, clearance)
- Greater susceptibility to cardiac … effects
Kidney and Liver diseases:
- Decreased drug …, metabolism changes
Neurological diseases:
- Reduced … levels
- Impaired … blood flow
- … sensitivity to neurological effects

Cardiac disease:
- Impaired cardiac output (decreased absorption, metabolism, clearance)
- Greater susceptibility to cardiac adverse effects
Kidney and Liver diseases:
- Decreased drug clearance, metabolism changes
Neurological diseases:
- Reduced neurotransmitter levels
- Impaired cerebral blood flow
- Greater sensitivity to neurological effects

Physiological changes associated with normal ageing:

… Water
… fat
… muscle mass
… hepatic metabolism
Decreased renal excretion
Decreased responsiveness of baroreceptors

Less Water
More fat
Less muscle mass
Slower hepatic metabolism
Decreased renal excretion
Decreased responsiveness of baroreceptors

Physiological changes associated with normal ageing:

Less Water
More fat
Less muscle mass
… hepatic metabolism
… renal excretion
… responsiveness of baroreceptors

Less Water
More fat
Less muscle mass
Slower hepatic metabolism
Decreased renal excretion
Decreased responsiveness of baroreceptors

Absorption - older patient

… rate of absorption
…. saliva production
… gastric acid secretion (increased gastric pH)
…. gastric emptying
Reduced GI motility
Decreased GI surface area
These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or malabsorption syndromes, doses may need to be increased

Reduced rate of absorption
Reduced saliva production
Reduced gastric acid secretion (increased gastric pH)
Delayed gastric emptying
Reduced GI motility
Decreased GI surface area
These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or malabsorption syndromes, doses may need to be increased

Absorption - older patient

Reduced rate of absorption
Reduced saliva production
Reduced gastric acid secretion (increased gastric pH)
… gastric emptying
… GI motility
…. GI surface area
These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or … syndromes, doses may need to be increased

Reduced rate of absorption
Reduced saliva production
Reduced gastric acid secretion (increased gastric pH)
Delayed gastric emptying
Reduced GI motility
Decreased GI surface area
These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or malabsorption syndromes, doses may need to be increased

Distribution - Older patient

…. adipose tissue (… fat)
↑ VD and t ½ of … drugs
… body water (less H2O)
↓ VD of water soluble drugs
Decreased a… (↓ muscle mass)
↑ concentration (‘free’ concentration increase) of … bound drugs (warfarin, digoxin, phenytoin) – Lower maintenance doses required
Reduced systemic perfusion

Increased adipose tissue (more fat)
↑ VD and t ½ of lipophilic drugs
Reduced body water (less H2O)
↓ VD of water soluble drugs
Decreased albumin (↓ muscle mass)
↑ concentration (‘free’ concentration increase) of albumin bound drugs (warfarin, digoxin, phenytoin) – Lower maintenance doses required
Reduced systemic perfusion

_Distribution - Older patient_ * .... adipose tissue (more fat) * ↑ VD and t ½ of lipophilic drugs * Reduced body water (less H2O) * ↓ VD of water soluble drugs * Decreased albumin (↓ muscle mass) * ↑ concentration (‘free’ concentration increase) of albumin bound drugs (warfarin, digoxin, phenytoin) – Lower ... doses required * ... systemic perfusion

* Increased adipose tissue (more fat) * ↑ VD and t ½ of lipophilic drugs * Reduced body water (less H2O) * ↓ VD of water soluble drugs * Decreased albumin (↓ muscle mass) * ↑ concentration (‘free’ concentration increase) of albumin bound drugs (warfarin, digoxin, phenytoin) – Lower maintenance doses required * Reduced systemic perfusion

_Metabolism - Older patient_ * ↓ first pass metabolism → ↑... * ... in hepatic blood flow * ... delivery of drug to liver * ↓ ... → ↑ t ½ and peak concentration * Metabolic capacity * Reduced by up to 60% * ↑ blood levels and t ½

* ↓ first pass metabolism → ↑bioavailability * Reduction in hepatic blood flow * Reduced delivery of drug to liver * ↓ metabolism → ↑ t ½ and peak concentration * Metabolic capacity * Reduced by up to 60% * ↑ blood levels and t ½

_Metabolism - Older patient_ * ↓ ... pass metabolism → ↑bioavailability * Reduction in ... blood flow * Reduced delivery of drug to ... * ↓ metabolism → ↑ t ½ and peak concentration * Metabolic capacity * Reduced by up to ...% * ↑ ... levels and t ½

_Elimination: - Older patient_ * ... renal function * Reduction in size by ....% * Loss of ~ 30% of functioning g... * Reduced clearance leads to extended ... ... and increased serum levels - accumulation and toxicity * Can also be affected by ... illness

* Decreased renal function * Reduction in size by ~20% * Loss of ~ 30% of functioning glomeruli * Reduced clearance leads to extended half life and increased serum levels - accumulation and toxicity * Can also be affected by acute illness

Pharmacodynamics is..

