Caring for the Aging Population Presentation

7/25/2019 Caring for the Aging Population Presentation

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10th Annual Mini Medical School

GERIATRICSCaring for our ging Population


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Pharmacology Considerations in

the Elderly

Common Concerns with the use

of Medications

Roger Hefflinger, Pharm.D.

Associate Professor

Idaho State University

College of Pharmacy

Family Medicine Residency of Idaho


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Disclosure

I have no fiscal connections to disclose with

any of the manufactures of medications

discussed during this presentation


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Objectives:

Upon completion of this presentation theaudience member shall be expected to:

Recognize changes in the elderly that may

contribute to medication adverse events Identify classes of medications that are more likely

to have adverse events in the elderly

Organize therapy plans for appropriate

management of various disease states in the

elderly

Modify existing therapy plans for more effective

and potentially safer disease state management


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The Life-Span

Fetal Development

First Trimester

Second Trimester

Third Trimester

Gestational Issues

Perinatal Issues

Infant

Toddler

Adolescent

Puberty

Adult

Organ System Failure

Renal

Liver

Geriatrics

End of Life

Hospice Care


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What Factors Most Affected

Pharmacokinetics of Medications:

Dissolution Stomach acid, motility, affect product delivery

Absorption Stomach acid inc/dec effect, concurrent medications

First Pass Metabolism Genetic inc/dec, enzyme inducers, enzyme inhibitors

Distribution Protein binding, albumin stores, fat stores

Elimination Gut, liver, renal function


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What are realistic goals of

medication administration Stop the disease process

Cancer chemotherapy, Antibiotics

Slow the progression of the disease

High blood pressure, Diabetes, Depression

Minimize the symptoms of the disease

COPD, Pain,

Minimum amount of side effects

In the most cost effective manner


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What is Acceptable Risk

Food and Drug

Administration

Phase 1 drug trials

Phase 2 drug trials Phase 3 drug trials

Drug approval

Drug release

Post marketing adverse

event reporting

Side Effects: Pick an organ system

Central Nervous System

Cardiovascular System Heart, Blood vessels

Respiratory System

Hepatic (Liver)

Renal (Kidney)

Gastrointestinal

Skin

Bone Marrow


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Central Nervous System

Drowsiness

Dizziness

Ringing in ears

Confusion

Depression

Psychosis

Elderly:

Altered sleep patterns

More easily sedated

More likely to getdizziness

Underlying vertigo

Changes in brain wire

chemistry as age

Decrease in brain mass

as age

Cerebral atrophy


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Cardiovascular System

Heart block

Arrhythmias

High blood pressure

Low blood pressure

Angina

Heart Failure

Edema

Elderly more likely to:

Have more medications

that can become

additive in CV SE

Heart becomes more

sensitive to ischemia

Beta receptors decrease

in elderly

Altered sympathetic

nervous system tone


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Respiratory System

Shortness of breath

Pulmonary scaring

Pulmonary fibrosis


Have either long

standing asthma or if

smoking history COPD May also have anemia

Decrease in red blood

cells = carry oxygen

around the body

More sensitive to

decrease in oxygen drops


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Altered Organ System Function

Liver dysfunction

Much more to follow

Long standing alcoholmay affect livers ability

to metabolize and clear

medications

Renal dysfunction

It is a normal part of

aging to have a gradual

decline in the kidneysability to filter and

excrete

Many drugs are

eliminated in the urine

Many drugs affect the

ability to urinate


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Gastrointestinal System

Nausea

Vomiting

Diarrhea

Constipation

Abdominal Cramping

Peptic ulcer disease


Have less protective

mucus in stomach

More sensitivity to

medications

Less nerve innervation of

the intestinal tract

= more diarrhea or more

common moreconstipation

More SE if on

medications and get viral

infections


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Adult Medicine

All medications are formulated for effective

dosing in the Normal adult population

Very general rule- Lower tablet strengths

availability is/are generally acceptable starting

dose for desired action

Citalopram: 10,20, 40 mg- 10 mg HS good start

HCTZ: 12.5, 25, 50 mg- 12.5 mg q d good start


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At what individual risk?

Every patient has the right to refuse a

medication if they feel the risk is too great

Back to goals of therapy

If you are going to refuse all medications that are

offeredwhy are you here?- rgh


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Example Package Insert


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Adult Medicine

Drugs with a Narrow Therapeutic Window

deserve to be monitored.

Digoxin Lanoxin

Levothyroxine Synthroid, Levoxyl

Warfarin Coumadin

Sodium channel blocker for seizure disorder

Enzyme inducers and inhibitors- look for interactions!

