Pharmacotherapeutics Lecture 1st Year Lecture-2 PDF

Pharmacotherapeutics In The Elderly Michelle A. Hart, MD CCFP (COE) M.Sc.C.H. Assistant Professor, University of Toronto Staff Physician, Baycrest Health Sciences  Your Objectives: 1. Gain a public health and population perspective on the Elderly 2. Understand the physi...

Pharmacotherapeutics In The Elderly Michelle A. Hart, MD CCFP (COE) M.Sc.C.H. Assistant Professor, University of Toronto Staff Physician, Baycrest Health Sciences  Your Objectives: 1. Gain a public health and population perspective on the Elderly 2. Understand the physiological changes that occur with age 3. Understand the changes in pharmacokinetics and pharmacodynamics that occur with age 4. Identify the common conditions/ indications for therapy that the Elderly need to be screened for 5. Utilize a general approach to caring for the Elderly 6. Gain an overall understanding of the challenges of diagnosis and management of medical conditions in the Elderly In the next 2 hours I am going to try and convince you that: Taking care of older patients can be challenging but incredibly rewarding and meaningful!  OBJECTIVE #1: A population and public health perspective on the Elderly The Elderly- Public Health Perspective Growth of elderly population Decreased mortality Increased life expectancy Increased health care cost Lower socioeconomic status Increased number of chronic conditions  Demographics of aging: Population aged 80 and over Source: Statistics Canada  The Elderly 13% of the population in Ontario Use 40% of the drugs prescribed Use 3x more drugs than their proportion of the population Increased use of non-prescription drugs (>50%) So these will be some of your patients… The Elderly – population overview and prescribing High prescribing rates = high rates of adverse drug reactions (ADRs) Risk increases with > 4 meds and rises dramatically when ≥ 9, multiple doses/day (>12) ADRs contribute to 11-31% of hospitalizations for the elderly It’s not just polypharmacy….  4 Categories of drug utilization problems in the elderly 1) Altered Physiology (changes with aging) 2) Altered Pharmacokinetics and Pharmacodynamics (drug sensitivity) 3) Polypharmacy and Drug Interactions 4) Medication Adherence  OBJECTIVE #2: Physiological changes with aging  Physiological changes that occur with age: Cardiovascular system ↓ maximum heart rate (HR) -Longer for HR and BP to return to normal resting levels after exertion Blood vessels - thicker and stiffer - ↑ systolic BP - hypertension - ↑ risk of stroke, heart attack, renal failure  Physiological changes that occur with age: Cardiovascular system Heart valves thicken and become stiffer -heart murmurs common Pacemaker of the heart loses cells, develop fibrous tissue and fat deposits -can lower HR and cause heart block -arrhythmias, extra heart beats common  Physiological changes that occur with age: Cardiovascular system Baroreceptors which monitor blood pressure become less sensitive Quick changes in position may cause dizziness – orthostatic hypotension  Physiological changes that occur with age: Respiratory system Lungs stiffen ↓ muscle strength and endurance ↑ chest wall rigidity Lung function: ↔Total lung capacity ↓ Vital capacity ↑ residual volume  Physiological changes that occur with age: Respiratory system ↓ in alveolar surface area by up to 20 % - Alveoli collapse sooner on expiration ↑ mucus production ↓ in activity and number of cilia ↓ efficiency in monitoring and controlling breathing  Physiological changes that occur with age: Gastrointestinal system ↑ prevalence of Atrophic Gastritis, Achlorhydria ↓ liver efficiency- drug metabolism, cell repair ↓ Decreased intestinal absorption of lactose, calcium, iron Diverticuli in the colon → pain. ↓ peristalsis of the colon →constipation.  