Medication Management from the Geriatric PerspectiveJennifer Tjia, MD, MSCE, Division of Geriatric Medicine
What are we doing here today?Very few of you will be geriatricians…But many of you will care for geriatric
patients, andthe most common intervention you will be
doing is prescribing..
The “Don’t Kill Granny List” A minimum set of standards that every
medical student should be able to demonstrate before graduating and caring for elderly patients.
“…Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed.
She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.”
http://www.nytimes.com/2009/07/02/opinion/02leipzig.html
“Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won’t hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she’s considered ready for discharge — but she is no longer the woman she was before her illness. She’s more frail, and needs help with walking, bathing and daily chores.
This shouldn’t happen.”
“All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics, even though patients 65 and older account for 32 percent of the average doctor’s workload in surgical care and 43 percent in medical specialty care, and they make up 48 percent of all inpatient hospital days. Medicare, the national health insurance for people 65 and older, contributes more than $8 billion a year to support residency training, yet it does not require that part of that training focus on the unique health care needs of older adults.”
The “Don’t Kill Granny List”1. Medication Management2. Cognitive and Behavioral Disorders3. Self-Care Capacity4. Falls, Balance, Gait Disorders5. Health Care Planning and Promotion6. Atypical Presentation of Disease7. Palliative Care8. Hospital Care for Elders
Adapted from Kaufman (2002)
*Prescription medications, over-the-counter drugs, vitamins/minerals, and herbals/supplements, during the preceding week, by sex and age. .
Use of all medications*
Boyd C, et al. JAMA 2005; 294:716-724.
Treatment regimen for a 79 year-old woman with HTN, DM, osteoporosis, OA, and COPD:
12 meds5 dosing times
Medication Management1. Understand how age affects the
metabolism and manifestation of the desired (and undesired) effects of the drug
Medication Management1. Understand how age affects the
metabolism and manifestation of the desired (and undesired) effects of the drug
2. Understand that some medications should be avoided in the elderly
Medication Management1. Understand how age affects the
metabolism and manifestation of the desired (and undesired) effects of the drug
2. Understand that some medications should be avoided in the elderly
3. Do a medication review and write it down
“…Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed.
She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.”
http://www.nytimes.com/2009/07/02/opinion/02leipzig.html
Pharmacokinetics in Older Persons
Absorption Neuro & GI disease: impaired swallowing Diabetes, anticholinergics: delayed gastric
emptying Frail: decreased subcutaneous fat affecting
topical absorptionDistribution (Volume of distribution ∝ half-life) Inactive, frail: Fat mass
Longer half life of lipophilic agents Higher serum concentration of water soluble
agents CNS penetration
Age
Volu
me
of D
istrib
utio
n
Pharmacokinetics in Older Persons
Metabolism Healthy older persons
No change in hepatic glycosylation No definite change in P450 enzymes Hepatic mass and blood flow: less first-pass effect and increased
serum levels of unmetabolized drug Comorbid disease
Further decrease in hepatic mass and blood flow Concomitant medications that induce or inhibit P450 enzymes
Clearance Healthy older persons
Renal: small decrease in GFR Comorbid disease
Renal: Significant decrease in GFR, underestimated by serum creatinine
GI: decreased transit time
Renal FunctionChanges with Aging
Age
Cre
atin
ine
Cle
aran
ce
t1/2 ~ ↑Vd/↓Clearance
Prolonged t1/2
What happens to drug half life?
And it takes less drug to get an effect… Pharmacodynamics
Classic age-related pharmacodynamic change is increased benzodiazepine sensitivity at the receptor level
Summary of PD/PK
“a dose of antibiotic that would be right for a woman in her 50s might be twice as much as
an 80-year-old patient should get…”
Antihypertensive Drug Therapy and Quality of LifePhysician’s Assessment
Improved No Change Worse0
20
40
60
80
100
Perc
ent
Jachuck et al, 1982
Antihypertensive Drug Therapy and Quality of LifePatient’s Assessment
Improved No Change Worse0
20
40
60
80
100
Perc
ent
Jachuck et al, 1982
Antihypertensive Drug Therapy and Quality of LifeRelative’s Assessment
Improved No Change Worse0
20
40
60
80
100
Perc
ent
Jachuck et al, 1982
Inappropriate Prescribing Cascade
77 yo woman with urgency; gets nifedipine for HTN Edema, constipation,
impaired bladder emptyingNocturia, urgency, some UI
OAB!
Add antimuscarinic
constipation Add laxative....
Inappropriate Prescribing Cascade
77 yo woman with urgency; gets nifedipine for HTN Edema, constipation,
impaired bladder emptyingNocturia, urgency, some UI
OAB!
Add antimuscarinic
constipation Add laxative....
Clinical Pearl“In evaluating virtually any symptom
in an older patient, the possibility of an adverse drug event should be considered in the differential diagnosis.”
Medication Management1. Understand how age affects the
metabolism and manifestation of the desired (and undesired) effects of the drug
2. Understand that some medications should be avoided in the elderly
Inappropriate Prescribing
12 - 25% outpatients receive at least one inappropriate medicine
92% of frail elderly VA inpatients received at least one inappropriate medicine
Risk factors Number of medications Comorbidity Poor self-rated health
50% of ADRs linked to inappropriate meds
Examples of Drugs to Avoid in the Beers Criteria
Propoxyphene Pentazocine Meperidine NSAIDs
Indomethacin Ketorolac Naproxen Oxaprozin Piroxicam
Short-acting benzos Lorazepam 3 mg Oxazepam 60 mg Alprazolam 2 mg Temazepam 15 mg Triazolam 0.25 mg
Long-acting Chlordiazepoxide Flurazepam Diazepam
Fick DM Arch Intern Med 2003;163:2716-2724 Beers MH Arch Intern Med 1997;157:1531-1536
Medication Management1. Understand how age affects the
metabolism and manifestation of the desired (and undesired) effects of the drug
2. Understand that some medications should be avoided in the elderly
3. Know why you’re prescribing, do a medication review and write it down
What and Why in Prescribing
Treatment Targets Acute illness
Chronic disease Symptoms Risk factors
Goals of Care Primary prevention Secondary prevention Slow disease
progression Prolong life Prevent morbidity Prevent decline Comfort
Sachs, GA. JAGS 1998; 46: 782-3.
Pathophysiology
AgingComorbidity
Pathophysiology
TolerabilityEfficacy
PharmacologyPolypharmacy
Impact on target disease, symptoms, quality of life
Do these drugs work in older persons?
Are there differences in adverse effects?
Factors in Management - Ease of Use
The right drug at the right time for the right person…
A pill for all…