* What the drug does to the body. * **Changes in sensitivity to particular agents** * **Change in receptor binding** * **Change in receptor number**

_Examples of Pharmacodynamic Changes:_ * ... response * Warfarin * Benzodiazepines * Diltiazem * ... response * Beta-Blockers * Beta2-Agonists * Furosemide

* Increased response * Warfarin * Benzodiazepines * Diltiazem * Decreased response * Beta-Blockers * Beta2-Agonists * Furosemide

_Fall: why did Mrs Anderson fall?_ * ... Status: * Uses walker at baseline * Dependent in other ADLs * ... Impairment: * Peripheral neuropathy * ... Diseases: * Dementia * Parkinson's disease * ...-... Diseases * Cardiovascular (syncope) * Diabetes (hypoglycaemia) * Anaemia (hypotension)

* Functional Status: * Uses walker at baseline * Dependent in other ADLs * Sensory Impairment: * Peripheral neuropathy * CNS Diseases: * Dementia * Parkinson's disease * Co-Morbid Diseases * Cardiovascular (syncope) * Diabetes (hypoglycaemia) * Anaemia (hypotension)

Why is 'Mrs Anderson' Confused?

* Head Injury? * Dementia? * Delirium? * Infection? * Drugs? * Hospital environment?

_What is Delirium?_ * More than confusion! * ... onset * Inattention * ... thinking or altered level of consciousness * Associated with low levels of ... * Low levels in patients with ...

* More than confusion! * Acute onset * Inattention * Disorganised thinking or altered level of consciousness * Associated with low levels of acetylcholine * Low levels in patients with dementia

_D.E.L.I.R.I.U.M._

Pharmacological Tug of WAR - older patients

_Anticholinergic Drugs: problems?_ * Examples: * ... * ... antidepressants * Antispasmodics and muscle ... * Side effects: * .. Mouth * ... retention * Constipation * ..., delirium

* Examples: * Antihistamines * Tricyclic antidepressants * Antispasmodics and muscle relaxants * Side effects: * Dry Mouth * Urinary retention * Constipation * Confusion, delirium

_Anticholinergic Drugs: problems?_ * Examples: * Anti... * T... ... * Anti.... and muscle relaxants * Side effects: * ... Mouth * Urinary .... * C... * Confusion, delirium

* Examples: * Antihistamines * Tricyclic antidepressants * Antispasmodics and muscle relaxants * Side effects: * Dry Mouth * Urinary retention * Constipation * Confusion, delirium

_Principles + goals of drug therapy in the elderly_ * Avoid ... drug therapy: - Is it necessary – is there a non-drug alternative? * Effect of treatment on quality of life * Treat the ... rather than the ...: A patient presenting with ‘indigestion’ won’t benefit from a PPI if the cause is angina. * ... History: - Crucial – establishes allergies, previously ineffective treatments, helps avoid potentially serious interactions * Concomitant medical illness: as discussed; e.g. cardiac failure, renal impairment, hepatic dysfunction – all can and do impact on drug handling. * Choosing the drug: Remember the ‘circles’ – efficacy + tolerability + lifestyle * Dose ...: Most ADRs are type A – i.e. dose-related, pharmacologically predictable with attenuation likely – therefore start low + go slow. * the most appropriate ... form: Is there a syrup a suspension or effervescent tablet (possibly a trans-dermal form) rather than large tablets or capsules? * ... and ...: Can your arthritic patient mange with blister-packs, Child-resistant containers? Also, would large–print labels help? * Regular ... and ... of treatment.

* Avoid unnecessary drug therapy: - Is it necessary – is there a non-drug alternative? * Effect of treatment on quality of life: * Treat the cause rather than the symptom: A patient presenting with ‘indigestion’ won’t benefit from a PPI if the cause is angina. * Drug History: - Crucial – establishes allergies, previously ineffective treatments, helps avoid potentially serious interactions * Concomitant medical illness: as discussed; e.g. cardiac failure, renal impairment, hepatic dysfunction – all can and do impact on drug handling. * Choosing the drug: Remember the ‘circles’ – efficacy + tolerability + lifestyle * Dose titration: Most ADRs are type A – i.e. dose-related, pharmacologically predictable with attenuation likely – therefore start low + go slow. * the most appropriate dosage form: Is there a syrup a suspension or effervescent tablet (possibly a trans-dermal form) rather than large tablets or capsules? * Packaging and labelling: Can your arthritic patient mange with blister-packs, Child-resistant containers? Also, would large–print labels help? * Regular supervision and review of treatment.

_Principles + goals of drug therapy in the elderly_ * Avoid unnecessary drug therapy: - Is it necessary – is there a non-drug alternative? * Effect of treatment on ... of ... * Treat the cause rather than the symptom: A patient presenting with ‘indigestion’ won’t benefit from a PPI if the cause is angina. * Drug History: - Crucial – establishes allergies, previously ineffective treatments, helps avoid potentially serious ... * Concomitant medical illness: as discussed; e.g. cardiac failure, renal impairment, hepatic dysfunction – all can and do impact on drug handling. * ... the drug: Remember the ‘circles’ – efficacy + tolerability + lifestyle * ... titration: Most ADRs are type A – i.e. dose-related, pharmacologically predictable with attenuation likely – therefore start low + go slow. * the most appropriate ... ...: Is there a syrup a suspension or effervescent tablet (possibly a trans-dermal form) rather than large tablets or capsules? * Packaging and ...: Can your arthritic patient mange with blister-packs, Child-resistant containers? Also, would large–print labels help? * Regular ... and ... of treatment.

When to start, how to stop? elderly medicine

Warning/recommendations in therapeutics in the elderly (1)

Warning/recommendations in therapeutics in the elderly (2)