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11/1/17
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MedicationsinanAgingPopulation
MichelleA.Fritsch,Pharm.D.,CGP,BCACP
ObjectivesAsaresultofthisContinuingEducationActivity,readerswillbeableto:1)Asktherightquestionstodetermineallmedicationstakenbya
patientandhowtheyaretakenwithemphasisoncommonwarningsigns.
2)Describehowmedicationsimpactsenioradultsdifferentlythanyoungercounterparts.
3)Explainthecommonroleofmedicationsinfalls,negativecardiovascularevents,strokes,andotherlife-alteringevents.
4)Describewhymedicationregimensareoftensolargeandcomplicatedandwhatcanbedonetoreducerisksofcomplexregimens.
5)Usingcases,applytheinformationfromthepreviousobjectivestoriskreductionactionforpatients.
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Question
Whatisyourprimarypracticesite?a. Hospitalinpatientb. Hospitalbasedoutpatientc. Privateclinicd. Chainclinice. Schoolsystemf. Homebasedcareg. Other
Question
Whatpercentofyourpatients/clientsareoverage65?1. 0-9%2. 10-25%3. 26-50%4. 51-75%5. 76-100%
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GeriatricMedicationUse
AgingofAmerica
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
70,000,000
80,000,000
90,000,000
100,000,000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
Num
ber o
f Per
sons
65+
Population 65+ by Age: 1900-2050Source: U.S. Bureau of the Census
Age65-74
Age75-84
http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#age
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Medication Interview• Generic and brand name• Use of each medication• Prescription medications• Over-the-counter medications• Vitamins• Supplements• Herbals/nontraditional• How used vs. how prescribed
Medication Interview• Open-ended questions vs closed-ended
questions• Patience• Reminder questions• Follow-up questions• Information-drawing questions
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Sensory Senescence
VisionHearing
Olfaction/TasteTouch
• Medications can impact these• These can amplify the risks for falls,
nutrition deficiency, dizziness, and more
StartLow;GoSlow
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WhenUsedProperly
• Medicationscan– Curemedicalconditions– Improvecontrolandoutcomesofmedical
conditions– Alleviatesymptomsofmedicalconditions– Improvefunction/IADLs– Enhancequalityoflife– Enhancequantityoflife
WhenNotUsedProperly
• Medicationscan– Worsenmedicalconditions– Causesideeffects– Decreasefunction– Decreasequalityoflife– Decreasequantityoflife
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TypesofMedicationRelatedProblems
Needingpharmacotherapybutnotreceivingit.Receivingtoomuchofthecorrectdrug.Receivingtoolittleofthecorrectdrug.Receivingthewrongdrug.Experiencinganadversedrugreaction.Experiencingadrug-drugordrug-foodinteraction.Notreceivingthedrugprescribed.Takingadrugwithnovalidmedicalindication.
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Question
Mostpeopletaketheirmedicinesasprescribedbytheirdoctorsa. Absolutelyb. Withrareexceptionc. Mostofthetimed. Rarelye. Never
Drugs don’’t work in patients who don’’t take
them.
C.EveretteKoop,M.D.
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Types of Nonadherence
• Failure to fill prescriptions• Failure to refill the prescription• Omission of doses• Increase in dose or frequency• Errors of dosage• Incorrect administration• Errors in time of administration• Premature discontinuation
Detection of Nonadherence
Insufficient regimen or underprescribingThe groupimportant toidentify
Adherent
Not adherent
Therapeutic goal reached
Yes No
Idealsituation
Overprescribing- or -incorrectdiagnosis
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Incidence of Nonadherence
• As many as 66% of patient fail to take prescribed medications as directed.