Birth Control lose of efficacy

Monitor for established drug levels

For Bipolar?, Migraine?, Depression?, Psychosis?

Ad lt M di i D I t ti


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Adult Medicine Drug Interactions

Substrates- metabolized this route


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Adult Medicine Drug Interactions

Inhibitors- Stop the metabolism


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Adult Medicine Hepatic Impairment

You need to destroy 95% of your hepatocytefunction before you start to lose medication

clearing ability

Transaminitis:

AST/ALT elevations- Most drugs with transiently

elevate

Liver Function-

INR- synthetic marker of clotting factor production Auto anticoagulated- other drugs contribute bleed risk?

Albumin- synthetic

Alter distribution of protein bound medications


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Potentially Clinically Significant

Benzodiazepines for etoh withdrawal

Short Acting:

Lorazepam

AtivanOxazepam

Serax

Alprazolam

Xanax


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Adult Medicine Renal Impairment

Cockcroft and Gault

Normal GFR

100-130

Obligated to look GFR

60

Most drugs need GFR dosing adjustment 30

Most All drugs need renal dosing

15

Metformin

Contraindication:SrCr > 1.5 men

SrCr> 1.4 Women

CrCl


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Adult Medicine Significant

Interactions

Lithium

Very effective under

used

Short yet significant list

NSAIDs

Diuretics

ACEs, ARBs, Lithium toxicity may be

fatal

MAO-Inhibitors

Parkinsons Selegiline Eldepryl

Transdermal Emsam

Rasagiline Azilect

REFRACTORY Depression Parnate

Nardil Marplan

Anti- MRSA antibiotic Linezolid Zyvox


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Geriatric Medicine

Lean mass declines

Sarcopenia, decrease

strength, mass

Andropause?

Androgen replacement

therapy males?

Fat deposits increase

Alterations of fatdeposited medications

Lipophilicity

Altered loading doses

Gastrointestinal PH

changes B-12 deficiency

Folate deficiency Iron deficiency

Drug induced? PPI

Albumin decreases Less protein binding

More free drug = toxicity

Less balance Falls- drug induced dizzy


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Geriatric Medicine Beers List

http://www.fmda.org/beers.pdf Comprehensive list of every medication that may

cause ADR in elderly patients
http://www.fmda.org/beers.pdfhttp://www.fmda.org/beers.pdf


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Collective Overconsumption-

rgh

2 Distinct different phenomenon

#1- Tipping over the edge

Poly-pharmacy and the latest dosage change ofmedication addition causes the patient adverse

events

Make small dosing changes and only 1 drug

change at a time

#2- Oh my goodness- Loved one is on TOO

MANY medications

When you break it down individually- they are not


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Geriatric Medicine

Fixed income concerns: If you have a sample in your office- it is not

inexpensive

Co-pay waivers Actual costs health plan

What disease can you not manage

generically?

Price matching education Every chain will price match if the PATIENT asks

Does not work if they have insurance

Less than co-pay?


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Elderly Medicine: Bone Health

Bisphosphonates

Alendronate Fosamax PO

Abandronate Boniva PO

Risedronate Actonel PO

Zoledronic Acid Reclast IV

Women are 4 times

more likely to developosteoporosis than men 77% of women who are

osteoporotic are

undiagnosed 1 in 3 women will

develop a fracture

1 in 8 men will develop

a fracture

Dont forget the Calcium 1500 mg a day

And the Vitamin D- 400-800 units a day!


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Elderly Medicine Arthritis = Pain

Osteoarthritis

Wear and tear

Knees, Hips, Feet

Decrease in the

softness of the

meniscus resulting in

thinning, tearing of

tissue

Treatment:

Analgesics

Rheumatoid Arthritis

Inflammatory disorder

characterized by the bodyattacking itself and eating

up the meniscus, cartilage,

and eventually bone

Treatment: Analgesics

Disease Modifying Agents

Immune modulating agents


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How do we measure efficacy?

Drug A Better than Drug B

TOPAR

Total Pain Reduction 4 hours, 8 hours, 12 hours


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How do we measure functionality

Range of motion

With or without pain Specific disease state

assessments

RA

Osteoarthritis

Back Pain

Neuropathic

Quality of Life


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First Line Therapy:

Acetaminophen

= Tylenol

Scheduled improves

pain

Does not relieve

swelling

Hepatic Toxin

NMT 4 Grams Total/day

Blood Pressure?

