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geropharmacology

JasminFlorian
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geropharmacology

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    1. Geropharmacology Everything that you wanted to know about drugs and the elderly, but were afraid to ask Jim Webster MS, MD Supported by a grant from the Retirement Research Foundation

    4. The Message for Today Start low Go slow (but get to therapeutic levels) Sometimes say no (how about other non-drug treatments?)

    5. What Geriatricians Do (that makes a difference) Counsel families about dying Stop drugs ! --- because although the elderly are 14% of the population they use 40 % of the prescriptions, and They are especially likely to suffer adverse drug events (ADE’s)

    6. Pharmacokinetics 101 Absorption Distribution Metabolism Clearance

    7. Absorption From a practical standpoint this is not usually a problem in the elderly Caveat: Tube feedings may reduce absorption if continuous

    9. Clearance via Kidney-Reduced Lower GFR (decreased: size, tubular secretion, renal blood flow) Serum creatinine is not a reliable measure and Cockcroft-Gault is an estimate Renal (fx) shows big individual variations in the elderly (140-age) x body wt. (kg.) Cr cl. = 72 x Serum Cr. (x 0.85 for Women)

    10. Drug Metabolism is Very Liver Dependent Reduced liver (fx) due to decreased liver size, blood flow, and dsz. (e.g. CHF) Phase I - first pass oxidative/reduction activities are reduced (e.g. propranolol) Phase II - drugs are preferred (oxazepam) In general, biotransforming enzymes are reduced in the elderly

    11. Pharmacodynamics Alterations are complex and poorly studied Generally the elderly are more sensitive to drug effects (e.g. the blood/brain barrier and anticholinergics and benzodiazapines) But, Beta-adrenergic effects are reduced Homeostasis is more effected by drugs (e.g. postural BP, extrapyramidal system, thermoregulation, cognition)

    12. Adverse Drug Events (ADE’s) in the Elderly are: Common in both in-patients and out-patient environments ( ? 35 % !) A frequent cause of hospitalization Costly Under-diagnosed Mostly preventable, and are due to errors in prescribing (40%) or monitoring and supervision (50%)

    13. Medications Causing Preventable Averse Drug Events (PADE’s) in Ambulatory Settings Diuretics 22% Other CV Drugs 25% Hypoglycemics 11% Anticoagulents 10% Analgesics 15% Sedative Hypnotics 17% Gurwitz

    14. PADE Errors Excess Dosing 24% Wrong Drug 27% Known Interaction 13% Inadequate Pt. Educ. 18% Pt. Adherence 21% Inadequate Monitoring 36% Gurwitz

    15. ADE Risk Factors Six drugs or > 12 doses a day Female Low BMI High # of comorbidities (Charleson Index Score) > 85 years old Low Cr. Cl.

    16. High Risk Drugs for Elderly Warfarin Digoxin > 0.125/day Meperidine Ticlodipine Antihistimines (especially Diphenhydramine-Benadryl!) Imdomethicin Chlorpropamide NSAIDS Propoxyphene (Darvon) Review the indications, dose, and monitoring of: Corticosteroids Anticholinergics Amnioderone Anticoagulents Benzodiazapines (especially the long acting ones)

    17. In Prescribing for Elderly Ask: Are there non-drug Rx’s? (e.g. for sleep, anxiety, PT for Msk. Sxs) Could these sxs. be due to a drug effect? What is the end point? Can this patient afford this medication? Can they open the pill container? Will they understand how and when to take it?

    18. “Writing” Prescriptions Use the Computer whenever possible Sit down and print Watch decimal points (mcg. 0.5, 1) What is this for? When is it taken? Watch spaces (Inderal40) No “as directed” directions Stamp out abbreviations

    19. Verbal orders Spell Drugs out Use Pilot numbers “one five not 15 mg’s Speak clearly and slowly Clearly specify concentrations Have the receiver (R.N. or RPh.) read back the order

    20. Adherence in the Elderly: Is better in the functional older patient than in most patients (They like and trust us!) Non-adherence may be up to 50% in some older populations, frequently those who need medications the most Consider the patient’s financial, cognitive and functional status, and their health beliefs

    21. Strategy I - Simplify It Once a day dosing Large fonts on the labels Pill boxes, calendars and drug diaries Decrease the numbers of meds.

    22. Strategy II - Clarify Administration Put the indication on the label or diary Specify the exact times of administration Give written instructions and information, encourage package inserts Involve others such as family, home health

    23. Strategy III - Systems Approaches Have a (computerized?) medication list on every chart A brown bag inventory by staff each visit Patient to use one pharmacy (?print out) Computerized prompts for blood levels

    24. In Summary For Elderly Patients: Start low Go slow (But get to therapeutic levels) Sometimes say no That’s all folks ! Thank you

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