ELDERLY PATIENT’S COCKTAIL OF DRUGS · Effectively Managing the Elderly Patient’s Cocktail of Drugs Dr. Akber Mithani Vice President, Medicine, Providence Health Care & Clinical

2 0 0 4 L E A D E R S H I P P R O G R A M F O R M E D I C A L D I R E C T O R S &

C O O R D I N A T O R S I N L O N G T E R M C A R E

I N B R I T I S H C O L U M B I A

6-1 The Centre for

Aging and Health

EFFECTIVELY MANAGING THE

ELDERLY PATIENT’S COCKTAIL OF

DRUGS

DAY: TWO (November 6, 2004)

TIME: 0915-0945

DURATION: 0.5 HOUR

his talk is led by Dr. Akber Mithani and will discuss issues presenting themselves in elderly

patients on multiple medications.

A. Course Outline

1. Didactic ~20 minutes

2. Discussion period ~10 minutes

B. Learning Objectives

1. Understand the complex nature of geriatric patients with complex comorbid illnesses as they

relate to pharmaceutical interventions.

2. Understand the unique side-effect profile of selected drugs in the geriatric population.

3. Understand the importance of interdisciplinary care in long-term care.

Instructor

Akber Mithani, MD, Vice President, Medical Affairs, Providence Health Care and Clinical Associate Professor,

Department of Psychiatry, UBC, Vancouver, Canada

Dr. Mithani is Vice President, Medical Affairs, Providence Health Care and Clinical Associate

Professor in the Department of Psychiatry at UBC. He has numerous publications in the area of

geriatrics and geriatric psychiatry and he has been the co-editor of 2 books; one entitled

"Therapeutics in Geriatric Neuropsychiatry" and the other "Adolescence to Senescence: A Guide to

the Diagnosis and Management of Depression and Anxiety throughout the Life Cycle"

Session

6

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C O O R D I N A T O R S I N L O N G T E R M C A R E I N B R I T I S H C O L U M B I A

6-2 The Centre for

Aging and Health

Effectively Managing the Elderly Patient’s Cocktail of Drugs

Dr. Akber MithaniVice President, Medicine, Providence Health

Care & Clinical Associate Professor, Department of Psychiatry, UBC

General Principles

• Aging -- Predispose the elderly to adverse drug reactions (ADR)– decrease reserve in all major organ systems– increased tendency toward accumulation of chronic

diseases associated with increased use of prescription and over-the-counter medications



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Aging and Health

General Principles

• Elderly 12% of population but consume 38% of prescribed medications

• Average elderly in community consumes 4.5 medications

• Elderly in Nursing Homes consume >7 medications

General Principles• Drugs should be considered as potential cause of

any symptom• ADR presents often atypically and nonspecifically

as a “geriatric giant”– Confusion -- delirium, dementia– Depression– Falls– Incontinence– Decreased ADL’s



6-4 The Centre for

Aging and Health

Why are elderly at risk?

• Changes in drug distribution and metabolism• Multiple symptoms leading to multiple drugs • Expectations -- “pill for every ill”• Over reliance on symptoms rather than emphasis

on geriatric assessment • Multiple factors that affect drug adherence in the

elderly

Why is the geriatric population so special ?

• Fastest growing population in Canada• Largest consumer of health care $$$• Psychiatric Comorbidity is common

(Dementia+Depression+Delirium+Anxiety)• Medical Comorbidity is even more common

– CVS Diseases, Arthritis, Parkinson’s, Infections etc commonly co exist

• Drug - Drug - Drug - Drug - Drug - Drug interactions are common



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Aging and Health

Why is the geriatric population so special ?

• Physiological Milieu is very different– Renal Function decreases exponentially with age– Liver function also affected with age– Blood Brain Barrier becomes leakier– Redistribution of adipose tissue– Fragile state of homeostasis

The Bottom Line -- Drugs behave very differently in the geriatric

population



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Aging and Health

Managing Drug Cocktails and reducing ADR in the Elderly

Analgesics



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Aging and Health

Analgesia in Elderly

• Little evidence supporting use of NSAID’s in chronic Osteoarthritis

• Tylenol # 3 -- Should be avoided in elderly• Too much codeine, not enough Tylenol• #1 prescribed medication

• Appropriate analgesia - Tylenol 1 gm PO QID• Use narcotics (Morphine) for breakthrough pain

NSAID’s

• Depressogenic• Can cause acute confusion and delirium• Gastritis and GI Bleeds• Renal Failure• Exacerbation of hypertension and CHF• Others



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Aging and Health

Meperidine (Demerol)

• Should NOT be used in the elderly• Very short half life and therefore requires

frequent dosing• Metabolite (Normeperidine) lowers seizure

threshold significantly in the elderly and therefore associated with seizures and status

• Possibly the most addictive of all Narcotics

Meperidine (Demerol)

• Commonly causes delirium leading to high morbidity and mortality

• Oral form -- of little use as most of the drug is metabolized in the “first pass metabolism” route



6-9 The Centre for

Aging and Health

Antidepressants

Tricyclic Antidepressants (Tertiary Amines)

• Examples include Imipramine and Amitryptalline• Very Anticholinergic

– Vision Problems ----> Functional Blindness– Constipation ----> Bowel Obstruction– Delirium and confusion– Urinary Retension– Dry Mouth ----> Mouth ulcers– Tachycardia



6-10 The Centre for

Aging and Health

Tricyclic Antidepressants cont.

