Geriatric Pharmacotherapy

Geriatric Pharmacotherapy

• Polypharmacy: The simultaneous use of multiple medications, increasing the risk of adverse drug interactions, and decreased medication adherence in older adults.

Adverse Consequences

• Prescribing Cascades: A series of events where a medication is prescribed to treat an adverse effect of another medication, leading to a cycle of additional medications and potential harm.

Safe Prescribing Practices

• Beers Criteria: A list of medications considered potentially inappropriate for older adults due to their high risk of adverse effects, such as sedatives, hypnotics, and anticholinergics.

Key Considerations

• Age-related changes: Older adults experience decreased renal and hepatic function, leading to altered drug metabolism and increased sensitivity to medication side effects.
• Multimorbidity: Many older adults have multiple chronic conditions, requiring complex medication regimens and increasing the risk of polypharmacy and prescribing cascades.

Geriatric Pharmacotherapy Concepts

• Polypharmacy: The concurrent use of multiple medications by an individual, typically five or more, which increases the risk of adverse drug reactions, drug interactions, and decreased medication adherence.

Polypharmacy Risks

• Increased risk of adverse drug reactions (ADRs) due to drug-drug interactions and cumulative side effects
• Decreased medication adherence due to complexities in dosing regimens and pill burden
• Higher risk of hospitalizations, morbidity, and mortality in older adults

Prescribing Cascades

• Prescribing Cascade: A series of medications prescribed to treat the side effects of previous medications, leading to a cascade of inappropriate medication use
• Examples: prescribing a medication to treat a side effect of another medication, rather than addressing the underlying issue

Beers Criteria

• Beers Criteria: A set of guidelines for potentially inappropriate medications (PIMs) to avoid in older adults due to higher risk of adverse effects, limited efficacy, or availability of safer alternatives
• Criteria include medications with high anticholinergic properties, CNS active drugs, and medications with a high risk of falls or fractures

Geriatric Pharmacotherapy Key Concepts

Polypharmacy

• Polypharmacy is the concurrent use of multiple medications by an individual
• It is a common issue in geriatric patients, who often have multiple chronic conditions
• Polypharmacy increases the risk of adverse drug reactions, drug interactions, and medication non-adherence

Prescribing Cascades

• A prescribing cascade occurs when an adverse drug reaction is mistakenly diagnosed as a new medical condition
• This leads to the prescription of additional medications to treat the perceived condition
• The prescribing cascade can result in a vicious cycle of polypharmacy and increased healthcare costs

Beers Criteria

• The Beers Criteria is a list of potentially inappropriate medications (PIMs) for older adults
• Developed by Dr. Mark Beers, the criteria aim to reduce medication-related harm in geriatric patients
• The list includes medications with high risks of adverse effects, drug interactions, or diminution of benefit in older adults

Geriatric Pharmacotherapy Key Concepts

• Polypharmacy: The concurrent use of multiple medications, often prescribed by different healthcare providers, increasing the risk of adverse drug interactions and reactions.
• Prescribing Cascades: A process where a medication is prescribed to treat an adverse effect of another medication, leading to a cascade of subsequent prescriptions to treat additional adverse effects.

Beers Criteria

• A list of medications considered potentially inappropriate for older adults due to their high risk of adverse effects, interactions, and decreased efficacy in this population.
• Criteria include medications with strong anticholinergic properties, those that exacerbate common geriatric conditions, and those with significant drug-drug interactions.

Age-related Physiological Changes on Drug Pharmacokinetics

• Absorption: Decreased gastrointestinal motility and blood flow can lead to altered drug absorption rates in elderly patients.
• Distribution: Changes in body composition, including increased fat mass and decreased water content, can affect drug distribution and volume of distribution.
• Metabolism: Age-related decline in liver function and cytochrome P450 enzyme activity can impact drug metabolism, leading to increased serum drug levels.
• Excretion: Decreased kidney function can impair drug excretion, leading to accumulation and potential toxicity.

Impact on Pharmacodynamics in Elderly Patients

• Altered pharmacological response: Age-related changes in receptor density, receptor affinity, and signal transduction pathways can affect the efficacy and potency of medications.
• Increased sensitivity: Elderly patients may be more susceptible to adverse effects due to age-related changes in pharmacokinetics and pharmacodynamics.
• Dose adjustments: Consideration of age-related changes is essential when prescribing medications to elderly patients to minimize adverse effects and optimize therapeutic outcomes.

