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GERIATRIC PHARMACOLOGY

DRUGS: AFFECT BOTH WELL-BEING AND WALLET!!!

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INTRODUCTION

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• Elderly population percentage

• Consumption of medications

o ˜- 31 % of total prescribed drugs

o 80-90% elderly consume at least 1 drug/day in

developing countries

JAMA, 2002

• A major public health problem

Public Health Reviews,

2010

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Physiological Basis of Aging and Geriatrics Fourth EditionAuthor: Paola S. Timiras

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BURDEN

• Medication related hospital admissions

• Consequences of poly-pharmacy & ADR

• Financial burden:

Economic profile of Indian elderly:

Old age dependency ratio=13.1%

Ministry of Statistics & Program Implementation,

Govt. of India, June 2011

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DRUGS & BODY INTERACTION

What happens to the drug when it enters the body?

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PHASES

Study of what happens to

the drug in the body or

how the body processes

the drug

Study of what the drug

does to the body i.e. what

are the effects of the drug

on the body, both at the

systemic and cellular

levels

PHARMACOKINETICS PHARMACODYNAMICS

• Absorption

• Distribution

• Metabolism

• Elimination

• Intensity

• Peak

• Duration

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ABSORPTIO

N

Intestinal blood flow

Gastric emptying time

Mucosal cell absorption

area

Altered gastric pH

Lipophilic drugs

Acidic drug

binding

Total body fat,

à-1 glycoprotein

Total body mass, total

water content, albumin

DISTRIBUTIO

N

Drug-drug

interaction

Drug-food

interaction

PHASESAGE-RELATED

CHANGESIMPLICATION

S

METABOLIS

M

Hepatic mass

hepatic blood flow

Impaired phase-1

reaction

Lower doses may

be therapeutic

Clearance (vs.)

Dose (vs.)

Duration

Renal blood flow

GFR

Renal mass

Tubular secretion

ELIMINATIO

N

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PHARMACODYNAMICSAge-related systemic changes:

Homeostatic control

Thermoregulatory mechanisms

Altered cellular responses:

Receptor level

Changes in intra cellular structure and

function

Alterations in the sensitivity to drug

Altered therapeutic effects of drug

Example: Hypertension

Age-related changes like:

Reduced baroreceptor function

Reduced peripheral venous tone

Drug: vasodilators

Younger

individuals

response:

tachycardia

Elderly individuals:

No CV response

due to age-related

changes

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ADVERSE DRUG EVENTS IN ELDERLY

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ADR

Chronic Illness

Poly-pharmacy

Altered Drug Metabolism

Altered Drug Excretion

Drug-drug interaction

Drug Toxicity

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PATTERN OF DRUG USE• High percentage of drug usage• Prevalence of multiple chronic diseases • Community dwelling elderly: non-prescription

drugs

Polypharmacy

ADRDrugs to treat ADR

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REASONS FOR MEDICATION

RELATED PROBLEMS

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Critical Reviews in Oncology/Hematology, 2009

ALTERED RESPONSES

•Physiological and pathological changes due to aging

•Altered pharmacokinetic and pharmacodynamics response

•Cumulative effects of aging and drugs

•Altered response: longer drug half life

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MULTIPLE & CHRONIC

DISEASES

• Multiple disease state is defined as the presence of

at least more than one disease conditions that is

commonly found in geriatric population.

• Prevalence of multiple chronic diseases

Centers for Disease Control and

Prevention ,2010

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RESEARCH IN GERIATIC

PHARMOCOLOGY• Lack of clinical trials

• Lack of guidelines for drug dosage and regimen

for elderly

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DRUG-TAKING BEHAVIOUR

• Self-medication/ Over-the-counter medication

• Adherence to prescribed medication

Factors affecting adherence to medication

Pathological conditions: cognitive decline, arthritis of hand, poor eyesight

Polypharmacy

Side-effects of medications

Financial burden

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POLYPHARMACY

Definition

Factors

Consequences

Assessing inappropriate drug

Tools to reduce polypharmacy

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DEFINITION• Lack of clear definition

• Number of drugs

• Older definitions

• Polypharmacy (5-9 medications) and high-level

Polypharmacy (>or=10 medications)

• Inappropriate medication

Br J Clin Pharmacol. 2007

Br J Med Pract. 2008

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FACTORS LEADING TO POLYPHARMACY

• Clinics in Geriatric Medicine, 2012 May; 28(2): 159-72• Guccione A. Geriatric Physical Therapy, second edition

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• Patient Related

o Socio-demographics

o patients' conditions. 

o patient behavior, such as patient's self

medication with all types of medications

o Medications from relatives etc.

