Physical and Sensory in the Older Adult: Considerations for … · Older Adults: The Growing Population •By 2030, 20.3% of the US population is expected to be >65 years of age –Increase

Physical and Sensory Changes in the Older Adult:

Considerations for Medication Management

Amber M. Hutchison, PharmD, BCPSAssistant Clinical Professor

Auburn University Harrison School of Pharmacy

Disclosure/Conflict of Interest

• I, Amber M. Hutchison, have no actual or potential conflict of interest in relation to this program.

Objectives

• Review age‐related considerations for pharmacokinetic and pharmacodynamics changes in the older adult population.

• Describe how age‐related sensory changes affect an older adult’s ability to self‐manage medications.

• Simulate age‐related sensory changes experienced by an older adult population.

What does aging look like to you?

Older Adults: The Growing Population

• By 2030, 20.3% of the US population is expected to be >65 years of age– Increase from 13.7% in 2010 and 9.8% in 1970

• By 2030, all of the baby boomers will be considered to be older adults

• The population >85 years will double by 2036 and triple by 2049

Ortman JM. “An Aging Nation: The Older Population in the United States.”

Dependency Ratios in the US

Adapted from: Ortman JM. “An Aging Nation: The Older Population in the United States.”

Pharmacotherapeutic Considerations

• Physical changes• Pharmacokinetic changes• Pharmacodynamic changes

Physical Changes

• Swallowing difficulties• Poor nutrition• Dependence on feeding tubes• Visual disturbances• Arthritis• Sensory changes• Decreased lung function

Wooten JM. South Med J. 2012;105(8):437-445.

Pharmacokinetic Changes

• Absorption• Distribution• Metabolism• Excretion

Absorption• Reduced gastrointestinal (GI) motility

– Possible increased drug absorption• Reduced gastric acid secretion increased gastric pH– Reduced drug absorption

• Reduced gastric blood flow– Reduced drug absorption

• Drugs with first‐pass metabolism may have increased absorption

Wooten JM. South Med J. 2012;105(8):437-445.Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient. 2011.

Distribution• Volume of distribution (Vd) affected

– Decreased albumin levels • Highly protein‐bound drugs—increased concentration of drug

– Increased proportion of body fat• Fat soluble drugs—increased Vd• Drugs distributed to muscle—decreased Vd

– Possible decrease in total body water


Metabolism

• Changes in the liver– Decreased hepatic blood flow– Decreased hepatic metabolism by decreased activity in oxidase system

– Decreased liver mass


Knowledge Check• Your 73 year old patient is on drug A which requires an acidic environment for absorption. What may happen to the drug absorption in this elderly patient?

• A. Increase• B. Decrease• C. No effect

Knowledge Check

• Your 82 year old patient is on drug B which is highly protein bound. What may happen to the drug distribution in this elderly patient?


Knowledge Check

• Your 79 year old patient is on drug C which is fat soluble. What may happen to the drug distribution in this elderly patient?


Excretion

• Renal elimination– Decreased GFR– Decreased renal blood flow– Estimates of CrCl

• Cockcroft‐Gault• MDRD


Equations to Estimate CrCl


CrCl Estimations

• Weight to be used:– If actual body weight (ABW) is less than ideal body weight (IBW), use ABW

– In patients with normal ABW, use IBW– In obese patients, use a factor of 0.4 to calculate an adjusted body weight

Winter, MA, et al. Pharmacotherapy. 2012; 32(7):604–612.Wooten JM. South Med J. 2012;105(8):437-445.Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient. 2011.

CrCl Estimations

• IBW calculation– Men: IBW = 50 + 2.3 kg (every in >5 ft)– Women: IBW = 45.5 + 2.3 kg (every in >5 ft)

• Adjusted body weight calculation– AdjBW = IBW + 0.4 (TBW‐IBW)


A Note about CrCl Estimations• SCr depends on albumin• Common practice is to “round up” SCrvalues for older adults

• This may not be the best estimate of CrClin elderly patients


CrCl Estimations

n=12

CrClMean + SD (mL/min)

Mean Difference (95% CI) (mL/min)

Pearson’s Correlation (r)

P value

24‐hour CrCL 62.7 + 23.2

Actual SCr CrCl 59.6 + 23.2 ‐3 (‐20.8‐14.9) 0.551 1

Rounded SCr CrCl 46.5 + 19.5 ‐16.2 (‐31.6 to ‐0.8) 0.620 0.039

Adapted from: Winter, MA, et al. Pharmacotherapy. 2012; 32(7):604–612.

