Therapeutics in the Older Patient

Question 1

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.’

Answer 1

• ‘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.’

Question 2

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

Answer 2

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

Question 3

Pharmacological Treatment - Elderly

Answer 3

Question 4

Polypharmacy: elderly

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

Answer 4

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

Question 5

What is polypharmacy?

Answer 5

•The use of at least four to five medicines

Question 6

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.

Answer 6

• 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.

Question 7

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

Answer 7

• 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

Question 8

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

Answer 8

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

Question 9

… million prescriptions are issued each day in England.

Answer 9

2 million prescriptions are issued each day in England.

Question 10

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

Answer 10

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

Question 11

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

Answer 11

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

Question 12

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

Answer 12

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

Question 13

Dangers of Polypharmacy:

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

Answer 13

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

Question 14

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

Answer 14

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

Question 15

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

Answer 15

• 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

Question 16

Challenges for prescribing in the elderly:

Answer 16

Question 17

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?

Answer 17

• 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

Question 18

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

Answer 18

• 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

Question 19

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

Answer 19

• 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

Question 20

Physiological changes associated with normal ageing:

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

Answer 20

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

Question 21

Physiological changes associated with normal ageing:

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

Answer 21

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

Question 22

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

Answer 22

• 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

Question 23

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

Answer 23

• 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

Question 24

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

Answer 24

• 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

Question 25

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

Answer 25

• 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

Question 26

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

Answer 26

• ↓ 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

Question 27

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

Answer 27

• ↓ 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

Question 28

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

Answer 28

• 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

Question 29

Pharmacodynamics is..

Answer 29

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

Question 30

Examples of Pharmacodynamic Changes:

• … response
  
  • Warfarin
  • Benzodiazepines
  • Diltiazem
• … response
  
  • Beta-Blockers
  • Beta2-Agonists
  • Furosemide

Answer 30

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

Question 31

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)

Answer 31

• 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)

Question 32

Why is ‘Mrs Anderson’ Confused?

Answer 32

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

Question 33

What is Delirium?

• More than confusion!
  
  • … onset
  • Inattention
  • … thinking or altered level of consciousness
  • Associated with low levels of …
  • Low levels in patients with …

Answer 33

• 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

Question 34

D.E.L.I.R.I.U.M.

Answer 34

Question 35

Pharmacological Tug of WAR - older patients

Answer 35

Question 36

Anticholinergic Drugs: problems?

• Examples:
  
  • …
  • … antidepressants
  • Antispasmodics and muscle …
• Side effects:
  
  • .. Mouth
  • … retention
  • Constipation
  • …, delirium

Answer 36

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

Question 37

Anticholinergic Drugs: problems?

• Examples:
  
  • Anti…
  • T… …
  • Anti…. and muscle relaxants
• Side effects:
  
  • … Mouth
  • Urinary ….
  • C…
  • Confusion, delirium

Answer 37

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

Question 38

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.

Answer 38

• 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.

Question 39

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.

Answer 39

• 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.

Question 40

When to start, how to stop? elderly medicine

Answer 40

Question 41

Warning/recommendations in therapeutics in the elderly (1)

Answer 41

Question 42

Warning/recommendations in therapeutics in the elderly (2)

Answer 42