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GERIATRIC PHARMACOLOGY

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Presentation on theme: "GERIATRIC PHARMACOLOGY"— Presentation transcript:

1 GERIATRIC PHARMACOLOGY
DRUGS: AFFECT BOTH WELL-BEING AND WALLET!!!

2 INTRODUCTION

3 Elderly population percentage
Consumption of medications ˜- 31 % of total prescribed drugs 80-90% elderly consume at least 1 drug/day in developing countries JAMA, 2002 A major public health problem Public Health Reviews, 2010

4 Physiological Basis of Aging and Geriatrics Fourth Edition Author: Paola S. Timiras

5 BURDEN Medication related hospital admissions
Consequences of poly-pharmacy & ADR Financial burden: Economic profile of Indian elderly: Old age dependency ratio=13.1% Ministry of Statistics & Program Implementation, Govt. of India, June 2011

6 DRUGS & BODY INTERACTION
What happens to the drug when it enters the body?

7 PHASES PHARMACOKINETICS PHARMACODYNAMICS
Study of what happens to the drug in the body or how the body processes the drug Study of what the drug does to the body i.e. what are the effects of the drug on the body, both at the systemic and cellular levels Absorption Distribution Metabolism Elimination Intensity Peak Duration

8 PHASES AGE-RELATED CHANGES IMPLICATIONS
Intestinal blood flow Gastric emptying time Mucosal cell absorption area Altered gastric pH Hepatic mass hepatic blood flow Impaired phase-1 reaction Drug-drug interaction Drug-food interaction Lower doses may be therapeutic ABSORPTION METABOLISM Total body fat, à-1 glycoprotein Total body mass, total water content, albumin Renal blood flow GFR Renal mass Tubular secretion Lipophilic drugs Acidic drug binding Clearance (vs.) Dose (vs.) Duration DISTRIBUTION ELIMINATION

9 PHARMACODYNAMICS Age-related systemic changes: Example: Hypertension
Homeostatic control Thermoregulatory mechanisms Example: Hypertension Age-related changes like: Reduced baroreceptor function Reduced peripheral venous tone Drug: vasodilators Altered cellular responses: Receptor level Changes in intra cellular structure and function Younger individuals response: tachycardia Elderly individuals: No CV response due to age-related changes Alterations in the sensitivity to drug Altered therapeutic effects of drug

10 ADVERSE DRUG EVENTS IN ELDERLY

11 ADR Chronic Illness Poly-pharmacy Altered Drug Metabolism
Altered Drug Excretion Drug-drug interaction Drug Toxicity

12 PATTERN OF DRUG USE High percentage of drug usage
Prevalence of multiple chronic diseases Community dwelling elderly: non-prescription drugs Polypharmacy ADR Drugs to treat ADR

13 REASONS FOR MEDICATION RELATED PROBLEMS

14 ALTERED RESPONSES Physiological and pathological changes due to aging
Altered pharmacokinetic and pharmacodynamics response Cumulative effects of aging and drugs Altered response: longer drug half life Critical Reviews in Oncology/Hematology, 2009

15 MULTIPLE & CHRONIC DISEASES
Multiple disease state is defined as the presence of at least more than one disease conditions that is commonly found in geriatric population. Prevalence of multiple chronic diseases Centers for Disease Control and Prevention ,2010

16 RESEARCH IN GERIATIC PHARMOCOLOGY
Lack of clinical trials Lack of guidelines for drug dosage and regimen for elderly

17 DRUG-TAKING BEHAVIOUR
Self-medication/ Over-the-counter medication Adherence to prescribed medication Factors affecting adherence to medication Pathological conditions: cognitive decline, arthritis of hand, poor eyesight Polypharmacy Side-effects of medications Financial burden Prob with drug adherence and self-edu (study from guccione)

18 POLYPHARMACY Definition Factors Consequences
Assessing inappropriate drug Tools to reduce polypharmacy

19 DEFINITION Lack of clear definition Number of drugs Older definitions
Polypharmacy (5-9 medications) and high-level Polypharmacy (>or=10 medications) Inappropriate medication Br J Clin Pharmacol. 2007 Br J Med Pract. 2008

20 FACTORS LEADING TO POLYPHARMACY
Clinics in Geriatric Medicine, 2012 May; 28(2): 159-72 Guccione A. Geriatric Physical Therapy, second edition

21 Medications from relatives etc. Physician Related
Patient Related Socio-demographics patients' conditions.  patient behavior, such as patient's self medication with all types of medications Medications from relatives etc. Physician Related Patient Physician Interaction  Physicians’ rely mainly on medications rather than lifestyle modification etc which can prevent polypharmacy Patient’s behavior: self medication,

22 CONSEQUENCES Drug-drug interaction leading to adverse drug reactions
Decreased compliance Increased financial burden

23 TOOLS TO REDUCE POLYPHARMACY
Non-pharmacological management should be first line of action Communication between physicians Communication between physician and patient Regular monitoring 3-main points to check in a prescription: Number Regimen Dosage Merle L et al., Drugs Aging, 2005

24 Medications Related Falls in Elderly
Huang et al., Drug Aging, 2012

25 Common drugs associated with high incidences of fall are:
Factors: Medications with half life period more than 24hrs Polypharmacy: more medications lead to higher incidence of fall Wilson,1998 Common drugs associated with high incidences of fall are: Anti-hypertensives Anti- depressants Narcotics & sedative