CrCl Estimations in Patients > 65 years with SCr <0.8 mg/dL

CrCl Estimations

n=12

CrClMean + SD (mL/min)

Mean Difference (95% CI) (mL/min)

Pearson’s Correlation(r)

P value

24‐hour CrCL 62.7 + 34.5

Actual SCr CrCl 53.7 + 21 ‐9 (‐22.2‐4.2) 0.629 0.279

Rounded SCr CrCl 40.2 + 16.4 ‐22.5 (‐35.1 to ‐9.9) 0.711 <0.001

Adapted from: Winter, MA, et al. Pharmacotherapy. 2012; 32(7):604–612.

CrCl Estimations in Patients > 65 years with SCr <1 mg/dL

Calculate the CrCl for a 79 year old male pt with

SCr=1.1. Pt is 5’11” tall and weighs 180 pounds.

Calculate the CrCl for a 79 year old female pt with SCr=1.1. Pt is 5’11” tall and weighs 180

pounds.

A Note about CrCl Estimations

• Consider:– Reviewing the literature of the drug manufacturer and determine how CrCl was calculated in trials

– Consider calculating CrCl rounded and not rounded and evaluate the patient


Pharmacodynamic Changes

• Altered– Number of receptors– Receptor affinity– Second messenger function– Cellular response– Cellular nuclear response


SECURE Project Activity

SECURE Project• Developed by Lee Memorial Health System in Fort Meyers, Florida

• Designed to be used for a wide range of experiences– Medical personnel– Non‐medical personnel

• Including workers in sales, etc.

• Simulates sensory changes in the older adult

First Activity—Eye Troubles• Take out glasses 1, 2, and 3

– Try reading the newspaper article– Take out your phone and try to read the phone screen

• Take out glasses 4– Again, try reading the package insert and your phone screen

– Look at your neighbors– Use the printed Number Card Game—trace from 1 through 10

First Activity—Eye Troubles• Take out glasses 5 and put them on

– Open the pill bottle, sort out these “tablets”:

• One white• Two green • Two blue• Two yellow

– Try reading the package insert– Take out your phone and try to read the phone screen

First Activity—Eye Troubles• Glasses simulation

– Glasses #1: Glaucoma– Glasses #2: Macular degeneration– Glasses #3: Hemianopsia– Glasses #4: Cataracts– Glasses #5: Age‐related yellowing of the lens

Other Eye Issues• Age‐related vision changes:

– Decreased ability to see objects clearly– Decreased ability to focus on objects at varying distances

– The need for more lighting in order to function

– Decreased ability to perceive depth– Slow accommodation to changes in light sensitivity

– Decreased ability to discriminate colors in the blue‐green‐violet range

Eye Issues: How can we help?• Have a system for identifying medications besides just color

• Avoid glare areas—use blinds• More light on signs• Use large print for handouts and signs

• Bold print for publications• Avoid printed materials in blue‐green‐violet range

• Use yellow background with red print

Eye Issues: How can we help?

• Place‐mats or tablecloth in contrasting color from tableware

• Have curbs, edges of steps, handrails, door knobs, etc. marked in contrasting colors

• Stand close to the older person and use touch

• Utilize high intensity light for reading areas

Hearing Loss Issues

• Video– https://auditoryneuroscience.com/HearingLossSimulator

– http://facstaff.uww.edu/bradleys/radio/hlsimulation/

Hearing Loss Issues• How can we help?

– May try to lower pitch of your voice– Face the person who you are speaking to– Speak at a distance of 3‐6 feet– Use touch to get the person’s attention– Enunciate your words slowly and clearly– Keep sentences short and simple– Eliminate background noises

Impaired Manual Dexterity • Take out the gloves

– Sort out the pills– Open a safety pin– Button a button on your shirt or blouse– Take off a earring or watch– Remove a card from your wallet or purse– Use your phone

• For more fun: put on the gloves and glasses TOGETHER– Try to do all of the activities above

Useful Tools for Managing Therapy in Older Adults

• Explicit criteria– Beers Criteria– START– STOPP

• ASCP Drug Regimen Review Checklist

Elliott DP. PSAP. 2011;213‐238.