• Hypotension ----> Falls and fractures• Cardiotoxic• Sedation and drowsiness• Sexual Dysfunction• Lethal in overdose

Fluoxetine (Prozac)

• The first SSRI on the market in Canada• Very agitating in the elderly• Metabolite - long half life a problem in the frail

elderly• Insomnia more common in the elderly• Should be avoided in geriatrics



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Aging and Health

Anti depressants

• Many choices available• Many different classes• Most are efficacious in the elderly• Tolerability and side effect profile most important

factor in making the right choice• Compliance is a major issue in the elderly• Frequency of administration is therefore

important issue

Anti depressants

• Features of depression is important in delineating which anti depressant to choose

• Associated with anxiety• Agitated depression• Associated with Insomnia• Psychomotor retardation• Psychotic features• Previous response to anti depressants• Family history of response to anti depressants



6-12 The Centre for

Aging and Health

Anti-aggressives, Antipsychotics & Anti-anxiety/Anti-agitation Drugs

Haloperidol (Haldol)

• One of the most common prescribed antipsychotic in the elderly

• Limited use in geriatrics• Not tranquilizing and therefore not indicated in the

management of acute agitation or aggression• Very high EPS side effects including akithisia -- will

worsen agitation • Cytotoxic -- Eye, liver, bone marrow• Anticholinergic• Tardive Dyskinesia



6-13 The Centre for

Aging and Health

Antipsychotic use in elderly

• In Acute Agitation:• Nozinan• Clopixol Accuphase• Loxapine

• Much better and safer antipsychotics choices are now available:– Risperidone– Olanzepine– Quetiapine

Benzodiazepines

• Depressogenic• Ataxia --- leading to falls and fractures• Confusion• Disinhibition -- aggression & sexually

inappropriate behaviour• Withdrawal symptoms• AVOID long acting Benzo’s such as diazepam

and flurazepam



6-14 The Centre for

Aging and Health

Benzodiazepines

• Short and intermediate acting preferred• used as adjunctive therapy mostly• Sometimes indicated as a hypnotic -- after organic

and other psychiatric disorders have been ruled out and simple measures of sleep hygiene have failed or are inappropriate

Anxiety Disorders

• “Late onset” AD likely depression in elderly• Anxiety Disorders - Treatment of choice are SSRI• Benzodiazepines should be used with great

caution in elderly -- only indicated for short periods

• Buspar - Efficacy in Rx of Anxiety Disorders is very questionable



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Aging and Health

Antibiotics

Ciprofloxacin (Cipro)

• Broad Spectrum Antibiotic• Tends to be over used in the elderly creating

unnecessary resistance • Should be reserved for serious infections e.g.

pseudomonas • Has clearly shown to cause confusion in the

elderly and therefore its use needs to be monitored closely



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Aging and Health

Ciprofloxacin (Cipro)

• Cipro induced delirium is now a known entity:– Restlessness & agitation– Visual hallucinations– Myoclonus (twitching) -- mild clonic movements of

large muscle groups– Symmetrical hyperreflexia

• Use cautiously

Antibiotics and the Elderly

• UTI and RTI are common in the elderly• Cipro induced delirium is common in elderly• Alternate safer Antibiotics should be tried first

• Amoxil• Clavulin BID• Septra• Cephalosporins



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Aging and Health

Conclusions• Appropriate pharmaceutical intervention requires

and interdisciplinary approach• Problem drugs in elderly should be avoided where

possible and alternatives must be sought• Close monitoring of drug use is critical in the

elderly• Particular attention must be paid to drugs causing

serious side effects

Summary Points

• Geriatrics involves complex comorbid illnesses• Geriatrics focuses on multidisciplinary care• Geriatrics -- a special population• Geriatrics -- Drugs behave differently in the

elderly• Side effect profiles -- “Killers v/s non Killers

Documents

ELDERLY PATIENT’S COCKTAIL OF DRUGS · Effectively Managing the Elderly Patient’s Cocktail of Drugs Dr. Akber Mithani Vice President, Medicine, Providence Health Care & Clinical