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27 Medication problems that affect the physical therapist’s work
COMMON DRUG REACTIONS

28 Drug induced ototoxicity Drug Induced oculotoxicity
e.g. Aminoglycoside antibiotics cause irreversible deafness - like gentamicin loop diuretics - furosemide (lasix) NSAIDs (aspirin), quinine cause tinnitus is reversible Deafness - problem communicating visual acuity - problem seeing demonstration Drug Induced oculotoxicity Amantadine - corneal opacities amiodarone -corneal micro deposits Anticholinergics,antidepressants, antihistamines: blurred vision glaucoma anticonvulsants - diplopia, nystagmus adrenergic blocker - reduced tears digoxin - colored halos amatadine - antiparkinson’s antiviral - corneal opacities amiodarone - antiarrythmic corneal microdeposits -reversible - 10% of patients - high incidence of hypothyroidism too! anticholinergics - ipratropium atrovent blurred vision and glaucoma antidepressants - anticholinergic side effects antihistamines - anticholinergic side effects anticonvulsants - diplopia (double vision), nystagmus  -adenergic blocker - reduced tears bromocriptine - myopia blurred vision corticosteroids - glaucoma cataracts digoxin - colored halos - sign of toxicity methotrexate 25% conjunctivitis - reduced

29 Drug induced Dizziness, Fainting and Weakness
Cytotoxic agents: treat cancers, arthritis, autoimmune diseases Antihypertensive medications - beta blockers, Ca++ channel blockers, diuretics, ACE inhibitors Problems while performing exercise,and can be hazardous remembering instructions Drug Induced drowsiness, anemia, muscle wasting Glucocorticoid steroids Drugs that cause insomnia - prevent a good night sleep e.g. caffeine, aminophylline Pain medications Muscle relaxants Antinauseants NSAIDs amatadine - antiparkinson’s antiviral - corneal opacities amiodarone - antiarrythmic corneal microdeposits -reversible - 10% of patients - high incidence of hypothyroidism too! anticholinergics - ipratropium atrovent blurred vision and glaucoma antidepressants - anticholinergic side effects antihistamines - anticholinergic side effects anticonvulsants - diplopia (double vision), nystagmus  -adenergic blocker - reduced tears bromocriptine - myopia blurred vision corticosteroids - glaucoma cataracts digoxin - colored halos - sign of toxicity methotrexate 25% conjunctivitis - reduced

30 CONDITIONS & DRUGS ADVERSE EFFECTS PT IMPLICATIONS & PRECAUTIONS Drugs for CV conditions Digitalis CHF symptoms, toxicity Nitrates Angina B-blockers CV problems Safety Ca++ channel blockers vitals monitoring Diuretics fatigue vasodilatos Postural hypotension Drugs for MSk system NSAIDs GI problems( anemia) Baclofen sedation Scheduling sessions, Diazepam Narcotics Sedation, OH, GI prob, Steroids Catabolic effects Electrotherapeutic modalities, Osteoporosis

31 DRUGS COMMON ADVERSE EFFECTS PT IMPLICATIONS & PRECAUTIONS Anti-epileptics Sedation, confusion, GI problems, skin problems, other cerebellar signs like ataxia, etc. Emergency codes Co-ordinate sessions Epilepsy evoking stimulus Electrotherapeutic modalities Levadopa Postural hypotension, GI problems, CV problems, behavioral changes, etc. Scheduling sessions: ON-phase Cardiac pts. : vitals monitoring Safety Anti-depressants Sedation, confusion, GI problems, CV problems, vision, behavioral changes Active participation of pts, schedule sessions Vitals monitoring, Safety Anti-psychotics Dyskinesia, drug-induced Parkinson disease, dystonia, CV problems, vision Scheduling sessions

32 Monitoring exercises based on drugs pharmacokinetics
Monitor adverse reactions due to drugs & differentiate ADR from symptoms Monitoring exercises based on drugs pharmacokinetics Scheduling rehabilitation sessions Drug and physiotherapy interactions Modifications in case of adverse reaction Advice to caregivers Compliance to drug regimen Pill box for dementia, arthritis patients, etc. If physiotherapists have proper knowledge about drugs they can suggest modifications in case of adverse reactions.

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34 Conclusion from the evidences:
Drugs similar as in Lepzig et al., study The most commonly used physical performance measures are: Walking speed Chair stand Grip strength Careful assessment and management considering the drugs

35 REFERENCES

36 Guccione A. Geriatric Physical Therapy. Second edition,2000.
Timiras P. Physiological Basis of Aging and Geriatrics Fourth Edition, 2007 Lewis C. and Bottomley J. Geriatric Physical Therapy A Clinical Approach Situation analysis of the elderly in India. Ministry of Statistics & Program Implementation, Govt. of India, June 2011

37 Hanlon JT, Linblad CI, Hajjar E, McCarthy T
Hanlon JT, Linblad CI, Hajjar E, McCarthy T. Uptade on Drug- Related Problems in the Elderly. Am J Geri Pharmathera. 2003; 1(1): 38-43 Guaraldo L, Cano F, Damasceno G, Rozenfeld S. Inappropriate medication use among the elderly: a systematic review of administrative datbases. BMC Geraitric. 2011,11(79) Kirsten KV, Blix HS, Moger TA, Reikvam A, Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clinc Pharma. 2006; 63(2):


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