• 50% on chronic regimens stop them after one year• 20-30% of prescriptions never filled• Compliance rates are worse with more frequent
dosing/complicated regimens• Noncompliance rates are higher among low income
groups and those with disabilities• The World Health Organization estimated that by 2020,
the number of Americans affected by at least one chronic condition requirement medication therapy will grow to 157 million
Nonadherence—Economic
Directcostestimatedat$100billionto$289billionannually• Costs$2000perpatientinphysicianvisitsannually• Improvedself-managementofchronicdiseases
resultsinanapproximatecost-to-savingsratioof1:10
• Cost-relatednonadherence reportedby11.4%(~543,000individuals)ofstrokesurvivors,mostlyamongtheuninsuredandyounger(45to64years)
Sources:Ho2009,Circulation;Levineetal.2013,AnnalsofNeurology
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Adherence for Selected Illnesses
National Council on Patient Information and Education
0
10
20
30
40
50
60
70
DM & CHF
TB
HTN
Schizophrenia
PCN
Prescriptioninterpretation
Youareprescribedamedicationwithinstructionstotakeitthreetimesdaily.Howwouldyoutakeit?1. Threeinthemorning2. Morning,midday,bedtime3. Withyourthreemeals4. Every8hours5. Threeatbedtime
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CaseExample
• Whitemaninhis50’sinanadherencetrial• Bloodpressuremedicineprescribedthree
timesperday• Bloodpressuremuchdifferentatmorning
clinicvisitsthanatafternoonclinicvisits
Adherence Aids
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AutomatedDispensingOptions
PharmacokineticsWhatthebodydoestothedrug
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Absorption
Body
Water
Food
Medication
Commonmedicationscanimpactthis,butagingitselfhaslittleimpact
Distribution
FAT
WATER
Whereinthebodythemedicationgoes
Withaging,totalbodywaterdecreases,totalbodyfatincreases
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MetabolismBreakdown– howthemedicationisbrokendowninthebody
LiverToamoreorlessactivemetabolite,usuallyless
Someenzymesfailtoactuntilaboutage5;somediminishwithadvancedage
Excretion
Howthemedicationiseliminatedfromthebody- Feces
- UrineRenalfunctiongraduallydeclineswithageafteraboutage40- Medicalconditions(diabetes)- Medications- Othercanfurtherdecreaserenalfunction
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PharmacodynamicsRelationshipbetweendoseandtherapeutic
responseWhatthedrugdoestothebody
CellularEffects
• Examples– antibiotics– Biologicresponsemodifyingmedications
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SystemicEffects
• Upregulation ordownregulation ofreceptors• Alterationsinthephysiologicresponseto
medications– E.g.selectiveserotoninreuptakeinhibitorsfor
depression
http://en.wikipedia.org/wiki/Reuptake#/media/File:Reuptake_both.png
Drug Related Morbidity and Mortality
1995: In the United States, drug related morbidity and mortality estimatedto cost $76.6 billion ($30.1-136.8)per year2001: $160 billionNearly 1:1 ratio – spent and treatment related M&MJohnson JA, Bootman JL. Arch Intern Med 1995;155:1949-56Ernst FR, Grizzle AJ. J Am Pharm Assoc 2001;41(2):192-99
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CaseExamples
StartingDose
• An81yearoldpatientwasexperiencingneuropathicpain
• Shewasstartedongabapentin300mg• Shetookherdoseanddrovetothemall• Acarpulledoutinfrontofherintheparkinglot• Shepushedthepedal…• Andlaunchedhercarontoanothercar
– Shereactedtooslowlytorealizeandchangepedals
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Mixingprn’s• Policeman’smother• Livedalong– usuallyfine• Onceinawhileneighborswouldcallpolice• Shewouldleaveherhousetoletherdogout,get
disoriented,gotoanotherhouse,getupsetwhencouldn’tgetinclaimingsomeonehadlockedheroutofherhome
• Oneveningswhenshedidn’tfeelgoodshewouldtakeprn painmedicine,sleepmedicine,andanxietymedicine
Alzheimer's• Advanceshavebeenmadetounderstandthe
condition• NOCURE• Bestoptionsmightbeabletostabilizeorslow
progression• Cholinergic
– Startatlowdoseandtitrateupslowly– Risksandbenefitsofsideeffectsandimpacton
disease• Morepromisingoptionsinthefuture
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donepezil
• Startat5mg• Iftoleratedafter2weeks,increaseto10mg• Perhaps60%noticeabledifferencein
progression• Considerations
– Highlyvariablerateofadvancewiththedisease– Muchdataextrapolation– Qualityvs quantityoflife– ethicalconsiderations
Osteoarthritis
• AmericanCollegeofRheumatologyguidelines2012
• Forpeopleoverage75,TOPICALnonsteroidalanti-inflammatorydrugs(NSAIDs)arerecommendedoversystemic/oralforms
• SystemicNSAIDrisks– Cardiovascular– bloodpressure,heartattack– Renal– decreasedkidneyfunction– Gastrointestinal– ulcers,irritation,bleeding
Hochberg,MC,Altman,RD,April,KT,etal.ArthritisCareRes(Hoboken).2012;64:465-474.)