Physiological changes that occur with age: Kidneys ↓ kidney mass by 25-30 % ↓ number of glomeruli by 30 to 40 % - ↓ ability to filter/concentrate urine, clear drugs ↓ hormonal response (vasopressin) Impaired ability to conserve salt -↑ risk for dehydration  Physiological changes that occur with age: Urinary system ↓ Bladder capacity - ↑ residual urine – urgency and frequency - ↑ chances for urinary infections, incontinence, obstruction.  Physiological changes that occur with age: Endocrine system Pituitary gland shrinks with age Insulin resistance - impaired conversion of glucose into energy - diabetes ↓ aldosterone and cortisol - impaired immune and cardiovascular function  Physiological changes that occur with age: Reproductive system Women: Ovulation ceases, estrogen levels ↓ by 95%. Vaginal walls become thinner and lose elasticity Most women experience a decrease in the production of vaginal lubrication  Physiological changes that occur with age: Reproductive system MEN: In some men, testosterone ↓ by up to 35% ↓ size of the testes ↓ rate of sperm production Erectile dysfunction (impotence) experienced by 15% of men by the age of 65 and increases to 50% by age 80  Physiological changes that occur with age: Musculoskeletal system Loss of height (age 80, avg ~ 2”) - vertebral compression, changes in posture, ↑ curvature of the hips and knees Weight - gain until age 60 – lifestyle (inactivity, poor eating habits) - fat mass can double, lean muscle mass ↓ - Loss after 60  Physiological changes that occur with age: Musculoskeletal system ↓ bone mass ↓ muscle strength, endurance, size, weight -loss of ~ 23% by age 80 -inactivity, poor nutrition, chronic illness Skin: wrinkling, pigmentation, thinning - loss of moisture, ↓ elastin and collagen - ↓ cell size - 20% thinning between dermis + epidermis - hair graying and hair loss - ** sun exposure  Physiological changes that occur with age: Oral cavity 40% of those >65 are edentulous - mostly because of neglect Risk of caries increases with age as a result of gingival recession and loss of jaw bone density - think of antibiotic coverage Physiological changes that occur with age: Immune system ↓ Production of thymic hormones ↓ Levels of antibody response ↓ Response to antigens ***Importance of vaccination: yearly flu shot, Pneumovax in all elderly patients !  Physiological changes that occur with age: Immune system Increased risk for infections: 3 x more likely to die of pneumonia or sepsis 5 - 10 x more likely to die of urinary tract infections 15 - 20 x more likely to die of appendicitis Mortality rate from infection is much higher than in the young  Physiological changes that occur with age: Nervous system ↑ Incidence of cognitive impairment with age - by age 85, up to 1/3 of elderly have some degree of cognitive impairment Attention (to perform tasks) often preserved Semantic knowledge (word retrieval) declines Linguistic abilities ↔ Physiological changes that occur with age: Nervous system ↓ visual-spatial ability ↓ conceptualization (mental flexibility and capacity for abstraction) (> age 70) ↓ performance scores in problem solving ↔ comprehension, math, vocabulary ↓ speed of information processing - ↓ reaction time Physiological changes that occur with age: Nervous system Memory Encoding (getting info into system) declines - affected by ↓ senses (vision, hearing, smell, taste, touch) - most likely the reason for age-related declines in short-term memory Storage (retaining information) ↔ Retrieval (recalling information) - recognition doesn’t decline but recall does “As you get older three things happen. The first is your memory goes, and I can't remember the other two...” ~ Sir Norman Wisdom ~ 1915-2010  OBJECTIVE #3: Changes in pharmacokinetics and pharmacodynamics that occur with aging Pharmacokinetic Changes with age: The action of drugs in the body over a period of time which include processes of: 1) Absorption 2) Distribution 3) Metabolism 4) Elimination  Pharmacokinetic changes that occur with age: Absorption Oral ↑ gastric pH ↓ splanchnic blood flow Delayed gastric emptying ↓ intestinal transit ↓ GI absorptive surface Overall: No significant changes in drug absorption in the elderly for most drugs. **May be slower but extent is generally unchanged.  