Dr. D. K. BrahmaAssociate Professor

Department of PharmacologyNEIGRIHMS, Shillong

Demographic transition – a global demographic event

WHO – People 60 years of age and older is 650 million now and forecast to reach 2 Billion by 2050

Persons aged 65 years and older constitute 13% of the population and purchase 33% of all prescription medications

By 2040, 25% of the population will purchase 50% of all prescription drugs

Medications play crucial role in geriatric health care as they treat chronic diseases, alleviate pain and improve quality of life

Age-related changes in drug disposition and pharmacodynamic responses have significant clinical implications

Increased use of a number of medications in elderly raises the risk of medicine-related problems that may occur

Medication use and the incidence of adverse drug outcomes increase with advancing age

It is important to ensure quality use of medicines in older people

Large number of new drugs available each year

Off-label indications are expandingAdvanced understanding of drug-drug

interactions Increasing popularity of “nutriceuticals”Multiple co-morbid statesPolypharmacyMedication complianceEffects of aging physiology on drug therapyMedication cost

Rate of absorption may be delayed• Lower peak concentration

• Delayed time to peak concentration

Factors:• Increased GI pH

• Decreased gastric emptying

• Dysphagia

• Route of administration

• Co-morbidity conditions

• Presence of drugs (pH and gastric emptying) and additives

Aging Effect Vd Effect Examples

body water Vd for hydrophilic

drugs

ethanol, lithium

lean body mass Vd for drugs that

bind to muscle

digoxin

fat stores Vd for lipophilic

drugs

diazepam, trazodone

plasma protein

(albumin)

% of unbound or

free drug (active)

diazepam, valproic acid,

phenytoin, warfarin

Reduced amount of water in the body - fat soluble drugs remain longer in

the body with prolonged effects – of importance for some sedatives and

anxiolytics

Pathway Effect Examples

Phase I: oxidation, hydroxylation, dealkylation, reduction

Conversion to metabolites of lesser, equal, or greater

diazepam, quinidine, piroxicam, theophylline

Phase II: glucuronidatio, conjugation, or acetylation

Conversion to inactive metabolites

lorazepam, oxazepam, temazepam

•Reduced liver function

•Hepatic microsomal

drug metabolizing activity

may be reduced due to:decreased hepatic

blood flow

decreased liver size

and mass

Examples: morphine,

metoprolol, propranolol,

verapamil, amitryptyline,

nortriptyline (sensitivity to

beta-blockers reduced)

Reduced kidney function - decreased excretion of some cardiovascular drugs, some antibiotics, diabetic drugs, antiinflammatory drugs – need to reduce dosage

Decreased kidney size Decreased renal blood flow Decreased number of functional nephrons Decreased tubular secretion Result: glomerular filtration rate (GFR) Decreased drug clearance: atenolol, gabapentin,

H2 blockers, digoxin, allopurinol, quinolones Creatinine clearance (CrCl) is used to estimate

glomerular rate

Brain and nervous system more sensitive to psychotropic and analgesic drugs –dizziness, confusion, cognitive impairment

Decreased capacity to regulate blood pressure – blood pressure fall, fainting, vertigo when using drugs for hypertension

Gastrointestinal sensitivity to anti-inflammatory drugs - bleeding

Balance between overprescribing and underprescribing• Correct drug

• Correct dose

• Targets appropriate condition

• Is appropriate for the individual patient

Avoid “a pill for every ill”

Always consider non-pharmacologic therapy

Adverse drug events (ADEs)

Drug interactions

Duplication of drug therapy

Decreased quality of life

Unnecessary cost

Medication non-adherence

Responsible for 5-28% of acute geriatric hospital admissions

Greater than 95% of ADEs in the elderly are considered predictable (Type A) and approximately 50% are considered preventable

