GERIATRICS
Pharmacology Considerations in
the Elderly
Common Concerns with the use
of Medications
Roger Hefflinger, Pharm.D.
Associate Professor
Idaho State University
College of Pharmacy
Family Medicine Residency of Idaho
Disclosure
I have no fiscal connections to disclose with
any of the manufactures of medications
discussed during this presentation
Objectives:
Upon completion of this presentation the
audience member shall be expected to:
Recognize changes in the elderly that may
contribute to medication adverse events
Identify classes of medications that are more likely
to have adverse events in the elderly
Organize therapy plans for appropriate
management of various disease states in the
elderly
Modify existing therapy plans for more effective
and potentially safer disease state management
The Life-Span
Fetal Development
First Trimester
Second Trimester
Third Trimester
Gestational Issues
Perinatal Issues
Infant
Toddler
Adolescent
Puberty
Adult
Organ System Failure
Renal
Liver
Geriatrics
End of Life
Hospice Care
Absorption
Stomach acid inc/dec effect, concurrent medications
Distribution
Protein binding, albumin stores, fat stores
Elimination
Gut, liver, renal function
Side Effects:
Pick an organ system
Central Nervous System
Cardiovascular System
Heart, Blood vessels
Respiratory System
Hepatic (Liver)
Renal (Kidney)
Gastrointestinal
Skin
Bone Marrow
Drowsiness
Dizziness
Ringing in ears
Confusion
Depression
Psychosis
Elderly:
Altered sleep patterns
More easily sedated
More likely to get
dizziness
Underlying vertigo
Cardiovascular System
Heart block
Elderly more likely to:
Have more medications
Arrhythmias
that can become
High blood pressure
additive in CV SE
Low blood pressure
Heart becomes more
sensitive to ischemia
Angina
Beta receptors decrease
Heart Failure
in elderly
Edema
Altered sympathetic
nervous system tone
Respiratory System
Shortness of breath Elderly more likely to:
Pulmonary scaring
Have either long
Pulmonary fibrosis
standing asthma or if
smoking history COPD
May also have anemia
Decrease in red blood
cells = carry oxygen
around the body
More sensitive to
decrease in oxygen drops
Renal dysfunction
It is a normal part of
aging to have a gradual
decline in the kidneys
ability to filter and
excrete
Many drugs are
eliminated in the urine
Many drugs affect the
ability to urinate
Gastrointestinal System
Nausea
Vomiting
Diarrhea
Constipation
Abdominal Cramping
Peptic ulcer disease
More SE if on
medications and get viral
infections
Adult Medicine
All medications are formulated for effective
dosing in the Normal adult population
Very general rule- Lower tablet strengths
availability is/are generally acceptable starting
dose for desired action
Citalopram: 10,20, 40 mg- 10 mg HS good start
HCTZ: 12.5, 25, 50 mg- 12.5 mg q d good start
Adult Medicine
Drugs with a Narrow Therapeutic Window
deserve to be monitored.
Digoxin Lanoxin
Levothyroxine Synthroid, Levoxyl
Warfarin Coumadin
Sodium channel blocker for seizure disorder
Enzyme inducers and inhibitors- look for interactions!
Birth Control lose of efficacy
Albumin- synthetic
Alter distribution of protein bound medications
Metformin
Contraindication:
SrCr > 1.5 men
SrCr> 1.4 Women
CrCl <60
60
NSAIDs
Diuretics
ACEs, ARBs,
Lithium toxicity may be
fatal
MAO-Inhibitors
Parkinsons
Selegiline Eldepryl
Transdermal Emsam
Rasagiline Azilect
REFRACTORY Depression
Parnate
Nardil
Marplan
Geriatric Medicine
Lean mass declines
Sarcopenia, decrease
strength, mass
Andropause?
Androgen replacement
therapy males?
Gastrointestinal PH
changes
B-12 deficiency
Folate deficiency
Iron deficiency
Drug induced?