Pharmacokinetic changes that occur with age: Distribution Three key areas change with age that affect the distribution of drugs in the body: Distribution is dependent on: 1) Protein Binding – Albumin (acidic drugs) – Alpha-1-acid glycoprotein (basic drugs) 2) Volume of Distribution 3) Blood Flow  Drugs significantly bound to Plasma Proteins Plasma Protein Drug Protein Binding (%) Albumin (acidic drugs) Naproxen 99 Phenytoin 95 Warfarin 99 Alpha 1-glycoprotein (basic drugs) Lidocaine 80 Propranolol 90 Quinidine 88 Imipramine 89 Change in body composition with age 120 100 14% 30% 80 % Fat 60 61% Water 53% Cell Solids 40 Bone Mineral 20 13% 12% 0 Age 25 Age 70 Pharmacokinetic changes that occur with age - Distribution ↓ Total Body Water Hydrophilic Drugs -↓ Vd, ↑ plasma concentration e.g. Lithium, Ethanol, Digoxin, Morphine ↓ Lean Body Mass Drugs which distribute into muscle -↓ Vd and ↑ plasma concentration e.g. Digoxin ↑ Body Fat Lipophilic Drugs - ↑ Vd, ↓ plasma concentration e.g. Diazepam, Amitriptyline, Chlorpromazine ↓ or ↔ Serum Albumin ↓ or ↔ binding acidic drugs, ↑ or ↔ free drug e.g. Warfarin, Phenytoin, Naproxen ↔ or ↑ alpha-acid ↔ or ↑ binding basic drugs, ↓ or ↔ glycoprotein free drug e.g. Lidocaine, Propranolol  Pharmacokinetic changes that occur with age: Metabolism ↓ Hepatic mass by 25-35 % – capacity limited e.g. Theophylline, Warfarin, Diazepam, Phenytoin ↓ Hepatic blood flow by > 40 % – blood flow limited e.g. Morphine, Meperidine, Lidocaine, Verapamil, Tricyclic Antidepressants, Calcium Channel Blockers  Pharmacokinetic changes that occur with age: Metabolism Drug interactions due to polypharmacy may result in other drugs inhibiting or inducing their hepatic metabolism -phase I cytochrome P450 system Large inter-individual variation – other variables more important than age  Pharmacokinetic changes that occur with age: Metabolism Interindividual Variability Genotypes - fast vs. slow acetylators - rapid vs. poor oxidizers Lifestyle - smoking, ethanol, grapefruit juice Cardiac Output Gender, hormones Age  Pharmacokinetic changes that occur with age: Renal Elimination ↓ RBF (Renal Blood Flow) ↓ GFR (Glomerular Filtration Rate) ↓ Tubular secretion Renal mass ↓ by 30% Require decreased dosing: e.g. Digoxin, Fluoroquinolones, Fluconazole, Cotrimoxazole, Cephalosporins, Enoxaparin Avoid in renal dysfunction: e.g. Glyburide, Nitrofurantoin, Metformin, Aminoglycosides  Pharmacokinetic changes that occur with age: Renal Elimination Overall: ↓ renal functioning CrCl 30-50% from age 40 to 80 for the majority of elderly especially those with comorbid conditions e.g. hypertension, diabetes, etc. Renally eliminated drugs need to be dose adjusted and monitored; some must be avoided Pharmacokinetic changes that occur with age: Renal Elimination Not all healthy elderly have ↓ renal functioning 25-30 % of healthy elders maintain relatively good renal function with a CrCl > 70 mL/min well into old age A Normal Serum Creatinine is not an indicator of normal renal function in the elderly Muscle mass also declines with age Therefore, serum creatinine levels are also expected to decrease with age A CrCl must be calculated to estimate renal function For example, 70 kg male with SCr 100 µmol/L Age (yrs) 40 60 80 90 CrCl 86 69 52 43 (mL/min)  Calculate Creatinine Clearance (Cockcroft & Gault Formula) CrCl (mL/min) = (1.2)(140-age) (weight kg) Serum Creatinine (umol/L) Correction factor for females x 0.85 Pharmacodynamic changes that occur with age: The relationship between the drug concentration and the receptor site and the body’s response. Enhanced drug sensitivity in the elderly. Pharmacodynamic changes that occur with age 4 Possible Mechanisms for changes in drug sensitivity in elderly; 1) Changes in receptor numbers 2) Changes in receptor affinity 