Geriatrics

CNS Depressants

• Benzodiazepines: 2-3x sensitivity, leading to more falls and fractures
• Barbiturates: CNS depressant
• Antipsychotics: sedation, anticholinergic effects, orthostatic hypotension, and arrhythmias; decrease dopamine receptors/neurons, levels, and increase risk of EPS effects
• Opioids: 2-8x higher risk of respiratory depression, but decreased N/V; hallucinations and cognitive impairment may increase risk of falls and fractures
• Antidepressants: increase risk of falls and fractures

Pharmacodynamics in the Elderly

• Increased sensitivity to:
  • Sedative hypnotics
  • Anticholinergics
  • Analgesics
  • Warfarin

Geriatric Giants

Geriatric Giant 1: Cognitive Impairment

• Delirium:
  • Acute disturbance in attention and disorganized thinking
  • Disorientation, perceptual disturbances, memory impairment
  • 60% of elderly hospitalized for surgery
  • Medical emergency; can cause death
  • Causes: drugs (e.g. sedatives, anticholinergics, narcotics), infection, pain, metabolic disturbances
  • Treatment: quiet, dim room, 1:1 care, hydration, reorientation, discontinuation of causative drugs
• Dementia:
  • Newly acquired cognitive impairments that interfere with social or occupational functioning
  • Prevalence increases with advancing age
  • Types: Alzheimer's Dementia (AD), Vascular Dementia, Mixed Vascular + AD, Dementia Lewy Body (DLB), and Frontotemporal Dementia (FTD)
  • Progressive and irreversible
• Alzheimer's Dementia:
  • Memory problems (e.g. losing items, missing appointments)
  • Difficulty performing complex tasks
  • Word finding difficulties, difficulty with names
  • Geographic disorientation (e.g. getting lost driving, familiar places)
  • Apathy and disinterest in surroundings
  • Sleep disturbances (e.g. increased daytime sleeping)
  • Disinhibiting behavior (e.g. impulsivity, socially inappropriate)
• Alzheimer's Disease Treatment:
  • Cholinesterase inhibitors (e.g. Donepezil, Rivastigmine, Galantamine) to slow progression
  • NMDA receptor activator (e.g. Memantine) for moderate/severe dementia

Depression

• Most common psychiatric illness in the elderly
• Often under-recognized and under-treated
• Geriatric Depression Scale (GDS) screening tool
• Common in Long Term Care patients, those with dementia, bereavement, disabilities, stroke, Parkinson's Disease, chronic illness, social isolation, poor education, poverty, alcoholism, and chronic pain
• Mnemonic for Depression: "Sig.E Caps" - depression checklist:
  • Suicidal Ideation
  • Interest, lack of G uilt E nergy, none C oncentration, poor A ppetite(s), altered P sychomotor changes (slowed or revved up) S leep
• Depression Treatment:
  • Non-pharmacologic: psychotherapy
  • Pharmacologic: Selective serotonin reuptake inhibitors (SSRIs) - safest in elderly, less concern for overdose and interaction with other meds

Geriatric Giant 2: Falls in the Elderly

• Falls are serious!
• More than 1/3 of patients > 65 fall each year in the community
• ½ of people who fall do so repeatedly
• ~5% of falls result in fractures
• ~5-10% result in other serious injuries
• 10% of visits to the ER
• Reason for 40% of nursing home admissions
• Orthostatic Hypotension:
  • Excessive drop in BP when changing from lying/sitting to standing
  • Symptoms: dizziness, faints, near falls/falls
  • Causes: diarrhea/vomiting, anemia, salt-losing kidney disease, alcohol, adrenal insufficiency, stroke, Parkinson's disease, deconditioning, and prolonged bed rest, autonomic problems associated with diabetes, drugs

Take Home Messages

• Changes due to aging (physiological, PK, and PD), co-morbidities, and many other drugs make drug prescribing in the elderly complex
• Caring for the elderly is a team sport! - Teamwork with the health professional team, patient, family, and caregiver
• Education is important to avoid ADRs and IDP
• "Start Low, Go Slow" (but keep going!)
• Review regimen regularly
• Non-specific complaints should prompt review to avoid prescribing cascades

General Approach to Caring for the Elderly and the Role of the Pharmacist

• Take a thorough history
• Collateral history - family member, caregiver
• Patient needs to bring in all pill bottles, blister packs, OTC meds, etc. to EVERY VISIT; complete and regular MedsChek
• Improving prescribing:
  • "I medicate first and ask questions later."
• Teamwork with MD: Before prescribing, think about:
  • What are we treating (Disease? Symptom? Prevention? Could it be an ADR caused by a drug?)
  • Can we use a non-drug approach?
  • Can we treat locally rather than systemically?
  • Can we remove something before adding something?
  • What interactions will there be?
  • Do we know this drug's pharmacology (e.g. renal clearance vs hepatic, P450 interactions, etc)
• Deprescribing:
  • Apply tools/methods for patients and clinicians - help make decisions about reducing or stopping medications
• Beers Criteria:
  • List of drugs NOT recommended for use in adults older than 65 in all settings.
  • First version in 1991, last update 2023.