• Physician Related

• Patient Physician Interaction 

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CONSEQUENCES

• Drug-drug interaction leading to adverse drug

reactions

• Decreased compliance

• Increased financial burden

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TOOLS TO REDUCE

POLYPHARMACY

• Non-pharmacological management should be first line of

action

• Communication between physicians

• Communication between physician and patient

• Regular monitoring

• 3-main points to check in a prescription:

o Number

o Regimen

o Dosage

Merle L et al., Drugs Aging, 2005

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Medications Related Falls in Elderly

Huang et al., Drug Aging, 2012

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Factors:

Medications with half life period more

than 24hrs

Polypharmacy: more medications lead to

higher incidence of fall

Wilson,1998Common drugs associated with high

incidences of fall are:

• Anti-hypertensives

• Anti- depressants

• Narcotics & sedative

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Medication problems that affect the physical

therapist’s workCOMMON DRUG REACTIONS

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Drug induced ototoxicity

e.g. Aminoglycoside antibiotics cause irreversible deafness -

like gentamicin

loop diuretics - furosemide (lasix)

NSAIDs (aspirin), quinine cause tinnitus is reversible

Drug Induced oculotoxicity

Amantadine - corneal opacities

amiodarone -corneal micro deposits

Anticholinergics,antidepressants, antihistamines: blurred

vision glaucoma

anticonvulsants - diplopia, nystagmus

adrenergic blocker - reduced tears

digoxin - colored halos

Deafness - problem

communicating

visual acuity - problem seeing

demonstration

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Drug induced Dizziness, Fainting and Weakness

• Cytotoxic agents: treat cancers, arthritis, autoimmune

diseases

• Antihypertensive medications - beta blockers, Ca++

channel blockers, diuretics, ACE inhibitors

Drug Induced drowsiness, anemia, muscle wasting

• Glucocorticoid steroids

• Drugs that cause insomnia - prevent a good night sleep

e.g. caffeine, aminophylline

• Pain medications

• Muscle relaxants

• Antinauseants

• NSAIDs

Problems while performing exercise,and can be

hazardous

remembering

instructions

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CONDITIONS & DRUGS

ADVERSE EFFECTS PT IMPLICATIONS & PRECAUTIONS

Drugs for CV conditions

Digitalis CHF symptoms, toxicity

Nitrates Angina

B-blockers CV problems Safety

Ca++ channel blockers CV problems vitals monitoring

Diuretics fatigue

vasodilatos Postural hypotension

Drugs for MSk system

NSAIDs GI problems( anemia)

Baclofen sedation Scheduling sessions,

Diazepam sedation vitals monitoring

Narcotics Sedation, OH, GI prob,

Steroids Catabolic effects Electrotherapeutic modalities, Osteoporosis

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DRUGS COMMON ADVERSE

EFFECTS

PT IMPLICATIONS &

PRECAUTIONS

Anti-

epileptics

Sedation, confusion, GI

problems, skin problems,

other cerebellar signs

like ataxia, etc.

Emergency codes

Co-ordinate sessions

Epilepsy evoking stimulus

Electrotherapeutic modalities

Levadopa Postural hypotension, GI

problems, CV problems,

behavioral changes, etc.

Scheduling sessions: ON-

phase

Cardiac pts. : vitals monitoring

Safety

Anti-

depressants

Sedation, confusion, GI

problems, CV problems,

vision, behavioral

changes

Active participation of pts,

schedule sessions

Vitals monitoring, Safety

Anti-

psychotics

Dyskinesia, drug-induced

Parkinson disease,

dystonia, CV problems,

vision

Scheduling sessions

Safety

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• Monitor adverse reactions due to drugs &

differentiate ADR from symptoms

• Monitoring exercises based on drugs

pharmacokinetics

• Scheduling rehabilitation sessions

• Drug and physiotherapy interactions

• Modifications in case of adverse reaction

• Advice to caregivers

• Compliance to drug regimen

• Pill box for dementia, arthritis patients, etc.

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Conclusion from the evidences:

• Drugs similar as in Lepzig et al., study

• The most commonly used physical performance

measures are:

o Walking speed

o Chair stand

o Grip strength

• Careful assessment and management considering

the drugs

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REFERENCES

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• Guccione A. Geriatric Physical Therapy. Second

edition,2000.

• Timiras P. Physiological Basis of Aging and

Geriatrics Fourth Edition, 2007

• Lewis C. and Bottomley J. Geriatric Physical

Therapy A Clinical Approach

• Situation analysis of the elderly in India. Ministry

of Statistics & Program Implementation, Govt. of

India, June 2011

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• Hanlon JT, Linblad CI, Hajjar E, McCarthy T. Uptade

on Drug- Related Problems in the Elderly. Am J Geri

Pharmathera. 2003; 1(1): 38-43

• Guaraldo L, Cano F, Damasceno G, Rozenfeld S.

Inappropriate medication use among the elderly: a

systematic review of administrative datbases. BMC

Geraitric. 2011,11(79)

• Kirsten KV, Blix HS, Moger TA, Reikvam A,

Polypharmacy as commonly defined is an indicator

of limited value in the assessment of drug-related

problems. Br J Clinc Pharma. 2006; 63(2):187-195