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

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.

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):