3) Post-receptor alterations 4) Age-related impairment of homeostatic mechanisms  Pharmacodynamic changes that occur with age ↑Sensitivity of receptors in brain & changes in NA, muscarinic, serotonergic systems leading to common ADRs. e.g. CNS depressants: - Benzodiazepines (diazepam 2-3x sensitivity, leads to more falls/fractures) - Barbiturates - Antipsychotics (e.g. sedation, anticholinergic, orthostatic hypotension and arrhythmias) (↓dopamine receptors/neurons, levels, ↑ risk of EPS effects) - Opioids: 2-8 x higher risk of respiratory depression but N/V decreased. Hallucinations and cognitive impairment may ↑ risk of falls/fractures - Antidepressants  Pharmacodynamics in the Elderly ↑ Sensitivity - Sedative hypnotics - Anticholinergics - Analgesics - Warfarin  So now that we know about the physiological, pharmacokinetic, and pharmacodynamic changes with aging, which medical conditions do we need to be concerned about?  OBJECTIVE #4: Common conditions/ indications for therapy that seniors need to be screened for, aka “The Geriatric Giants”  Geriatric Giant 1: Cognitive Impairment Delirium Dementia Depression  Delirium d attention & disorganized thinking PLUS things like 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, d/c drugs that might be causing  Dementia Newly acquired cognitive impairments interfere with social or occupational functioning Prevalence increases with advancing age Types: Alzheimer’s Dementia (AD) most common (65%), Vascular Dementia, Mixed Vascular + AD, Dementia Lewy Body (DLB) and Frontotemporal Dementia (FTD) each ~ 10 % Progressive and irreversible  Alzheimer’s Dementia Memory problems usually occur first (losing items, missing appointments) Difficulty performing complex tasks they could normally do (e.g. paying bills) Word finding difficulties, difficulty with names, inability to follow the plot of a film or TV show  Alzheimer’s Dementia Geographic disorientation (getting lost driving, familiar places) Apathy and disinterest in surroundings Sleep disturbances (↑day time sleeping) Disinhibiting behavior (impulsivity, socially inappropriate)  Alzheimer’s Disease Treatment Cholinesterase inhibitors – attempt to slow progression but do not cure the disease - Donepzil (Aricept), - Rivastigmine (Exelon), - Galantamine (Reminyl) NMDA (N-methyl-D-aspartate) receptor activator - Memantine (Ebixa) – moderate/severe dementia  Depression Most common psychiatric illness in the elderly Overall under-recognized & under-treated Geriatric Depression Scale (GDS) screening tool but not diagnostic Common in Long Term Care patients, those with dementia, bereavement, disabilities, stroke, Parkinson’s Disease, any chronic illness, social isolation, poor education, poverty, alcoholism, chronic pain.  Mnemonic for Depression “Sig. E Caps” - depression checklist: S uicidal Ideation I nterest, 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 (SSRI’s) safest in elderly– less concern for overdose, less interaction with other meds Not anticholinergic as the older TCAs, fewer adverse cardiovascular effects Do not cause orthostatic hypotension Good treatment for those with comorbid dementia  Benzodiazepines Dangerous for the elderly - Depression, anxiety - Falls, hip fractures - Cognitive Impairment - Increased Mortality - Long term effects: drug dependence, tolerance, abuse ** Use judiciously **  Geriatric Giant 2: Falls in the Elderly Falls are serious !! More than 1/3 of patients > 65 fall each year in the community (1/2 over age 80; ½ in LTC) 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  Geriatric Giant: Postural Instability and Falls Orthostatic Hypotension: Excessive drop in BP (20 mmHg systolic / 10 mmHg diastolic) when changing from lying/sitting position to standing Symptoms: dizziness, faints, near falls/falls Causes: diarrhea/vomiting, anemia, salt loosing kidney disease, alcohol, adrenal insufficiency, stroke, parkinson’s disease, deconditioning and prolonged bed rest, autonomic