1. POLYPHARMACY

3. Factors that contribute to polypharmacy
Chronic medical conditions
Female gender
Multiple physicians, especially specialists
Prescribing by brand and generic names
Self medication with OTC medications
Increased elder mobility
Direct-to-the-consumer advertising
Physician on call

4. More factors that contribute to polypharmacy
Physicians are reluctant to stop a medication started by another physician
End points of drug therapy are seldom set and patients are not reevaluated for the need to continue medications
"Start slow, Go slow" may yield failure to raise the dose to a therapeutic level
Multiple pharmacies

5. Adverse Drug Effects

6. ADEs and Drug interactions in the elderly
25% of the elderly at home.
2 to 8% of hospital admissions of all patients.
If 65+, then 5 to 30% of hospital admissions.
60% of patients admitted due to adverse drug reactions were taking 11 or more drugs.
Risk increases with number of drugs.
Elders in the hospital get more drugs so at even greater risk of ADE while an inpatient.

8. Drug interactions
More common in the elderly simply because they take more drugs
More than 20% of adverse drug reactions in the elderly are due to drug interactions
Drug-drug interactions
Drug-nutrient interactions

10. Patient compliance problems

11. Patient compliance problems
Morbidity and disabilities from disease
Complex regimens
Drug characteristics
Solutions

12. Nonadherance and No. of Drugs

13. Morbidity and disabilities from disease
Movement disorders
Amputations
Impaired vision
Comprehension and memory deficits
Depression or psychosis

14. Complex regimens Multiple medications Multiple administration times
Complex administration
Devices

16. Miscellaneous drug characteristics
Taste
Cost
Side effects
Capsule or tablet size

17. Altered physiology in the elderly affects medications
Multiple organ system changes
Pharmacodynamics
Pharmacokinetics

18. Pharmacodynamics Altered drug receptor sensitivity Fewer receptors
Receptors are less sensitive
Receptors are more sensitive

19. Pharmacokinetics
Absorption
Distribution
Metabolism
Excretion

20. Absorption Reduced gastric acid and fluid- dissolution
Delayed gastric emptying
Reduced gastric acid - pH dependent absorption
Reduced GI blood flow - absorption

21. Distribution Decreased total body water Decreased lean body mass
Increased total body fat
CHF and impaired drug delivery

22. Metabolism Hepatic blood flow First pass metabolism
Liver enzyme system activity

23. Excretion Reduced renal blood flow Age related decline in blood flow
CCr declines 1% per year after 40

24. Solutions to Problem Once a day medications
Absolutely necessary medications only
Education
Involve family
Review of medications at each visit
Listening to the patient