1. Medication in the Elderly
Erica Wang BScPharm, PharmD, ACPR, BCPS

2. The Elderly… Have different goals of therapy
Have a variable response to medications
Are more sensitive to adverse reactions
Have reduced renal function
Increased risk for bleeding
Are at increased risk for falls

3. Therapeutic index.
Therapeutic index. For any drug, there is a relationship between dose and efficacy (black lines) and a second relationship between dose and toxicity (gray lines). These curves are derived from populations and efficacy may be incomplete, as indicated in these examples. The arrows on each plot identify the dose at which 50% of the response is seen, and the therapeutic index is indicated by the open arrow at the bottom of each plot. Some drugs considered here, such as warfarin and clopidogrel, have narrow therapeutic indices, whereas others (β-blockers, statins) have wider ones. DNA variants may modulate the relationship between efficacy and toxicity in populations and in individuals.
Dan M. Roden et al. Circ Res. 2011;109:
Copyright © American Heart Association, Inc. All rights reserved.

4. Goals of Therapy Reduce mortality Reduce morbidity
Maximize quality of life
Maintain functional capacity
Reduce functional decline
Maintain independence
Prevent cognitive decline and depression
Prevent falls
Maximize balance, flexibility, strength
Prevent adverse drug effects
Ensure compliance

5. Aging Frailty Multimorbidity Cognitive decline
Sensory impairment (hearing and visual)
Balance impairment
Sarcopenia
Osteoporosis
Risk for falls

6. Poll Everywhere The elderly are at increased risk for falls due to:
A) Muscle weakness
B) Impaired balance or gait
C) History of falls
D) Medications
E) All of the above

8. Anticholinergics Drug Class Examples Antidepressants
TCA (amitriptyline)
SSRIs (Paroxetine)
Antiemetics
Antipsychotics
Loxapine, methotrimeprazine, quetiapine
Antihistamines
Diphenhydramine, hydroxyzine
Opioids
Morphine, hydromorphone, fentanyl
Parkinson’s medications

9. Statins Elderly have reduced muscle mass
Increasing age increases risk for sarcopenia
Muscle mass reduces to ~15% of total body weight (TBW) in those ~75 years of age
30% of TBW in younger adults
Reduced muscle mass results in reduction in strength
Increases risk for incidence of disability and mortality
Combined with other co-morbid age-related changes, elderly with myalgias are at increased risk of falls

10. Statins Elderly are at risk of many adverse effects of statins
Muscle toxicity
Cognitive changes
Diabetes

11. ASPREE Trial ASPirin in Reducing Events in the Elderly
Multi-centered, randomized, double-blind, placebo-controlled trial in Australia and USA
Planned enrollment N=19000
Clinical question: in an elderly individual without CVD, does ASA 100mg daily compared to placebo increase the years of life free from physical and cognitive disability?
Recruitment ended 2014
Expected trial results in 2018

12. Bleeding
Advanced age is associated with platelet dysfunction, decreased clotting factor synthesis and increased fragility of blood vessels

13. Antiplatelets Benefits Proven (secondary prevention) Potential
Reduce mortality
Prevent cardiovascular events
Prevent cerebrovascular events
Reduce peripheral arterial disease progression
Potential
Reduce risk of vascular dementia
Reduce risk of functional decline
Decrease risk of cancer
Reduce depression

14. Antiplatelets ASA P2Y12 Inhibitors Dual antiplatelet therapy (DAPT)
Clopidogrel
Ticagrelor
Prasugrel
Ticlopidine
Dual antiplatelet therapy (DAPT)
ASA + P2Y12 inhibitor
Advanced age results in platelet dysfunction
ASA has 2 mechanisms for bleeding
Acid in contact with GI mucosa
Reduction in platelet aggregation
P2Y12 inhibitors have varying risks for bleeding
Ticlopidine > clopidogrel > ticagrelor > prasugrel
Avoid prasugrel for > 75 years of age and hx CVA (increased risk of ICH)
DAPT duration should be limited to minimum

15. Anticoagulants Warfarin Non-vitamin K oral anticoagulants (NOACs)
Dabigatran, Rivaroxaban, Apixaban, Edoxaban
IV unfractionated heparin (UFH)
Low molecular weight heparins (LMWH)
Enoxaparin, dalteparin, tinzaparin, nadroparin
Bivalirudin
Fondaparinux
Argatroban
Advanced age results in redcued synthesis of clotting factors
Increased risk of bleeding in elderly on anticoagulants
Generally, elderly are on lower doses
Low body weight
Reduced renal function
Poor nutritional status
Some have age-specific and renal function-specific dosage adjustments

16. J Clin Epidemiol 2002;55(2):
Risk of GIB

17. Take Home Points Goals of therapy differ between elderly patients
Prevention of falls is very important
Elderly have variable response to medication effects, so start low and go slow
Be extra vigilant and monitor for adverse effects of medications
Involve your pharmacist to help 