Pharmacokinetic Changes with Age

• The action of drugs in the body over time includes processes of absorption, distribution, metabolism, and elimination
• Age-related changes in absorption:
  • Gastric pH increases
  • Splanchnic blood flow decreases
  • Delayed gastric emptying
  • Intestinal transit slows down
  • GI absorptive surface decreases
• However, the extent of drug absorption is generally unchanged, but may be slower in the elderly

Pharmacokinetic Changes with Age: Distribution

• Three key areas that change with age and affect drug distribution:
  1. Protein Binding
     • Albumin binds to acidic drugs (e.g., Naproxen, Phenytoin, Warfarin)
     • Alpha-1-acid glycoprotein binds to basic drugs (e.g., Lidocaine, Propranolol, Quinidine, Imipramine)
  2. Volume of Distribution
  3. Blood Flow
• Changes in body composition with age:
  • Decrease in total body water (from 61% at age 25 to 53% at age 70)
  • Increase in fat percentage (from 14% at age 25 to 30% at age 70)
  • Decrease in cell solids and bone mineral

Predisposing Risk Factors for Falls

• Previous falls
• Depression
• Balance impairment
• Decreased muscle strength
• Medications
• Gait impairment and walking difficulty
• Visual impairment
• Arthritis
• Cognitive impairment
• Pain
• Age >80
• Female
• Low BMI
• Urinary incontinence
• Diabetes

Geriatric Giant: Urinary Incontinence

• Definition: Involuntary loss of urine in sufficient amount or frequency to constitute a social or health problem
• Types:
  • Urge incontinence: leakage due to urgency
  • Stress incontinence: leakage due to cough, laugh, or sneeze
  • Mixed incontinence: combination of urge and stress incontinence
  • Overflow incontinence: leakage due to overextended bladder
  • Functional incontinence: leakage due to inability to toilet

Acute, Reversible Causes of Urinary Incontinence (DRIP)

• D: Delirium
• R: Restricted mobility, retention
• I: Infection, inflammation, impaction (fecal)
• P: Polyuria, pharmaceuticals

Drugs Associated with Urinary Incontinence

• Alpha blockers (e.g., terazosin)
• Anticholinergics (e.g., amitriptyline)
• Antipsychotics/neuroleptics (e.g., methotrimeprazine, chlorpromazine)
• Calcium-channel blockers (e.g., diltiazem)
• Antihistamines (e.g., diphenhydramine)
• Diuretics (e.g., furosemide)
• Drugs for Alzheimer's disease (e.g., donepezil)
• Ethanol
• Lithium
• Metoclopramide
• Narcotics
• Phenytoin
• Sedatives/hypnotics (e.g., lorazepam)
• Skeletal muscle relaxants (e.g., Can)

Beers Criteria and STOPP/START Criteria

• Purpose: Improve medication safety in older adults by increasing awareness of inappropriate medication use
• Encourage healthcare providers to stop and consider carefully the risks, consider non-drug alternatives
• Guide clinicians in making decisions about safe medication use in older adults
• Broad application to electronic health records

Medication Appropriateness Index (MAI) – Toolkit Online

• Measures the appropriateness of prescribing for elderly patients using 10 criteria for each medication prescribed
• Criteria include:
  • Indication
  • Is drug effective?
  • Is dose correct?
  • Are directions correct?
  • Are directions practical?
  • Drug-drug interactions
  • Drug-disease interactions
  • Is there duplication with other drugs?
  • Is duration of therapy acceptable?
  • Economics

Strategies to Improve Adherence

• Provide education to patients, family, and caregivers
• Link medication doses with daily routines, such as meals
• Use memory aids and administration aids
• Team approach with MD: recommendations to assist in reducing the number of meds taken and/or frequency of doses

Take Home Messages

• Changes due to aging, co-morbidities, and multiple drugs make drug prescribing in the elderly complex
• Adjustments for age, weight, renal function, hepatic metabolism, and low serum albumin are necessary
• Education is important to avoid ADRs and IDP
• "Start Low, Go Slow" (but keep going!)
• Review regimen regularly
• Non-specific complaints should prompt review to avoid prescribing cascades