1. Medication Management from the Geriatric Perspective
Jennifer Tjia, MD, MSCE, Division of Geriatric Medicine

2. What are we doing here today?
Very few of you will be geriatricians…
But many of you will care for geriatric patients, and
the most common intervention you will be doing is prescribing..

3. 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.

4. “…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.”

5. This shouldn’t happen.”
“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.” 5

6. “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.” 6

7. The “Don’t Kill Granny List”
Medication Management
Cognitive and Behavioral Disorders
Self-Care Capacity
Falls, Balance, Gait Disorders
Health Care Planning and Promotion
Atypical Presentation of Disease
Palliative Care
Hospital Care for Elders

8. Use of all medications*
*Prescription medications, over-the-counter drugs, vitamins/minerals, and herbals/supplements, during the preceding week, by sex and age. .
Adapted from Kaufman (2002)

9. Treatment regimen for a 79 year-old woman with HTN, DM, osteoporosis, OA, and COPD:
12 meds
5 dosing times
Boyd C, et al. JAMA 2005; 294: 9

10. Medication Management
Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug
Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and central nervous system sensitivity.
Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs, that should be avoided or used with caution in older adults, and explain the potential problems associated with each.
Document a patient’s complete medication list, including prescribed, herbal, and over-the-counter medications, and, for each medication, provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

11. Medication Management
Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug
Understand that some medications should be avoided in the elderly
Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and central nervous system sensitivity.
Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs, that should be avoided or used with caution in older adults, and explain the potential problems associated with each.
Document a patient’s complete medication list, including prescribed, herbal, and over-the-counter medications, and, for each medication, provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

12. Medication Management
Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug
Understand that some medications should be avoided in the elderly
Do a medication review and write it down
Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and central nervous system sensitivity.
Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs, that should be avoided or used with caution in older adults, and explain the potential problems associated with each.
Document a patient’s complete medication list, including prescribed, herbal, and over-the-counter medications, and, for each medication, provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

13. “…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.”

14. Pharmacokinetics in Older Persons
Absorption
Neuro & GI disease: impaired swallowing
Diabetes, anticholinergics: delayed gastric emptying
Frail: decreased subcutaneous fat affecting topical absorption
Distribution (Volume of distribution ∝ half-life)
Inactive, frail:  Fat mass
Longer half life of lipophilic agents
Higher serum concentration of water soluble agents
CNS penetration

15. Volume of Distribution
Age

16. 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
Renal: small decrease in GFR
Renal: Significant decrease in GFR, underestimated by serum creatinine
GI: decreased transit time

17. Renal Function Changes with Aging
Creatinine Clearance
Age

18. What happens to drug half life?
t1/2 ~ ↑Vd/↓Clearance
Prolonged t1/2

19. And it takes less drug to get an effect…
Pharmacodynamics
Classic age-related pharmacodynamic change is increased benzodiazepine sensitivity at the receptor level

21. 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…”

23. Antihypertensive Drug Therapy and Quality of Life Physician’s Assessment
Percent
Jachuck et al, 1982

24. Antihypertensive Drug Therapy and Quality of Life Patient’s Assessment
Percent
Jachuck et al, 1982

25. Antihypertensive Drug Therapy and Quality of Life Relative’s Assessment
Percent
Jachuck et al, 1982

26. Inappropriate Prescribing Cascade
77 yo woman with urgency; gets nifedipine for HTN
Edema, constipation, impaired bladder emptying
Nocturia,  urgency, some UI
OAB!
Add antimuscarinic
 constipation
Add laxative....

27. Inappropriate Prescribing Cascade
77 yo woman with urgency; gets nifedipine for HTN
Edema, constipation, impaired bladder emptying
Nocturia,  urgency, some UI
OAB!
Add antimuscarinic
 constipation
Add laxative....

28. 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.”

29. Medication Management
Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug
Understand that some medications should be avoided in the elderly
Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and central nervous system sensitivity.
Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs, that should be avoided or used with caution in older adults, and explain the potential problems associated with each.
Document a patient’s complete medication list, including prescribed, herbal, and over-the-counter medications, and, for each medication, provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

30. Inappropriate Prescribing
% 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

31. 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
Propoxyphene – all the bad, none of the good
Indomethacin – CNS effects
Pentazocine – confusion, hallucinations, agonist/antagonist
Meperidine – high oral doses required for efficacy, with increased toxicity
Ketorolac – significant number of asymptomatic GI conditions
NSAIDs – GI, renal, HTN, CHF
Naproxen
Oxaprozin
Piroxicam
Fick DM Arch Intern Med 2003;163:
Beers MH Arch Intern Med 1997;157: 31

32. Medication Management
Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug
Understand that some medications should be avoided in the elderly
Know why you’re prescribing, do a medication review and write it down
Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and central nervous system sensitivity.
Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs, that should be avoided or used with caution in older adults, and explain the potential problems associated with each.
Document a patient’s complete medication list, including prescribed, herbal, and over-the-counter medications, and, for each medication, provide the dose, frequency, indication, benefit, side effects, and an assessment of adherence.

33. 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: 33

34. Factors in Management - Ease of Use
Do these drugs work in older persons?
Are there differences in adverse effects?
Tolerability
Efficacy
Polypharmacy
Pharmacology
Aging
Impact on target disease, symptoms, quality of life
Comorbidity
Pathophysiology
Pathophysiology

35. The right drug at the right time for the right person…

36. A pill for all… 36