problems associated with diabetes, drugs (e.g. antihypertensives, diuretics, opiates, tricyclic antidepressants)  Predisposing risk factors for falls: Previous falls Depression Balance impairment Dizziness & orthostatic Decrease muscle strength hypotension Functional limitation Medications Age >80 Gait impairment & walking Female difficulty Low BMI Visual impairment Urinary incontinence Arthritis Diabetes Cognitive impairment Pain How many of these Apply to Mr. F? Tinnetti ME and Kumar C. NEJM 2010;303(3):258-266  Geriatric Giant 3: Urinary Incontinence “ To pee or not to pee”  Geriatric Giant: Urinary Incontinence Involuntary loss of urine in sufficient amount or frequency to constitute a social or health problem Types: Urge – leakage due to urgency Stress – leakage due to cough, laugh, sneezing Mixed – Urge and Stress Overflow – leakage due to overextended bladder Functional – 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. methocarbamol, baclofen  Treatment of Incontinence Overflow - intermittent catheterization, double voiding - alpha blockers in males e.g. terazosin, tamsulosin Urge - regular “timed” toileting (q2 hours when awake), ↓oral fluids, ↓ caffeinated beverages, add bedside commodes/urinals within easy reach - anticholinergics e.g. oxybutynin, tolterodine Functional (E.g. Dementia, OA) -frequent and regular timed toileting, bedside commodes/urinals Stress - Kegel’s exercises, smoking cessation (and other measures to eliminate cough), weight loss in obese patients, surgery considered - try estrogen, TCAs, pseudoephedrine or phenylpropanolamine  Urinary Incontinence in Old Age “Old Age: First you forget names, then you forget faces, then you forget to pull your zipper up, then you forget to pull your zipper down.” ~ Leo Rosenberg ~ 1858-1918  Geriatric Giant 4: Osteoporosis One in four ♀ and one in eight ♂ over 50 have osteoporosis Causes 70-90% of the 30,000 hip fractures than occur in Canada each year 23 % of those who fracture a hip die within the year  Osteoporosis Loss of protein and mineral content, particularly calcium ↓ Bone mass and bone strength Bones fragile and break easily Leading risk factor for bone fracture, morbidity, or death post-fall Causes - Primary -Post-menopausal loss of estrogen in ♀ -Aging losses of osteoblasts seen in both ♀ & ♂ - Secondary to some other disorder -Osteomalacia, hyperparathyroidism, hyperthyroidism, glucocorticoid excess, chronic steroid use, renal/liver failure, etc.  Osteoporosis (in addition to calcium and vitamin D) 1) Alendronate (Fosamax) 10 mg daily, 70 mg once weekly orally Reduces vertebral fractures ~50-60% Helps build bone mass mostly in the spine Fosavance 70mg/5600IU weekly (incl Vitamin D) 2) Risedronate (Actonel) 5 mg daily, 35 mg weekly or 150 mg monthly orally Reduces risk within 1 year by 50% 3) Zoledronic Acid (Reclast or Aclasta) Annual Injection/IV infusion 4) Denosumab (Prolia) q6mo injection 5) Teriparatide (Forteo) Daily injection x 2 years max 6) Romosozumab (Evenity) q1mo injection x 1 year max Current Vaccination Recommendations for the Elderly (Geriatric Giant 5) Influenza Vaccine – annually (And for you!) Td - Tetanus-Diphtheria vaccine - repeat every 10 years or sooner (trauma) Pneumovax/Prevnar - Streptococcus pneumoniae vaccine recommended for all individuals ≥ 65 years of age - repeat in ~ 5 years Herpes zoster vaccine to prevent herpes zoster in patients with prior chickenpox infection: 2 approved in Canada – Zostavax II (Live zoster vaccine LZV)- SC, 1 dose – Shingrix (Recombinant Zoster Vaccine RZV)- IM, 2 doses 6 mo apart – need for booster?? Ongoing research (not currently known) – Current evidence: offer to patients ≥ 50 – Covered in Ontario for patients 65-70  Geriatric Giant 6: “Polypharmacy” “Polypharmacy” literally means “Many Drugs” Reflects the problems that occur when persons are taking too many (or simply too many of the wrong drugs, which is iatrogenesis) ≥ 5 or more new drugs in a 3 mo period  Compliance in the Elderly No difference with aging The problem is that they are taking too many! Number of meds, frequency of dosing Labeling, instructions, containers Are we spending more time talking to our older patients?  