Most errors occur at the ordering and monitoring stages

Most common medications associated with ADEs in elderly• Opioid analgesics• NSAIDs• Anticholinergics• Benzodiazepines• Also: cardiovascular agents, CNS agents, and

musculoskeletal agents

High potential to cause severe ADEs in

elderly – amitriptyline, chlorpropamide,

digoxin >0.125mg/d, disopyramide,

antispasmodics, meperidine, methyldopa,

pentazocine, ticlopidine

High potential but less severe:

antihistamines, diphenhydramine,

dipyridamole, ergot mesyloids,

indomethacin, muscle relaxants

ADE interpreted as new

medical condition

Drug 1

Drug 2

ADE interpreted as new

medical condition

Drug 3

Rochon PA, Gurwitz JH. Optimizing drug treatment in elderly people: the prescribing cascase. BMJ 1997;315:1097.

Combination Risk

ACE inhibitor + potassium Hyperkalemia

ACE inhibitor + K sparing diuretic Hyperkalemia, hypotension

Digoxin + antiarrhythmic Bradycardia, arrhythmia

Digoxin + diuretic

Antiarrhythmic + diuretic

Electrolyte imbalance; arrhythmia

Diuretic + diuretic Electrolyte imbalance; dehydration

Benzodiazepine + antidepressant

Benzodiazepine + antipsychotic

Sedation; confusion; falls

CCB/nitrate/vasodilator/diuretic Hypotension

Doucet J, Chassagne P, Trivalle C, et al. Drug-drug interactions related to hospital admissions in older adults: a

prospective study of 1000 patients. J Am Geriatr Soc 1996;44(9):944-948.

Combination Risk

NSAIDs + CHF

Thiazolidinediones + CHF

Fluid retention; CHF exacerbation

BPH + anticholinergics Urinary retention

CCB + constipation

Narcotics + constipation

Anticholinergics + constipation

Exacerbation of constipation

Metformin + CHF Hypoxia; increased risk of lactic acidosis

NSAIDs + gastropathy Increased ulcer and bleeding risk

NSAIDs + HTN Fluid retention; decreased effectiveness of diuretics

1. When meeting the patient - get ready to spent more time and understand the patient and his problems – see the whole patient as a part of whole

2. Identify the patient`s need of treatment – diagnosis important - Have a comprehensive view

3. Symptoms can be adverse reactions to drugs

4. Record which other drugs the patient is using

5. Evaluate what has to be prescribed – make a benefit risk assessment, is there any medication which should be stopped – must avoid Polypharmacy

6. Which dosage and administration form is appropriate

7. Make a plan for the treatment, when to meet for a follow-up of the effects of the treatment and discuss this with the patient or her or his carer

• Use of lower doses, longer intervals, slower titration are helpful in decreasing the risk of drug intolerance and toxicity

8. Careful monitoring is necessary to ensure successful outcomes

9. Remember:• Balance between under prescribing and overprescribing• Avoid “a pill for every ill”• Always consider non-pharmacologic therapy

10. Report adverse reactions if they occur

Always take utmost care and responsibility

while prescribing medicines to an aged

patient – think, re-think, discuss with

colleague/seniors - if needed and apply

your best intellectual knowledge - Be

cautious with NSAIDS, CNS drugs, CVS

drugs, diuretics and oral hypoglycaemics

Brahma DK, Wahlang JB, Marak MD, Ch. Sangma M. Adverse drug reactions in the elderly. J Pharmacol Pharmacother [serial online] 2013 [cited 2017 Sep 24];4:91-4.

Available from: http://www.jpharmacol.com/text.asp?2013/4/2/91/110872

We do not want to meet ageism

We do not want to be discriminated

We want to keep our self-determination

We want to keep our dignity, integrity

We want to feel we are a resource

When in need, we want access to high

quality care and services including

palliative care

At the very end of life we should not Barbro Westerholm.Prof.em, Member of Swedish Parliament. EFNS Stockholm 2012; Presentation - Healthy ageing and medicines - European Medicines ...www.ema.europa.eu/docs/en_GB/document_library/.../2012/.../WC500125120.pdf

“To care for those who once

cared for us is one of the

highest honours.”