1. ABHINAV SAWHNEY M.PHARMACY (PHARMACOLOGY) AMITY INSTITUTE OF PHARMACY AMITY UNIVERSITY NOIDA 1

2. It is the art and science of preventing disease in the geriatric population and promoting their health and efficiency 2 3. In treating the elderly, remember that the best intervention is prevention. 3 4. Geriatrics Senility Decline in sexual prowess Diminution in endocrine activity Loss of elasticity of blood vessels Rise in B.P 4 5. RISK OF GERIATRICS PRONE FOR INFECTIONS PRONE FOR INJURIES NEED SPECIAL ASSISTANCE PRONE FOR PSYCHOLOGICAL PROBLEMS PRONE FOR DEGENERATIVE DISORDERS INCREASED RISK FOR DISEASE INCREASED RISK OF DISABILITY INCRASED RISK OF DEATH 5 6. Changes in the body systems of the elderly 6 7. Common age-related systemic changes 7 8. GERIATRIC PEOPLE PROBLEMS HEALTH PROBLEMS 1.Joint problems 2.Impairment of special senses 3. Cardio vascular disease 4.Hypothermia 5.Cancer, Prostate enlargement, Diabetes& Accidental falls Psychological problems 1. Emotional problems 2. Suicidal tendency 3.& Senile dementia, Alzheimerdisease Social problems Poverty, Loneliness, Dependency, Isolation, Elder abuse, Generation Gap 8 9. 9 10. Polypharmacy many drugsindicates the use of more medication than is clinically indicated or warranted. 5+ drugs 2000 = 200 million visits to the doctor No prescription (30%) Prescription of 1 - 2 drugs (30%) Prescription of 3+ drugs (30%) 10 11. Physician Factors Presuming patient expects prescription medication and no medication review Prescribing without sufficient investigation of clinical situation Unclear, complex, incomplete instruction; not simplifying the regimen Ordering automatic refills Lack of knowledge of geriatric clinical pharmacologyinappropriate prescribing 11 12. Patient Factors Seeing multiple physicians and pharmacies Hoarding of medications Inaccurate reporting of ALL medicines concurrently being taken Assuming that when medication starts, they can continue indefinitely Changes in daily habits Changes in cognition, depression, insufficient funds, declining function, living alone 12 13. Polypharmacy leads to Adverse drug reactions Drug-drug interactions Decreased medication compliance Poor quality of life Unnecessary drug expense 13 14. Effects of Physiologic Aging Absorption Delayed gastric emptying; decreased gastric acidity; decreased splanchic blood flow Drug Distribution Higher percentage of fat; decreased total body water; decreased plasma albumin concentration 14 15. Effects of Physiologic Aging Serum Concentration Change in body composition changes serum concentration of water-soluble drugs Change in fat mass affect concentration of fat-soluble medications Drug Clearance Altered liver metabolism; decreased renal excretion of drugs 15 16. Adverse Drug Reactions Simulate conventional image of growing old: unsteadiness, confusion, nervousness, fatigue, insomnia, drowsiness, falls, depression, incontinence, malaise Criteria for potentially inappropriate medication use in older adults (US Consensus Panel of Experts, 2003) 16 17. Adverse Drug Reactions Fifth leading cause of death in older adults Falls from orthostatic hypotension Confusion and disorientation Hepatic toxicity Renal toxicity *Creatinine clearance formula 17 18. Iatrogenic Problems Anticholinergics: confusion; orthostatic hypotension; dry mouth; blurred vision; urinary retention Tricyclics: confusion and unstable gait Antiemetics: confusion; orthostatic hypotension; blurred vision; falls; dry mouth; urinary retention 18 19. Iatrogenic Problems Digoxin: toxicity H2 Blockers: confusion Benzodiazepines: CNS toxicity Narcotics: constipation; start low; go slow 19 20. 20 21. Pharmacokinetics (PK) Absorption bioavailability: the fraction of a drug dose reaching the systemic circulation Distribution locations in the body a drug penetrates expressed as volume per weight (e.g. L/kg) Metabolism drug conversion to alternate compounds which may be pharmacologically active or inactive Elimination a drugs final route(s) of exit from the body expressed in terms of half-life or clearance 21 22. Effects of Aging on Absorption Rate of absorption may be delayed Lower peak concentration Delayed time to peak concentration Overall amount absorbed (bioavailability) is unchanged 22 23. Hepatic First-Pass Metabolism For drugs with extensive first-pass metabolism, bioavailability may increase because less drug is extracted by the liver Decreased liver mass Decreased liver blood flow 23 24. Factors Affecting Absorption Route of administration What it taken with the drug Divalent cations (Ca, Mg, Fe) Food, enteral feedings Drugs that influence gastric pH Drugs that promote or delay GI motility Comorbid conditions Increased GI pH Decreased gastric emptying Dysphagia 24 25. Effects of Aging on Volume of Distribution (Vd) Aging Effect Vd Effect Examples body water Vd for hydrophilic drugs ethanol, lithium lean body mass Vd for 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 plasma protein (1-acid glycoprotein) % of unbound or free drug (active) quinidine, propranolol, erythromycin, amitriptyline 25 26. Aging Effects on Hepatic Metabolism Metabolic clearance of drugs by the liver may be reduced due to: decreased hepatic blood flow decreased liver size and mass Examples: morphine, meperidine, metoprolol, propranolol, verapamil, amitryptyline, nortriptyline 26 27. Metabolic Pathways Pathway Effect Examples Phase I: oxidation, hydroxylation, dealkylation, reduction Conversion to metabolites of lesser, equal, or greater diazepam, quinidine, piroxicam, theophylline Phase II: glucuronidation, conjugation, or acetylation Conversion to inactive metabolites lorazepam, oxazepam, temazepam ** NOTE: Medications undergoing Phase II hepatic metabolism are generally preferred in the elderly due to inactive metabolites (no accumulation) 27 28. Other Factors Affecting Drug Metabolism Gender Comorbid conditions Smoking Diet Drug interactions Race Frailty 28 29. Concepts in Drug Elimination Half-life time for serum concentration of drug to decline by 50% (expressed in hours) Clearance volume of serum from which the drug is removed per unit of time (mL/min or L/hr) Reduced elimination drug accumulation and toxicity 29 30. Effects of Aging on the Kidney 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 30 31. Estimating GFR in the Elderly Creatinine clearance (CrCl) is used to estimate glomerular rate Serum creatinine alone not accurate in the elderly lean body mass lower creatinine production glomerular filtration rate Serum creatinine stays in normal range, masking change in creatinine clearance 31 32. Determining Creatinine Clearance Measure Time consuming Requires 24 hr urine collection Estimate Cockroft Gault equation (IBW in kg) x (140-age) ------------------------------ x (0.85 for females) 72 x (Scr in mg/dL) 32 33. Limitations in Estimating CrCl Not all persons experience significant age-related decline in renal function Some patients muscle mass is reduced beyond that of normal aging Suggest using 1 mg/dL if serum creatinine is less than normal (