Polypharmacy and ADRs ADR- definition Any noxious or unintended response to a drug that occurs at doses used for prophylaxis, therapy, or diagnosis ADRs are related to number of medications, not age  How do ADR’s present in the elderly? Delirium Falls Fractures Urinary incontinence or retention Fecal incontinence or constipation Hypotension Electrolytes disorders Heart Failure Depression Hospitalization Death  Risk factors for ADR in the elderly Number of medications Comorbidity – remember the Geriatric Giants Age-related changes in PK Age-related changes in PD Multiple prescribers and pharmacies Unreliable drug history  Drug-Drug Interactions Increases with: Age of patients Number of drugs prescribed Number of physicians involved Number of comorbidities  Polypharmacy→Medication Optimization A more current term is Medication Optimization (since many patients truly need the many medications for their plethora of problems) Its not about reducing medications- we actually want to ensure that our older patients are on the optimum number and dose of medication for their problems  Prescribing cascades  An adverse reaction is misinterpreted as a new medical condition Drug 1 Adverse drug effect misinterpreted as a new medical condition Drug 2 Adverse drug effect Rochon P, Gurwitz JH. BMJ 1997:315:1096-1099  OBJECTIVE #5: A general approach to Caring for the Elderly and the Role of the Pharmacist  General Approach 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)  Teamwork with MD: Before prescribing, think about… Heterogeneity in the Elderly - Variability between seniors, vulnerability What evidence is available? -Clinical trials are often inadequate -Limited generalizability to the elderly, often participants are healthy with few drugs and diseases Quality improvement in Drug Therapy Take a thorough history Include family/caregivers Perform a periodic medication review at least annually Explain the purpose of the medication review to the patient Ask the patient to bring in all meds (incl. prescription, OTC, herbal, dietary supplements)  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 just based on Nursing Home Residents. Last update 2023. Can download the Beers Criteria 2023 Pocketcard Evidence-based approach Supported by American Geriatric Society (AGS)  Limitations of Beers Criteria Should not substitute for professional judgement and individualized care Does not address needs for palliative or hospice care  Deprescribing in the Elderly Canadian Deprescribing Network https://www.deprescribingnetwork.ca/ OPEN: Ontario Pharmacy Evidence Network – has deprescribing guidelines for the elderly https://open-pharmacy-research.ca/research/deprescribing MedStopper – Helping clinicians and patients make decisions about reducing/stopping meds, have a special “scale” for frail elderly https://medstopper.com/ STOPP/START Toolkit Screening Tool of Older Persons Potentially Inappropriate Prescriptions and Screening Tool to Alert Doctors to the Right Treatment https://www.cgakit.com/m-2-stopp-start  STOPP/START Criteria STOPP comprises of indicators pertaining to important drug-drug and drug-disease interactions (potentially leading to side effects such as cognitive decline and falls) START incorporates evidence-based indicators of common prescribing omissions  STOPP/START Criteria Helps to reduce: 1) Use of unnecessary drugs 2) Risk of drug-drug and drug-disease interactions 3) Prescriptions of drugs as incorrect doses, frequency, and duration 4) Under-prescribing for common conditions such as cardiovascular disease, diabetes, osteoporosis  Beers Criteria and STOPP/START criteria: the broader perspective Purpose to improve medication safety in older adults, increased awareness of