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Evidence-Based Medicine (EBM)Why
DiabetesRegimen:• Metformin• Sulfonylrurea - oralmedicine(e.g.glipizide,
glimepiride)• Basalinsulin(e.g.insulinglargine,detemir)• Aspirin• Statinforcholesterol(e.g.simvastatin,
rosuvastatin)• Manyandgrowingnumberofoptions
Evidence-Based Medicine (EBM)Why
HeartFailureRegimen:• Betablocker(e.g.metoprolol succinate,carvedilol)• ACEInhibitororARB(e.g.lisinopril,ramipril)• Loopdiuretic(e.g.furosemide,torsemide)• Thiazide-typesdiuretic(e.g.metolazone)***• Statinforcholesterol(e.g.simvastatin,rosuvastatin)• Aspirin• +/- Digoxin
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Metolazone
• Thiazide-typediuretic• Unlikeothersinitsclass,stilleffectivewith
diminishedrenalfunctionCrCl <30ml/min• Potent,powerful• Whilepromotingremovalofsodiumand
water,alsoremovingpotassium• Mathteacherexample
PrescribingGuidance
• START• STOPP• Beer’sCriteria
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BeersCriteria• Developed1991todecreasepotentiallyinappropriatemedications
innursinghomeresidents– Updated1997,2003,andbyAmericanGeriatricSociety2012– Expandedtootherpracticesettings
• Explicitcriteria;validatedinmultiplestudies• Nowincorporatedintopolicies• Medicationstoavoidinolderadults• Medicationpotentiallyinappropriateinolderadultswithparticular
medicalconditions• Medicationstousewithcaution*
– *newin2012update
JAmGeriatrSoc.2012April;60(4):616–631.doi:10.1111/j.1532-5415.2012.03923.x.
STOPPCriteria• TheScreeningToolofOlderPersons’Prescriptions• Medicationstostopingeriatricpatientswith7organ
systems,fallsrisk,analgesics,andduplicativetherapies
• Examples
Int JClin Pharmacol Ther.2008Feb;46(2):72-83
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STARTCriteria• ScreeningTooltoAlertdoctorstoRight
Treatment• Evidence-basedtherapiestostartforspecific
conditions– Organizedin7organsystems– Cardiovascular– Respiratory– CNS– GI– Locomotor– Endocrine
Screening tool to alert doctors to the right (i.e. indicated, but not prescribed) treatment for older people (START).
Barry P J et al. Age Ageing 2007;36:632-638
Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.
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Somanyotherfactors
EmptyNest• Formothers,oncethechildrenaregrown
– Youngerkidsas‘onlykids’foratime– Collegetransition– Attentionandcontrol– nolongertheconstantvigilanceover
thechildren– Socialchanges
• Nolongersocializeatchild-relatedevents• Pointofconnectionwithothermotherschanges
– Diet– Transportation– Householdduties– Shopping– Budget
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PersonalHealth
• Selfimage• Dealingwithhealthchanges
– Whatmightthesebe?• Exercise
– AJisa60yearoldwomanwhohasrecentlylostherhusband.Hertwochildrenareincollegeindifferentstates.Priortothistimeshepracticedsportswithandbikedwithherchildrenuntilgrown.Thenshewalkedmosteveningswithherhusband.Nowwhat?
RelationshipChanges• Growing/grownchildren
– Stories– Roleofchildrenchangesinpersonalhealth– https://www.youtube.com/watch?v=Aw2Bb7d3hSk
• Marriages– childrenin-law• Grandchildren• Agingparents
– Care,concern,loss– ‘Sandwich’stage– https://www.youtube.com/watch?NR=1&v=yMJ4ao-
Zsr8&feature=endscreen– https://www.youtube.com/watch?v=RVj888PT4L8
• Agingspouse
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RelationshipChanges
Lossofspouse• Responsibilitiesanddecisionsattimeofdeath• Matriarchoffamily– supportvs owngrieving• Surroundedbyfamilythenoftensuddenly
gone– (experiences)
Function
Laterlifefunction=selfcare+environment+genetics
Whatcanbecontrolled?Whendoesthatcontrolexist?