Geriatric Pharmacotherapy

• Polypharmacy: The concurrent use of multiple medications, often resulting in increased risk of adverse drug reactions, interactions, and decreased medication adherence.
• Prescribing cascades: A series of events where a medication is prescribed to treat an adverse effect of another medication, leading to a cascade of additional medications and potential interactions.

Beers Criteria

• A set of guidelines developed by Mark Beers in 1991 to identify potentially inappropriate medications for use in older adults.
• The criteria focus on medications that can cause harm, have limited efficacy, or have better alternatives.
• Examples of medications included in the Beers Criteria include benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticholinergics.

Age-Related Physiological Changes

• Pharmacokinetics:
  • Absorption: Age-related changes in gut motility, blood flow, and gastric pH can affect drug absorption.
  • Distribution: Changes in body composition, such as increased fat mass, can affect drug distribution and half-life.
  • Metabolism: Decreased liver function and enzymatic activity can lead to reduced drug metabolism.
  • Excretion: Decreased renal function can lead to impaired drug excretion.
• Pharmacodynamics: Age-related changes in receptor function, signal transduction, and homeostatic mechanisms can affect drug response and efficacy.
• These changes can lead to increased sensitivity to medications, increased risk of adverse effects, and altered drug response in elderly patients.

Geriatric Pharmacotherapy Concepts

• Polypharmacy: The use of multiple medications, often by older adults, which can lead to increased risk of adverse drug reactions, interactions, and decreased medication adherence.
• Prescribing Cascades: A series of events where a new medication is prescribed to treat an adverse effect of another medication, potentially leading to further adverse effects and additional medications.
• Beers Criteria: A list of medications that are potentially inappropriate for older adults due to their potential for adverse effects, especially in those with certain health conditions.

Age-Related Physiological Changes

• Absorption: Decreased absorption of medications in elderly patients due to decreased gastric acid secretion, reduced gut motility, and increased pH levels.
• Distribution: Changes in body composition, such as decreased lean body mass and increased fat mass, affecting the distribution of medications.
• Metabolism: Decreased liver function and metabolism, leading to increased plasma concentrations of medications.
• Excretion: Decreased renal function, leading to increased plasma concentrations of medications eliminated by the kidneys.
• Pharmacodynamics: Altered response to medications in elderly patients due to changes in receptor affinity, density, and sensitivity, as well as decreased homeostatic mechanisms.

Impact on Elderly Patients

• Increased Risk of Adverse Effects: Age-related physiological changes can increase the risk of adverse effects, such as sedation, confusion, and falls, due to altered pharmacokinetics and pharmacodynamics.
• Decreased Efficacy: Changes in pharmacokinetics and pharmacodynamics can also lead to decreased efficacy of medications in elderly patients.

Geriatric Pharmacotherapy Concepts

• Polypharmacy: The use of multiple medications, often by older adults, which can lead to increased risk of adverse drug reactions, interactions, and decreased medication adherence.
• Prescribing Cascades: A series of events where a new medication is prescribed to treat an adverse effect of another medication, potentially leading to further adverse effects and additional medications.
• Beers Criteria: A list of medications that are potentially inappropriate for older adults due to their potential for adverse effects, especially in those with certain health conditions.

Age-Related Physiological Changes

• Absorption: Decreased absorption of medications in elderly patients due to decreased gastric acid secretion, reduced gut motility, and increased pH levels.
• Distribution: Changes in body composition, such as decreased lean body mass and increased fat mass, affecting the distribution of medications.
• Metabolism: Decreased liver function and metabolism, leading to increased plasma concentrations of medications.
• Excretion: Decreased renal function, leading to increased plasma concentrations of medications eliminated by the kidneys.
• Pharmacodynamics: Altered response to medications in elderly patients due to changes in receptor affinity, density, and sensitivity, as well as decreased homeostatic mechanisms.

Impact on Elderly Patients

• Increased Risk of Adverse Effects: Age-related physiological changes can increase the risk of adverse effects, such as sedation, confusion, and falls, due to altered pharmacokinetics and pharmacodynamics.
• Decreased Efficacy: Changes in pharmacokinetics and pharmacodynamics can also lead to decreased efficacy of medications in elderly patients.

Geriatric Pharmacotherapy Key Concepts

• Polypharmacy: The simultaneous use of multiple medications, increasing the risk of adverse drug interactions, and potential negative outcomes in elderly patients.
• Prescribing Cascades: A series of events where a medication is prescribed to treat an adverse effect of another medication, leading to a cascade of additional medications and potential harm.

The Beers Criteria

• A set of guidelines for healthcare providers to identify potentially inappropriate medications (PIMs) for elderly patients.
• Criteria consider factors such as medication efficacy, safety, and potential drug interactions in older adults.

