1. Better Living through Chemistry: Pharmacologic Issues in Seniors
Amie Blaszczyk, Pharm.D., CGP, BCPS, FASCP
Associate Professor & Division Head – Geriatrics
Texas Tech University Health Sciences Center School of Pharmacy
October 17, 2013

2. Objectives By the end of this session, the learner should be able to:
Describe unique aspects of drug pharmacokinetics and pharmacodynamics for older adults
Discuss current prevalence and risk of polypharmacy among older adults
Discuss vulnerability of the older adult to specific adverse drug events
Describe best practice strategies to improve appropriate medication use

3. So, why do we care?

4. The Senior Patient “Older Adult” is a misnomer
Literature support for interventions
Changes in goals of therapy
Never what you think it is
Pharmacokinetic (PK) and Pharmacodynamic (PD) changes

5. PK/PD Pharmacokinetics Pharmacodynamics “What you do to the drug”
Absorption
Distribution
Metabolism
Excretion
Pharmacodynamics
“What the drug does to you”
More drug response

6. Pharmacokinetic Changes
Absorption
pH increased (more basic)
Medications affected
The wrath of the PPI!
Distribution
Albumin decreased
Increased monitoring

7. Pharmacokinetic Changes
Metabolism
Phase I metabolism
Greatly affected
CYP450 interactions
Medications typically affected
Phase II metabolism
Relatively unchanged
APAP Controversy

8. Pharmacokinetic Changes
Excretion
Decreased renal function
Medications affected

9. Pharmacodynamic Changes
Body Composition
Increased
Changes in body fat (%)
Decreased
Changes in body water (%)
Changes in lean body mass (%)
Start low, go slow, but go!

10. Pharmacodynamic Changes
Cardiovascular Function
Resting HR decreased
Medications to watch: Beta-blockers, Cholinesterase inhibitors
Baroreceptor response diminished
Alpha-blockers, Parkinson’s medications

11. Pharmacodynamic Changes
CNS Function
Blood supply to the brain
Increased BBB permeability
GI Function
Increased risk for GI bleeds
NSAIDs
ASA
SSRIs

12. Pharmacodynamic Changes
Renal Function
Difficulty maintaining appropriate volume status
Diuretics
ACE Inhibitors
Medications which can cause diarrhea
Genitourinary Function
Prostate & anticholinergics

13. It’s not just changes with medications…

14. Seniors have lives too! Heterogeneity of aging Other impacting factors
Environmental
Economic
Sociological
Psychological

15. PolyPharmacy: Have MERCY!

16. Polypharmacy Definition Depends who you ask!
Use of multiple medications or the use of an unnecessary medication
4? 5? 9? 12?
What determines unnecessary?

17. Polypharmacy Incidence Depends on where they live Community
94% of 65+ take at least 1 medication/week
2/3 of older adults take 5+ medications
Nursing home
67.2% take 9+ medications
Qato DM, et al. JAMA. 2008;300:
Centers for Medicare and Medicaid Services. MDS quality measure/indicator report. January-March 2008.

18. Polypharmacy Incidence
Depends on the definition of what is a “medication”
13% of the elderly with herbal use in previous 12 months
Impact of Medicare Part D
Bruno JJ, et al. Ann Pharmacother. 2005;39:

19. Seniors and Polypharmacy
Why are seniors at risk?
Increasing number of comorbid diseases
Increasing number of doctors
Prescribing cascade
Self-care
OTCs
Herbals

20. Example Prescribing Cascade
80 year old with osteoarthritis pain unresponsive to Tylenol
Starts taking OTC ibuprofen 600 mg PO Q6H scheduled without MD knowledge
Ibuprofen raises her blood pressure
Prescribed HCTZ 12.5 mg Qday
Diuretic effect leads to incontinence episodes
Prescribed Ditropan (Oxybutynin) 5 mg PO TID
Oxybutynin causes problems with memory
Prescribed Aricept (Donepezil) 5 mg Daily

21. Vulnerability of the Aged
Misuse of medications
Using another’s medication
The phantom pain med from 40 years ago
Problems with Labeling/Instructions
Vision
Contrast
Print size
Vague instructions
Personal favorite: 1-2 tablets PO Q4-6H PRN
Twice daily

22. Vulnerability of the Aged
Inappropriate prescriptions
Prescribing cascade
Somatic complaints vs. Psychological condition
Beers’ List & other like-minded “Inappropriate medication” lists
All leading to an increased risk of adverse drug reactions

23. Adverse Drug Reactions
Upwards of $177 billion a year
Many are preventable
27.6%-88% depending on the venue of care
Top 3 classes
Cardiovascular medications
Analgesics
Diabetes medications
Ernst FR, et al. J Am Pharm Assoc. 2001;41:
Gurwitz JH, et al. JAMA. 2003;289:
Hanlon JT, et al. J Gerontol Med Sci. 2006;61A:
Gurwitz JH, et al. Am J Med. 2000;109:87-94.
Gurwitz JH, et al. Am J Med. 2005;118:
Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