PPI
Albumin decreases
Less protein binding
More free drug = toxicity
Less balance
Falls- drug induced dizzy
Collective Overconsumptionrgh
2 Distinct different phenomenon
#1- Tipping over the edge
Poly-pharmacy and the latest dosage change of
medication addition causes the patient adverse
events
Make small dosing changes and only 1 drug
change at a time
Geriatric Medicine
Fixed income concerns:
If you have a sample in your office- it is not
inexpensive
Co-pay waivers
Actual costs health plan
Abandronate
Boniva PO
Risedronate
Actonel PO
Zoledronic Acid
Reclast IV
1 in 3 women will
develop a fracture
1 in 8 men will develop
a fracture
Dont forget the Calcium 1500 mg a day
And the Vitamin D- 400-800 units a day!
Rheumatoid Arthritis
Wear and tear
Inflammatory disorder
Knees, Hips, Feet
characterized by the body
Decrease in the
attacking itself and eating
softness of the
up the meniscus, cartilage,
meniscus resulting in
and eventually bone
thinning, tearing of
Treatment:
tissue
Analgesics
Treatment:
Disease Modifying Agents
Analgesics
RA
Osteoarthritis
Back Pain
Neuropathic
Quality of Life
Hepatic Toxin
NMT 4 Grams Total/day
Blood Pressure?
Overdose
Propionic Acid
Ibuprofen
Clinoril
Motrin et al
Fenprofen
Indocin
Ketoprofen
Tolectin
Voltaren,
Arthrotec
Anaprox RR
Naprelen SR
Ansaid
Oxaprosin Daypro
Phenylacetic acids
Diclofenac Sodium
Naproxen Sodium
Flurbiprofen
Naproxen HCL
Naprosyn
EC Naprosyn
Nalfon
Orudis
Oruvail
Diclofenac Potassium
Cataflam
Miscellaneous
Ketorolac Toradol
Fenamates:
Mefanamic Acid
Ponstel
Meclofenamate
Meclomen
Oxicams:
Piroxicam
Feldane
Meloxicam Mobic
Pyranocarboxylics
Etodolac
Lodine
Etodolac XR
Napthylakanones:
Nabumetone
Relafen
Acute Pain:
25-50 mg q day
> Celecoxib
= to Ibuprofen
Celecoxib:
Celebrex
Osteoarthritis:
100-200 mg q day
Rheumatoid Arthritis:
100-200 BID
(400 BID)
Meloxicam: Mobic
Osteoarthritis:
7.5-15 mg q day
Is it selective?
Valdicoxib Bextra
10 mg
20 mg
Caine anesthetics
Capsacian
Menthol Camphor
Adjunctive
medications
Anti-depressants
Membrane
Stabilizers
Geriatric Medicine:
Parkinsons Disease
Disease that is a functional decline in the
balance between 2 nervous system
transmitters- Dopamine and Acetylcholine
Presenting Symptoms:
Initial:
aches, pains, parasthesias,
numbness coldness
Classic:
Temor:
Pill rolling, thumb finger,
feet
At rest
Stress makes worse
Usually initial presenting
symptoms
Bradykinesia:
Slowing of movements
Hypokinesia
decreased ability to move
Masked Facies
Emotionless
Walking difficulties
Ridgidity:
Cog wheeling
Coordination difficulties
Walking difficulties
Options of Medication
Management:
Increase Dopamine
Carbidopa/Levodopa
Sinemet
Stimulate DA receptor
Ammantadine
Pramipaxole Mirapex
Ropinerole Requip
Selegiline Eldepryl
Rasagaline Azilect
Tolcalpone Tasmar
Entacapone Comtan
Psychosis
Weight loss
Dementia
Weight gain
Delirium
Anxiety
Sun Downing
Hospice Concerns
Die with dignity
Treat pain appropriately
Morphine High dose
Morphine 3 Glucuronide is INACTIVE
95% of MSO4 metabolite
Hospice Concerns
The death rattles
Air hunger
Inhaled morphine effective
Injectable and oral opioids effective
Constipation
Softeners at minimum, senna, stimulates, Mirilax
Hypersecretions:
Glycopyralate Robinul
1-2 mg PO TID-QID, IM or IV 0.1 mg Q 3-4 hours
Gestational Issues
Perinatal Issues
Infant
Toddler
Adolescent
Puberty
Adult
Organ System Failure
Renal
Liver
Geriatrics
End of Life
Hospice Care
Questions?
roger@otc.isu.edu