inappropriate medication use in older adults Encourage health care providers to stop and consider carefully the risks, consider non-drug alternatives To guide clinicians in making decisions about safe medication use in older adults Broad application to electronic health records  Medication Appropriateness Index (MAI) – Toolkit Online Hanlon et al. Clin Epidemiol 1992; 45:1045-51, A modified version has also been studied: Somers A, Mallet L, van der Cammen T, Robays H, Petrovic M. Applicability of an adapted medication appropriateness index for detection of drug-related problems in geriatric inpatients. Am J Geriatr Pharmacother. 2012 Apr;10(2):101-9. The Medication Appropriateness Index (MAI) measures the appropriateness of prescribing for elderly patients, using 10 criteria for each medication prescribed. 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 Other points: Used as part of a CGA (Comprehensive Geriatric Assessment) Uploaded on the Global RPH website or CGA toolkit website: https://www.cgakit.com/m-2- mai#:~:text=The%20Medication%20Appropriateness%20Index%20(MAI,criteria%20for%20each%2 0medication%20prescribed.&text=The%20MAI%20has%20been%20used%20in%20observational% 20and%20interventional%20studies.  Drugs in the Elderly Start low and go slow (but keep going!) Be aware of patients’ other medications: BEWARE OF PRESCRIBING CASCADES OTC meds can have significant adverse effects Adherence is always an issue Regularly review medications on list Usually less is better (but not always!)  Beware of QT prolongation drugs Risk for QT prolongation: Older age Female gender Left ventricular dysfunction Myocardial ischemia Bradycardia Hypokalemia, hypomagnesemia Hypothyroidism Congenital  Provide patient/family/caregiver with education Purpose of drug How to take it Expected side effects Important adverse reactions Up to date medication list – add pictures, colors of meds if possible Wallet medication card useful Information via leaflets, handouts If cognition impaired, involve other health care providers- Occupational therapist ax (drug compliance, behaviours, home safety)  Assess for adherence or non- adherence Use a non-judgemental approach, ask how often they miss doses of their medication Medication routine Method of administration Frequency of prescription refills Pill counts  Strategies to improve adherence Screen Elderly for additional risk factors for non- adherence: Cognitive impairment Decreased visual acuity – How close do they hold the pill bottle to their face? Impaired manual dexterity – watch how they unscrew the lid on the pill bottle Psychosocial risk factors – depressed mood, Do they express decrease expectations of health status?  Strategies to improve adherence Provide education- patient, family, caregiver Link medication doses with daily routines, such as meals Use memory aids, administration aids Team approach with MD: recommendations to assist in reducing # of meds taken and/or frequency of doses  OBJECTIVE #6: Summary: Challenges of diagnosis and management of medical conditions in the Elderly  Take home messages Changes due to aging (physiological, PK, and PD), co-morbidities and many other drugs make drug prescribing in the elderly complex – handle with care! Adjustments for age, weight, renal function, hepatic metabolism, low serum albumin in highly protein bound drugs  Take home messages Caring for the elderly is a team sport! -Teamwork with the health professional team, the 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  Take home message: Follow-up with your patient ! With older patients, sometimes we just want it all to go away! “No, Thursday’s out. How about never-is never good for you?”  Some words of wisdom from our elders…. “All drugs are poisons; there is none that is not a poison. The right dose differentiates a poison from a remedy” ~Paracelsus 1493-1541~ Taking care of older patients can be challenging but incredibly rewarding and meaningful! Thank you!