Beers Criteria

• Most recently updated in 2015• Applicable for all older adults except those in palliative and hospice care

• List of potentially inappropriate medications (PIM)

• Medications are included if there is a poor risk to benefit ratio

2015 AGS Updated Beers Criteria. J Am Geriatr Soc. 63(11): 2227‐2246.

Beers Criteria• Five tables summarizing recommendations:– Medications to avoid in older adults– Medications to avoid in older adults with certain disease states

– Medications to be used with caution in older adults

– Important drug‐drug interactions in older adults

– Medications requiring adjustments based on kidney function

2015 AGS Updated Beers Criteria. J Am Geriatr Soc. 63(11): 2227‐2246.

Beers Criteria• Provides rationale against use

– Helpful for report of irregularities to physician

• Gives recommendation– May recommend complete avoidance or avoiding drug in certain circumstances

• Classifies quality of evidence• Rates strength of recommendation2015 AGS Updated Beers Criteria. J Am Geriatr Soc. 63(11): 2227‐2246.

START Tool

• Screening Tool to Alert doctors to Right Treatment

• Designed to address errors of omission– Factors contraindications into recommendation

• Arranged by organ system• Article reports 57.8% of patients had one or more medications omitted

Barry PJ, et al. Age Ageing. 2007;36:632‐638.

Selected START Criteria

Organ System Recommendation

CV System Warfarin in the presence of chronic atrial fibrillation, where there is no contraindication to warfarin

Respiratory System

Inhaled steroid in mod‐severe asthma or COPD, where reversibility of airflow obstruction has been shown.

Locomotor system Bisphosphonate in patients taking glucocorticoids for >1 month (i.e. chronic corticosteroid therapy).

Endocrine System Aspirin therapy in diabetes mellitus with well controlled blood pressure

Barry PJ, et al. Age Ageing. 2007;36:632‐638.

STOPP Tool• Similar in intent to Beers criteria• Screening Tool of Older Persons’ Prescriptions

• Designed to address potentially inappropriate medications

• 65 criteria included in the tool– Arranged by organ system– Includes a recommendation and italicized rationale

Hamilton HJ, et al. BMC Geriatr. 2009;9:5.

Selected STOPP Criteria

Organ System Recommendation Rationale

CV System Calcium channel blockers with chronic constipation

May exacerbate constipation

CV System Aspirin at dose >150 mg/day ↑ bleeding risk, no increased efficacy

CNS and Psychotropics

TCA’s with cardiac conductive abnormalities

Pro‐arrhythmic effects

GI System Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhea of unknown cause

May delay recovery in unrecognized gastroenteritis

Adapted from: Hamilton HJ, et al. BMC Geriatr. 2009;9:5.

ASCP Drug Regimen Review Checklist

• Available from: http://www.ascp.com/resources/drr/upload/DRR%20Checklist.pdf


ASCP Drug Regimen Review Checklist• Drug Indications

– Does each prescribed medication have a current and valid indication?

– Does the resident have conditions or indications for which medications may be appropriate or are not being used?

• Medication effectiveness– Is the medication appropriate for the indication being treated?

– Is the dose of medication adequate?


ASCP Drug Regimen Review Checklist• Medication Safety

– Is the dose of medication excessive? – Is the resident experiencing signs or symptoms of adverse medication effects?

– Is the resident experiencing a problem resulting from a drug‐drug, drug‐food, or drug‐laboratory test interaction?

• Medication Monitoring– Are monitoring parameters in place to evaluate medication effectiveness and safety?

– Do results of medication monitoring indicate a need for intervention?


ASCP Drug Regimen Review Checklist

• Medication Errors– Is there evidence of a medication error?

• Medication Cost– Do any issues related to medication cost need to be addressed?


Physical and Sensory Changes in the Older Adult:

Considerations for Medication Management

Amber M. Hutchison, PharmD, BCPSAssistant Clinical Professor

Auburn University Harrison School of Pharmacy

Documents

Physical and Sensory in the Older Adult: Considerations for … · Older Adults: The Growing Population •By 2030, 20.3% of the US population is expected to be >65 years of age –Increase