Age-Related Physiological Changes and Drug Pharmacology

• Absorption: Decreased gastric acid secretion, slowed gastric emptying, and reduced gut surface area can affect drug absorption in elderly patients.
• Distribution: Changes in body composition, decreased plasma albumin, and increased body fat can alter drug distribution and affect drug efficacy.
• Metabolism: Decreased liver function, reduced renal clearance, and age-related changes in enzyme activity can impact drug metabolism and elimination.
• Excretion: Decreased renal function, reduced glomerular filtration rate, and increased tubular reabsorption can affect drug excretion and lead to toxicity.
• Pharmacodynamics: Age-related changes in receptor density, affinity, and responsiveness can alter drug efficacy and increase the risk of adverse effects.

Identifying Potentially Inappropriate Medications

• Use the Beers Criteria to identify medications that may be inappropriate for elderly patients due to their potential to cause harm, interact with other medications, or have limited efficacy.
• Consider patient-specific factors, such as age, medical conditions, and current medications, when selecting medications for elderly patients.

Geriatric Pharmacotherapy Concepts

• Polypharmacy: The simultaneous use of multiple medications by an elderly patient, increasing the risk of adverse drug reactions, interactions, and decreased medication adherence.
• Prescribing Cascades: A sequence of events where an adverse drug reaction is mistakenly diagnosed as a new medical condition, leading to the prescription of additional medications that can worsen the patient's condition.

Beers Criteria

• A list of potentially inappropriate medications (PIMs) for elderly patients, developed to improve medication safety and reduce adverse drug events.
• The criteria are used to identify medications that should be avoided or used with caution in elderly patients due to their potential to cause harm or have limited efficacy.

Age-Related Physiological Changes

• Absorption: Decreased gastric acid secretion and slowed gastrointestinal motility can affect drug absorption in elderly patients.
• Distribution: Age-related changes in body composition, such as increased fat mass and decreased lean body mass, can alter drug distribution.
• Metabolism: Decreased liver mass, blood flow, and enzyme activity can affect drug metabolism in elderly patients.
• Excretion: Reduced renal function can impact drug elimination, leading to potential toxicity.
• Pharmacodynamics: Age-related changes in receptor sensitivity and signal transduction can affect drug efficacy and adverse effects.

Using the Beers Criteria

• The Beers Criteria are used to identify PIMs that can cause harm, have limited efficacy, or have safer alternatives.
• Healthcare providers use the criteria to evaluate medication regimens and optimize therapy for elderly patients.

Key Concepts in Geriatric Pharmacotherapy

• Polypharmacy: the simultaneous use of multiple medications, increasing the risk of adverse drug reactions, drug-drug interactions, and decreased medication adherence in elderly patients.
• Prescribing cascades: a cycle of prescribing additional medications to treat the adverse effects of previous medications, leading to further polypharmacy and potential harm.

Age-Related Physiological Changes

• Changes in drug pharmacokinetics:

  • Decreased absorption: altered gastrointestinal physiology and decreased gastric motility affecting oral drug absorption.
  • Altered distribution: changes in body composition, blood flow, and protein binding affecting drug distribution.
  • Slowed metabolism: decreased liver function and enzyme activity affecting drug metabolism.
  • Impaired excretion: decreased renal function affecting drug elimination.

• Changes in drug pharmacodynamics:

  • Increased sensitivity to drug effects due to age-related changes in receptor density and function.
  • Decreased homeostatic responses, making elderly patients more susceptible to adverse drug reactions.

Beers Criteria

• A set of guidelines for identifying potentially inappropriate medications (PIMs) for elderly patients.
• Criteria include:
  • Medications with high risk of adverse effects in elderly patients.
  • Medications with decreased efficacy in elderly patients.
  • Medications with safer alternatives available.

Applying the Beers Criteria

• Identify PIMs by reviewing medications that:
  • Have a high risk of sedation, hypotension, or bleeding.
  • Have anticholinergic or antihistaminic properties.
  • Are not recommended for use in elderly patients due to safety concerns.

Key Concepts in Geriatric Pharmacotherapy

• Polypharmacy: the simultaneous use of multiple medications, increasing the risk of adverse drug reactions, drug-drug interactions, and decreased medication adherence in elderly patients.
• Prescribing cascades: a cycle of prescribing additional medications to treat the adverse effects of previous medications, leading to further polypharmacy and potential harm.

