1. Drug safety in the elderly EFNS Stockholm 2012 Barbro Westerholm Prof.em, Member of Swedish Parliament

2. The demograhic future

3. Who is old? 60+, 70+, 80+, 90+…? We are born as copies and die as originals Bo G Eriksson

4. Elderly more sensitive to drugs because (1) Reduced amount of water in the body -fat soluble drugs remain longer in the body with prolonged effects – of importance for some sedatives and anxiolytics Reduced kidney function - decreased excretion of some cardiovascular drugs, some antibiotics, diabetic drugs, antiinflammatory drugs – need to reduce dosage Reduced liver function – decreases metabolism of opioids, bensodiazepines and some antidepressive drugs Brain and nervous system more sensitive to psychotropic and analgesic drugs – dizziness, confusion

5. Elderly more sensitive to drugs because (2) Decreased capacity to regulate blood pressure – blood pressure fall, fainting, vertigo when using drugs for hypertension Gastrointestinal sensitivity to anti- inflammatory drugs - bleeding

6. Drug safety in the elderly Do we have a problem? Yes! Top ten medicines reported by the EU member states to WHO in 2010 - women and men 80+ 1. Acetylsalicycic acid 6. Enalapril 2. Warfarin 7. Rovecoxib 3. Lefloxacin 8.Digoxin 4. Furosemide 9. Clopidogrel 5. Acenocoumarol 10. Ciprofloxacin

7. Drug safety in the elderly Do we have a problem? Yes! Elderly run 2 – 3 times higher risks than younger adults to get adverse drug reactions Drug related problems is a common cause of hospitalization of older people 10 – 30 % of the admissions in emergency departments of internal medicine in Sweden are due to drug related problems In the US it has been estimated that 100 000 persons die per year of drug related problems

8. Drug safety in the elderly Do we have a problem? Still yes. Percentage of Swedish inhabitants 80+ with Ten or more Combinations Three or more medicines carrying risks psychotropics 2007 16.4 4.4 6.4 2008 14.2 3.6 5.9 2009 11.1 2.9 4.6 2010 10.8 2.7 4.5

9. Why do we have a problem with safety of drug treatment in the elderly? Many drugs prescribed to older patients not tested in this age group Prescribers lack education about how to treat older patients with drugs Older people are treated for their symptoms, not based on diagnosis Effects of drug treatment in the individual patient is not monitored Lack of coordination between different doctors` treatment of an individual treatment Patients lacking knowledge about drugs and how to use them

10. What can we do to improve drug safety in the elderly – EMA geriatric medicines strategy Ensuring that medicines used by geriatric patients are of high quality, and appropriately researched and evaluated, throughout the lifecycle of the product, for use in this population Improving the availability of information on the use of medicines for older people, thereby helping informed prescription Establishing specific pharmacovigilance activities

11. EMA continued Establishment of an Advisory Group on Geriatrics Interaction with stakeholders

12. What can we do to improve drug safety in the elderly Pre- and postgraduate education on drugs and their use especially in the elderly should be strengthened and given not only to medical students, physicians and pharmacists but also to nurses and other health and social welfare personnel.

13. What can we do to improve drug safety in the elderly As responsible physician- Have a comprehensive view – se the whole patient as a part of whole Self-care and non-pharmacological treatment always comes first The drug-list is the medical record for drugs and it should always be updated and correct Team work – use all competencies

14. What can we do to improve drug safety in the elderly - Prescribers When meeting the patient – Identify the patient`s need of treatment – diagnosis important Symptoms can be adverse reactions to drugs Record which other drugs the patient is using Evaluate what has to be prescribed – make a benefit risk assessment, is there any medication which should be stopped Which dosage and administration form is appropriate Make a plan for the treatment, when to meet for a follow-up of the effects of the treatment and discuss this with the patient or her or his carer Report adverse reactions if they occur

15. What can we do to improve drug safety in the elderly Pharmacies Information in agreement with the prescribing physicians

16. What can we do to improve drug safety in the elderly Consumers The elderly and their informal carers should obtain clear information about the effects of drugs on the elderly and Patients or their informal carers should always ask the prescribing physician: Why the drugs are being prescribed, Is the dosage right - have you checked the kidney function How should the drugs be taken and for how long. Can the drugs used together with herbal medicines. Which adverse reactions can occur What to do when adverse reactions are suspected.

17. Adverse reactions to drugs is not a new phenomenon but we should do all we can to prevent it and there is much we can do Mencius 100 B.C If a drug does not cause reactions in a patient it will not cure his disease either Ovidius 9 A C. The same drug both makes harm and cures

18. Thank you for your attention.