Overdose

Propionic Acid Fenamates: Indene acetic acid


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Propionic Acid

Ibuprofen

Motrin et al

Fenprofen

Nalfon

Ketoprofen

Orudis

Oruvail

Naproxen HCL

Naprosyn

EC Naprosyn

Naproxen Sodium

Anaprox RR

Naprelen SR

Flurbiprofen

Ansaid

Oxaprosin Daypro

Fenamates:

Mefanamic Acid

Ponstel

Meclofenamate Meclomen

Oxicams:

Piroxicam

Feldane Meloxicam Mobic

Pyranocarboxylics

Etodolac

Lodine Etodolac XR

Napthylakanones:

Nabumetone

Relafen

de e acet c ac d

Sulindac

Clinoril

Indole acetic acid Indomethacin

Indocin

Pyrole acetic acid Tolmentin

Tolectin

Phenylacetic acids Diclofenac Sodium

Voltaren,

Arthrotec Diclofenac Potassium

Cataflam

Miscellaneous

Ketorolac Toradol


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COX-2 Inhibitors Pain

Rofecoxib: Vioxx

Osteoarthritis:

12.5-25 mg q day

Acute Pain:

25-50 mg q day

> Celecoxib

= to Ibuprofen

Celecoxib: Celebrex

Osteoarthritis: 100-200 mg q day

Rheumatoid Arthritis:

100-200 BID

(400 BID)

Meloxicam: Mobic

Osteoarthritis:

7.5-15 mg q day

Is it selective?

Valdicoxib Bextra

10 mg

20 mg


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Additional Options of Analgesia

Acetaminophen = Tylenol

NSAIDS:

Cox-1 vs Cox-2

Steroids:

Opioids

C-II law

Opioids plus APAP

Dozens Increase Usage

Opioids plus NSAIDS

Empirin, Vicoprofen

Tramadol

Tramadol plus APAP

Muscle Relaxants:

Topical agents

Caine anesthetics

Capsacian

Menthol Camphor

Adjunctive

medications

Anti-depressants

Membrane

Stabilizers


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Geriatric Medicine:

Parkinsons Disease

Disease that is a functional decline in the

balance between 2 nervous system

transmitters- Dopamine and Acetylcholine


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Presenting Symptoms:

Initial:

aches, pains, parasthesias,

numbness coldness

Classic: Temor:

Pill rolling, thumb finger,

feet

At rest

Stress makes worse

Usually initial presenting

symptoms

Bradykinesia:

Slowing of movements

Hypokinesia

decreased ability to move

Masked Facies

Emotionless

Walking difficulties

Ridgidity: Cog wheeling

Coordination difficulties

Walking difficulties

O i f M di i


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Options of Medication

Management:

1. Replace the deficient chemical

2. Normalize relative imbalance of chemicals

3. Stimulate the receptor

4. Stop the normal breakdown of the chemical

5. Stimulate the release remaining chemicals

6. Increase the numbers or sensitivity of

remaining receptors


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Therapy for Parkinsons

Anticholiniergics:

Diphenhydramine

Benadryl

Trihexylphenadyl Artane Benztropine Cogentin

Increase Dopamine

Carbidopa/Levodopa

Sinemet

Stimulate DA receptor Ammantadine

Pramipaxole Mirapex

Ropinerole Requip

Stop the breakdown

Selegiline Eldepryl

Rasagaline Azilect

Tolcalpone Tasmar

Entacapone Comtan


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Other increasing elderly disorders

Depression

Weight loss

Weight gain

Anxiety

Psychosis

Dementia

Delirium

Sun Downing


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End of Life Issues

Can the elderly make decisions for

themselves?

Power of attorney

TALK about it BEFORE elderly is very sick

Get ALL family members on the same page


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Hospice Concerns

Die with dignity

Treat pain appropriately

Morphine High dose

Morphine 3 Glucuronide is INACTIVE

95% of MSO4 metabolite

Morphine 6 Glucuronide is ACTIVE

M3G ANTAGONIZES M6G and MSO4

May be worth your while to switch to another

phenanthrene opioid


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Hospice Concerns

The death rattles Air hunger

Inhaled morphine effective

Injectable and oral opioids effective

Constipation

Softeners at minimum, senna, stimulates, Mirilax

Hypersecretions: Glycopyralate Robinul

1-2 mg PO TID-QID, IM or IV 0.1 mg Q 3-4 hours


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Summary The Life-Span

Fetal Development

First Trimester

Second Trimester

Third Trimester

Gestational Issues

Perinatal Issues

Infant

Toddler

Adolescent

Puberty

Adult

Organ System Failure

Renal

Liver

Geriatrics

End of Life

Hospice Care


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Questions?


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[email protected]

Caring for the Aging Population Presentation

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