Age-Related Physiological Changes

• Changes in drug pharmacokinetics:

  • Decreased absorption: altered gastrointestinal physiology and decreased gastric motility affecting oral drug absorption.
  • Altered distribution: changes in body composition, blood flow, and protein binding affecting drug distribution.
  • Slowed metabolism: decreased liver function and enzyme activity affecting drug metabolism.
  • Impaired excretion: decreased renal function affecting drug elimination.

• Changes in drug pharmacodynamics:

  • Increased sensitivity to drug effects due to age-related changes in receptor density and function.
  • Decreased homeostatic responses, making elderly patients more susceptible to adverse drug reactions.

Beers Criteria

• A set of guidelines for identifying potentially inappropriate medications (PIMs) for elderly patients.
• Criteria include:
  • Medications with high risk of adverse effects in elderly patients.
  • Medications with decreased efficacy in elderly patients.
  • Medications with safer alternatives available.

Applying the Beers Criteria

• Identify PIMs by reviewing medications that:
  • Have a high risk of sedation, hypotension, or bleeding.
  • Have anticholinergic or antihistaminic properties.
  • Are not recommended for use in elderly patients due to safety concerns.

Geriatric Pharmacotherapy

• Polypharmacy refers to the use of multiple medications by an individual, which is common in older adults and can lead to adverse drug reactions and interactions.

Age-Related Physiological Changes

• Changes in pharmacokinetics with age:
  • Absorption: Decreased gastric acid secretion, reduced gut motility, and increased gastric pH can affect drug absorption.
  • Distribution: Body composition changes, including increased fat and decreased lean body mass, can affect drug distribution.
  • Metabolism: Decreased liver function and enzyme activity can impact drug metabolism.
  • Excretion: Decreased renal function can lead to drug accumulation and toxicity.
• Changes in pharmacodynamics with age:
  • Altered receptor affinity and density can affect drug response.
  • Increased sensitivity to certain medications, such as benzodiazepines and anticholinergics.

Prescribing Cascades

• A prescribing cascade occurs when an adverse drug reaction is misdiagnosed as a new condition, leading to the initiation of a new medication, which can further exacerbate the problem.

Beers Criteria

• A set of criteria used to identify potentially inappropriate medications for elderly patients, including medications that:
  • Have a high risk of adverse effects in older adults.
  • Have a narrow therapeutic index or are difficult to withdraw.
  • Have a lack of evidence for efficacy or safety in older adults.
  • Can exacerbate common geriatric conditions, such as dementia, delirium, or falls.

Drug Choice and Dose Adjustments

• Considerations for drug choice and dose adjustments in geriatric patients:
  • Age-related changes in pharmacokinetics and pharmacodynamics.
  • Presence of multiple comorbidities and polypharmacy.
  • Use of the Beers Criteria to identify potentially inappropriate medications.
  • Need for close monitoring and dose titration to minimize adverse effects.

Geriatric Pharmacotherapy Concepts

• Polypharmacy: the simultaneous use of multiple medications by a patient, which increases the risk of adverse drug reactions, drug interactions, and decreased medication adherence.
• Prescribing cascades: a sequence of events where a medication is prescribed to treat the side effect of another medication, leading to a cascade of medication use.
• Beers Criteria: a list of potentially inappropriate medications for elderly patients, which helps healthcare providers avoid medications that may be ineffective or cause harm in older adults.

Age-Related Physiological Changes

• Changes in absorption: decreased gastric acid secretion, slower gastric emptying, and decreased jejunal surface area affect drug absorption in elderly patients.
• Changes in distribution: decreased lean body mass, increased body fat, and decreased albumin levels affect drug distribution in elderly patients.
• Changes in metabolism: decreased liver size, decreased liver blood flow, and decreased enzyme activity affect drug metabolism in elderly patients.
• Changes in excretion: decreased renal function and decreased glomerular filtration rate affect drug excretion in elderly patients.
• Changes in pharmacodynamics: decreased responsiveness to certain medications, increased sensitivity to medication side effects, and altered receptor binding in elderly patients.

Beers Criteria Applications

• Identify potentially inappropriate medications for elderly patients based on factors such as drug-drug interactions, side effect profiles, and dosing requirements.
• Avoid medications with high risk of adverse effects, such as anticholinergics, benzodiazepines, and non-steroidal anti-inflammatory drugs (NSAIDs).

Implications of Age-Related Physiological Changes

• Decreased medication clearance and increased half-life in elderly patients require dose adjustments and monitoring for toxicity.
• Age-related changes in receptor sensitivity and binding affect medication efficacy and side effect profiles.
• Individualized medication regimens must consider age-related physiological changes to optimize therapeutic outcomes.