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ActivitiesofDailyLiving(ADLs)
• Eating• Dressing• Gettinginoroutofbed• Gettinginoroutofachair• Bathing• Usingthetoilet
InstrumentalActivitiesofDailyLiving(IADLs)
• Preparingmeals• Managingmoney• Shopping• Doinghousework• Usingatelephone
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Care/LivingEnvironments• Independentliving
– Ownhomeorapartment,sameasprioryears– Seniorcomplexorhousingarea– ContinuousCareRetirementCenter(CCRC)
• AssistedLiving– Facilitywherecleaning,food,dressing,bathing,orotherneeded
servicesareprovided– IsacomponentofaCCRC
• Homecare– ProgramofAll-inclusiveCarefortheElderly(PACE)
• Longtermcare– SkilledNursingFacilities(SNFs)– AlsoPACE– Medicaid’sProgramofAll-inclusiveCareforthe
Elderly
Over-the-CounterMedications
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Whattotakeforpain?
SleepAgents
Diphenhydramine
Melatonin
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Complimentary&AlternativeMedicines(CAM)
• ‘Natural’• Littlecriteria,oversight
– Notregulated byFDA
• Eachstillwithsideeffects• Limitedscientificevidenceforsafetyorefficacy
- glucosamine - fishoil- probiotics - soy- st. John’swort - chondroitin
AsNeeded‘prn’Medications
• Sleep• Cold• Flu• Headache• Jointpain• Nails• Hair• Vision
• Injury• Allergies• Stomachache• Indigestion• Diarrhea• Constipation• Weightcontrol• Overallhealth
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SubstanceAbuse
• Alcohol– Liver• Tobacco– Lungs,heart• Marijuana– Lungs,brain• Opiates– GI,brain• Heroin– Brain,heart,GI• Cocaine– Heart,brain
Drugabuse.govhttp://www.politicspa.com/pa-gov-wolf-vows-to-sign-medical-marijuana-bill/63312/
SomeCommonMedicalConditionsApplication
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Constipation
Bulking Osmotic Stimulant Stoolsofteners
Emollient Chloridechannelactivator
Psyllium$ Magnesiumhydroxide$$
Sennosides$$
Docusatesodium$
Mineraloil$$
Lubiprostone$$$$$$$$
Methyl-cellulose$$
Polyethyleneglycol$$
Bisacodyl$ Docusatecalcium$
Poly-carbophil$$
Lactulose$$
Sorbitol$$-
AdaptedfromEoff JC,etal.OptimalTreatmentofChronicConstipationinManagedCare.JMCP2008;14(9):S3-15
IncreasefluidintakeAddfiber
Higherprevalencewithdecreasedbodywater,decreasedexercise,decreasedfluidconsumption,slowedperistalticmovement
Parkinson’sDisease
• Prevalence:Upto1millionpeopleintheUS• Annualincidence
– 10/100,000ages50-59– 120/100,000ages80-89
• Usualageatdiagnosis55-65• Presentation- Atleasttwoofrestingtremor,
rigidity,bradykinesia withasymmetricalpresentation;posturalinstabilitylater
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Symptoms
Motor• Decreasedmanualdexterity• Difficultyarisingfromaseated
position• Diminishedarmswingwith
ambulation• Dysarthria• Dysphagia• Festinatinggait• Flexedposture• “freezing”atinitiationof
movement• Hypomimia/maskedfacies• Hypophonia• Micrographia
Autonomic&Sensory• Bladderandanalsphincter
disturbances• Constipation• Diaphoresis• Fatigue• Olfactorydisturbance• Orthostaticbloodpressurechanges• Pain• Parasthesia• Paroxysmalvascularflushing• Seborrhea• Sexualdysfunction• Sialorrhea
Treatment
• Dopamine• Carbidopa/levodopa• Dopamineagonists• COMTinhibitors• MOA-Binhibitor
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69Cartoon:http://fb.img.v4.skyrock.net/fb9/e-ide/pics/2059425594_small_1.jpg
VIDEO- https://www.youtube.com/watch?v=sf1N0Zf5IqA&feature=related
EarlyManagementFig68-4DiagnosisPD
NonRx:EducationExerciseNutrition
Psychsocial support Considerrasagiline
Needforadditionalsymptomatic
control
Tremor
Bradykinesia,rigidity,tremor
Rx
Consideranticholinergicoramantadine
Consideramantadine
Addamantadine,dopamineagonistorcarbidopa/levodopa
Addamantadine,dopamineagonist,orcarbidopa/levodopa
<65years* >65years*
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EarlyManagement,Fig68-4