24. Adverse Drug Reactions
3 Main Causes
Inappropriate drug selection
Overuse
Underuse
Where do they come from?
Prescribing
Dispensing
Administration & Adherence
Monitoring
Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

25. Adverse Drug Reactions: Prescribing
Inappropriate Drug Choice
Inappropriate Dose
Inappropriate Regimen/Instructions
Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

26. Adverse Drug Reactions: Dispensing
Medication Preparation
Medication Handling
Pre-dispensing storage and security
Dispensing
Related recordkeeping
Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

27. Adverse Drug Reactions: Administration & Adherence
Patient receives or takes the wrong drug or dose
Administered at the wrong time or wrong frequency
Administered via the wrong technique
Non-adherence
Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

28. Adverse Drug Reactions: Administration & Adherence
Most common types of error in administration
Other than wrong time
Administration of unauthorized drug (44.8%)
Omission of prescribed drug (41.5%)
Administration of wrong dose (11%)
Administration via wrong route (2%)
Administration of wrong form (0.4%)
Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing
Aspden P, et al. IOM Quality Chasm Series: Preventing medication Errors 2006 Committee on Identifying and Preventing medication Errors.

29. Adverse Drug Reactions: Monitoring
Important to note:
Safety
AND
Efficacy
Is it working for the condition prescribed?
Mention a medication side effect…
Sleeper RB. In: Fundamental of Geriatric Pharmacotherapy: An evidence-based approach. 2010; ASHP Publishing

30. Best Practices

31. A new symptom in an elderly person should always be considered a medication side effect first!

32. Your Role Be an advocate Be the voice of your patient
The passive-aggressive last ditch route
Be the voice of your patient
And eyes, ears…
Utilize non-pharmacologic methods first
Try to avoid calling the MD for an additional medication, if you can

33. Best Practices to Improve Appropriate Use
On intake, asking the right questions
What are you taking?
What are you taking it for?
Who prescribed it?
How do you know it’s working?
What commonly aren’t perceived as “medications”
Non-Rx medications

34. Best Practices to Improve Appropriate Use
Encouraging individuals/caregivers to keep track
All practitioners they see
Medications
Who prescribes what medications
Give the list to every practitioner they see
Utilize 1 pharmacy
Coupons

35. Best Practices to Improve Appropriate Use
Recognizing ADRs when they’re happening
If unsure, ask your pharmacist!
Recognizing when lower doses may be needed
Knowing when to stop a medication is as important as knowing when to start one
Utilize a patient’s loved ones/caregivers as viable, imperative sources of medication information.
“What were they REALLY taking?”

36. Best Practices to Improve Appropriate Use
Medication Class Overview
Cardiovascular medications
Analgesics
Diabetes medications
Psychotropics

37. Cardiovascular Medications
Prescribing
Dosing
Right medication for the right condition
Administration & Adherence
Checking vitals prior to administration
Crushable vs. non-crushable medications
Nitrate-free Interval

38. Cardiovascular Medications
Monitoring
Side effects
Bradycardia
Hypotension
Depression
Orthostasis ED
Cough/Angioedema
Pedal edema
Constipation
Lethargy
Monitoring
Efficacy
BP reduction
Pulse reduction
Anginal episode reduction
Improved exercise tolerance

39. Analgesics Prescribing Dosing Safe medications in the elderly
Remember PK and PD changes
Right medication for the right condition
APAP vs. NSAIDs vs. Opioids
Neuropathic (nerve) pain vs. Nociceptive pain
Long-acting vs. short-acting
APAP-containing opioids

40. Analgesics Administration & Adherence Timeliness PRN vs. Scheduled
The “right” PRN for the pain
Do not crush

41. Analgesics Monitoring Monitoring Side effects Efficacy
Respiratory depression
Constipation
Nausea/Vomiting
Sedation (excessive)
Occult blood
Elevated blood sugars
Monitoring
Efficacy
Pain relief (timely reassessment)
Pain scales
0-10
Wong-Baker Faces
Line

42. Diabetes Medications Prescribing Administration & Adherence Dosing
Right medicine for a senior patient
Administration & Adherence
Timely in regards to meals

43. Diabetes Medications Monitoring Monitoring Side effects/Safety
Hypoglycemia
Nausea
Edema
Monitoring
Efficacy
Glucose control
Fasting
Pre-meals
Decrease in pain
Wound healing

44. Psychotropics Gradual dose reduction trials Is it working?
Why?
When?
How?
Is it working?
Administration & Adherence
PRN antipsychotic use

45. Psychotropics Monitoring Monitoring Safety/Side effects Efficacy AIMS
Sedation
Activation
Disinterest
Disinhibition
Monitoring
Efficacy
PRN documentation
Mood
Agitation
Sleep

46. Questions? Amie.blaszczyk@ttuhsc.edu