A Practical Approach to a Geriatric Patient

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A Practical Approach to a Geriatric Patient

• Tatyana Gurvich, Pharm.D., CGP
• USC School of Pharmacy
• UCI Sr. Health Center
• Queenscare Family Clinics
• Glendale Adventist FPRP

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Medication-Related Problems in the Elderly

• Common, Costly and Preventable
• Total estimated healthcare expenditure related to
  potentially inappropriate medications is
  7.2billion
• 27 of adverse events in primary care settings
• 42 of adverse events in long term care
• 380,000-450,000 adverse drug events occur
  annually in hospitals.
• JAGS 2012
• Arch Int Med 2009

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Contributing Factors

• Multiple Medical conditions
• An average of 6-7 Rx and 3-4 OTC daily
• 40 have used some form of dietary supplement
• ADRs more common when taking 5 or more meds
  daily
• Multiple providers
• Time Constraints
• Patient driven prescribing

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Prescribing challenges for older patients

• Is pharmacotherapy is beneficial
• Adverse reaction/Drug interaction potential
• Prescribing Cascades
• Age related changes which alter drug response in
  older adults
• Dosing of medications

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Prescribing challenges for older patients (cont)

• Cost of medications/MediCare issues
• New vs. Established Medications
• Limitations of Pre-marketing Trials
• Problem Medications

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Geriatric PharmacologyPharmacokinetics

• Absorption
• Use of PPI, H2Blockers, Antacids
• Medications with anti-cholinergic profile
• Distribution
• Fat soluble medications an extended t1/2
• Water soluble medications Higher concentrations
  
• Dose adjustments are necessary

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Metabolism Drug Interactions

• Differences in metabolism/drug interaction
  potential within a drug class
• Statins Crestor/Pravachol fewer problems
• SSRIs Celexa/ Lexapro fewer problems
• H2blockers Cimetidine more problems
• Antibiotics Mixed
• Additive effect
• Serotonin syndrome/ QT prolongation
• Plavix and PPIs/ Codeine

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PK Excretion

• Creatinine clearance declines with age
• Serum Cr is a poor indicator of indicator and can
  overestimate renal function
• Dosing adjustment with reduced renal function
• Vague guidelines which lack clinical practicality
• Bisphosphonates
• Macrodantin

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Pharmacodynamics

• Blood Brain Barrier Permeability
• Increased Sensitivity medications
• CNS acting medications
• Diabetes medications
• Consequences of low Blood Glucose
• HTN meds
• Consequences of low Blood Pressure
• Drugs with anti-cholinergic profile

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Pharmacodynamics

• Examples of altered response in geriatrics
• Oxybutinin
• Diphenydramine
• Albuterol Inhaler
• Timoptic eye drops

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Polypharmacy/Polymedicine

• What is polypharmacy?
• The use of unnecessary medications which is
  independent of the number of medications being
  taken
• Increases the risk of
• Adverse reactions
• Drug/Drug Interactions
• Prescribing cascades
• Compliance

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The prescribing cascade

• Drug induced adverse events which mimic symptoms
  of other diseases or can precipitate confusion,
  and or falls.
• Prozac TO a FALL
• Prozac for depression. Ativan for Prozac induced
  anxiety and insomnia. Pt became dizzy, fell and
  broke a hip
• Plendil TO a diagnosis of GERD and an ORTHO work
  up
• Plendlil for HTN ORTHO work up ordered for
  Plendil induced edema PPI was added for GERD
• Verapamil TO Haldol
• Verapamil for HTN Lasix for Verapamil induced
  CHF/Edema Ditropan for diuretic induced
  incontinence Haldol for Ditropan induced
  confusion and agitation due to its
  anti-cholinergic effects

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ACOVE Assessing Care of Vulnerable Elders

• Document drug indication
• Provide adequate pt education
• Maintain current medication list
• Document response to therapy
• Review ongoing need for therapy

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Medication Considerations

• Benzodiazepines Long and short acting
• Risk of confusion, falling, dependence
• Non-BZD hypnotics Avoid chronic use
• More focus on behavioral management
• Opioids Increased risk of falls/fractures
• Tramadol Clcr 30ml/min SE/Seizure risk

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Medication Considerations

• Focus on Neuropathic pain alternatives
• SNRIs/Gapapentin/Pregabalin/Capsaicin/Lidocaine
• Gabapentin/Pregabalin Clcr less 60ml/min
• Increased risk of CNS side effects
• Duloxetine less Crcl 30ml/min
• More nausea/diarrhea

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Medication Considerations

• Mirtazapine/SNRI/ SSRIs SIADH Check Na when
  starting/changing dose
• SSRIs Increased risk of falling
• OTC Sympathomimetics Stimulant effects
• Insomnia, anxiety, agitation
• Antipsychotics for behavior management
• Risk of CVA and mortality Risk vs. Benefit

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Medications Considerations

• NSAIDs
• PPI/misoprostol doesnt ELIMINATE risk
• Indomethacin/Toradol
• CHF and CKD risk
• Increase in blood pressure with chronic use
• Skeletal muscle relaxants
• Poorly tolerated, all on the Beers list
• Potentially habit forming

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Medication Conisderations

• Ca channel blockers constipation/edema
• Verapamil/Diltiazem and CHF
• Beta blockers Hypoglycemia Fatigue
• Thiazides SE and CrCllt30ml/min
• Clonidine Bradycardia, orthostasis
• Alpha Blockers Orthostasis

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Medicaton Considerations

• Miscelaneous GI medications
• Reglan, Tigan, Lomotil
• DA antagonist Anticholinergic side effects
• Mineral oil
• Absorption of fat soluble vitamins risk of
  aspiration
• H2 antagonists in dementia/delirium
• Aniticholinergic effects
• Na Containing Antacids
• Substantial sodium load Edema and increase in
  BP

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Medication Considerations

• Endocrine
• Sliding scale insulin, Glyburide
• Actos/Avandia for CHF risk
• Desiccated thyroid
• Estrogen/Megace/Testosterone
• Lack of cardio-protective/cognitive effect
• Lack of weight gain/increased thrombosis
• Cardiac risk/prostate cancer

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Drugs with Strong Anti-cholinergic Properties

• 1st Generation antihistamines/Loratadine
• Artane/Cogentin
• Skeletal muscle relaxants
• TCAs/Paroxetine
• Old antipsychotics
• Compazine, Promethazine, Zyprexa
• Urinary and GI antispasmodics
• The concept of anti-cholinergic load

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Steps to Reducing Poly-pharmacy

• Brown Bag all medications at each office visit.
  Keep accurate records
• Identify all medications by brand/generic name
  and drug class
• All drugs prescribed should have a clinical
  indication
• Stop any drug without known benefit
• Consider what effect drug therapy has on quality
  of life

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Steps to Reducing Poly-pharmacy (CONT)

• Know the side effects of the drugs prescribed and
  what to expect from them
• Understand the PK and pharmacodynamics of drugs
  prescribed
• Substituting drugs within classes can eliminate
  DIs and ADRs
• Be aware for the prescribing cascade
• ONE DISEASE, ONE DRUG, ONCE DAILY
• START LOW, GO SLOW, BUT GO