Managementofmotorfluctuations:•Increasedosingfrequencyof
levodopa•AddMAO-BinhibitororCOMT
inhibitor•Addadopamineagonist
Managementofpeak-dosedyskinesia•Reducedopaminergic drugdose
•Addamantadine
Needformoresymptomaticcontrolofmotor
complications(despiteoptimizedpharmacotherapy):
Considersurgery
Frompreviousslide
Incontinence
• 200millionpeopleworldwide• Prevalenceashighas55%(dataranges20-70%)• Relationshiptoisolation• Relationshiptodepression• Relationshiptodehydration• Manyofthemedicationshaveanticholinergic
action(drying– impactsvision,drymouth,constipation,urinaryoutflow)
WoodLaurenN,AngerJenniferT.UrinaryincontinenceinwomenBMJ2014;349:g4531
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TypesofIncontinenceStress Urge Overactive
BladderOverflow Functional Mixed
Urinarysphincter
Detrusormuscleoveractivity
Detrusormuscle,ifincontinence
Urethraloveractivity&/orbladderunderactivity
Physicalorcognitivereasons
Combinationoftypes
α-adrenergicblockers;topicalestrogens;SSRIorSNRI
Antimuscarinic/anticholinergicorTCA
Sameasagentsforurge
α-adrenergicblockers;5-α reductaseinhibitors orantispas-modics;Cholino-mimetics
Removebarriers,useschedules,reviewneedforassistance
OwensNJ,EstusEL.RenalandUrologicDisorders.In:HutchisonLC,SleeperRB,eds.FundamentalsofGeriatricPharmacotherapy.Bethesda,MD:AmericanSocietyofHealth-SystemPharmacists,Inc.;2010;page202.
Vision
• Dryeyes• Uncorrectedvisionimpairment• Infection• Cataracts• Maculardegeneration• Glaucoma• Medicationsideeffects• Other
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Glaucoma– treatmentoptionsBeta-blockers Prostaglandin
analogsAlphaadrenergic
agonistsCarbonicanhydraseinhibitors
Cholinergicagents
AH production outflow AH production+outflow
AHproduction outflow
1st line Alternate1st
lineBrimonidine
alternate1st line2nd line
(systemicare3rd
line)
Lastline
MostBID At night MostBID-TID MostBID-TID MostBID-TID
Cautions:Heartfailure,bradycardia,asthma, COPD
Long-termusecanleadtomacularedema
Cautions:Cardiovascularorcerebrovasculardisease
Monitorwithage-relateddecreaseinrenalandhepatic function
Cautions:Parkinson’sdisease; longtermusemayleadtocataracts
AH– AqueousHumor
AdaptedfromJonesMD,Chapter61Glaucoma,inPharmacotherapyPrinciplesandPractice,2nd edition,2010:page1038
Osteoporosis
• Riskfactors• Calcium• VitaminD(buildingblocks)• Bisphosphonates
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OsteoporosisTreatmentForapatientwithaT-score<-2.5and/oralow-traumafracture-bone-healthylifestyle-Calcium1200mg/day-VitaminD800-1,000units/day-DrugTherapy
-1st line– bisphosphonates-2nd line– teriparatideorraloxifene-3rd line– intranasalcalcitonin
Reevaluatebonemineraldensity(BMD)in1-2years
AdaptedfromDiPiroJT,etal,eds.Pharmacotherapy:aPathophysiologicApproach,2011:figure99-3,page1567.
MetabolicSyndrome
Components• Diabetes• Hypertension• Cardiovasculardisease• Weight• Smoking• Diet• Excercise
Outcomes• Myocardialinfarction(MI)• Stroke(CVA)• Heartfailure• Neuropathy• Visiondecline• Wounds• Amputation
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Falls
Risks• Rugs• Pets• Steps• Otherenvironment• Cognition• MEDICATIONS
– Bloodpressure– Incontinence– Allergies– Mood– CNS– seizures,neuropathy,…– Manymore
Outcomes• Gaitchanges• Restrictedactivities• Surgery• Ambulationassistance
devices• Isolation• Dependence• Assistedliving• Skilledcare
MedicationsinanAgingPopulationSummary
• Thebodychangesphysiologicallywithage• Thesechangescanimpactmedicationeffect• Understandhowyourpatientactuallytakestheir
medications• Includethemedicinestheyselectforthemselves–
OTC,CAM,prn,vitamins,supplements• Considerlifestylechangesthatoftenaccompanyaging
impactingsleep,safety,isolation,nutrition,andmore• Remembertheadage,STARTLOW– GOSLOWiskeyto
medicationuseinanagingpopulation