Geriatric Pharmacology And Polypharmacy Problems

MUSTAFA.DS

Associate Magister of Pharmacology University of UNAYA - Aceh Medical School

7/7/2012

Departement pharmacology UNAYA

Tujuan Pembelajaran
1. Memahami apa saja yang menjadi topik utama dalam farmakoterapi geriatri 2. Memahami bahwa usia berpengaruh pada farmakokinetik dan farmakodinamik dari suatu obat. 3. memahami faktor risiko akan kejadian efek samping obat dan cara untuk mengatasi 4. Memahami prinsip-prinsip peresepan obat untuk pasien geriatri

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Departement pharmacology UNAYA

PENDAHULUAN sejarah

Gerontologi : geront (Greece) = orang usia lanjut - Elie Metchnikoff (1903) Geriatri - Ignatz Nascher (1909) - Dr. Marjorie Warren (Inggris, 1935)

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Definisi
Gerontologi : ilmu yang mempelajari proses menua & semua aspek biologi, sosiologi yang terkait dengan proses penuaan. Geriatri : cabang ilmu kedokteran yang menitik beratkan pada pencegahan, diagnosis, pengobatan dan pelayanan kesehatan pada usia lanjut.

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1. Usia > 60 tahun 2. Multipatologi 3. Tampilan klinis tidak khas 4. Polifarmasi 5. Fungsi organ menurun 6. Gangguan status fungsional 7. Gangguan nutrisi
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Boedhi Darmojo (modified)

INTERNAL FACTORS
GENETIC BIOLOGICAL

NORMAL AGING
EXTERNAL FACTORS
ENVIRONMENT LIFE STYLE SOCIOCULTURAL ECONOMIC
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SINDROM GERIATRI
Kumpulan gejala dan atau tanda klinis, dari satu atau lebih penyakit, yang sering dijumpai pada pasien geriatri.
- Perlu penatalaksanaan segera - Identifikasi penyebab - Comprehensive geriatric assessment
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SYNDROME GERIATRY
Immobility Instability Incontinence Intellectual impairment --- DEMENSIA Infection --- PNEUMONIA Impairment of hearing & vision Isolation (depression) Inanition (malnutrition) Impecunity Iatrogenic Insomnia Immune deficiency Impotence Irritable colon

Rapuh rentan terhadap penyakit Mati

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Comprehensive Geriatric Assessment

1987: Consensus Conference on Geriatric Assessment Methods for clinical decision-making.
Definition: multidisciplinary management in which the multiple problems of older people are detected, describe, and explained. The resources and strengths of the person are catalouged. The needs for services are assessed. A coordinated care plan is developed with interventions focused on the persons problems.
D Solomon, et al. J Am Geriatr Soc 1988

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Comprehensive Geriatric Assessment

Goals To improve diagnosis accuracy To guide the selection of interventions for restoring or preserving health To recommend an optimal environment for care To predict outcomes To monitor clinical changes over time
D Solomon, et al. J Am Geriatr Soc 1988

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Geriatric Pharmacotherapy

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Prescribed Medications
Most Commonly Prescribed in Ambulatory older adult:
Cardiovascular Antiseizure Non-opioid analgesics Anticoagulants Diuretics

 Adverse and drug interactions 7x more likely in geriatric patients.

Self medicating with OTCs Incorrect use Multiple providers Overdosing when S&S worsen Using other persons meds Effects of aging polypharmacy

 Drug doses should be reduced for elderly clients and gradually increased according to tolerance and adverse reactions. Toxicity may develop in the geriatric client with drug doses prescribed for younger adults.

Pharmacokinetics: ADME
Absorption Distribution Metabolism Excretion

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Physiologic changes associated with

aging have major effect on drug therapy Gastrointestinal:
gastric pH peristalsis and motility (delayed emptying times) first past effect

All contribute to slower absorption of oral drugs.

 Cardiac & Circulatory:

cardiac output blood flow

Impaired circulation can delay transport of drugs to the tissues.

Aging Effects on Distribution: Vd

Aging Effect
Body water

Vd Effect

Examples
Ethanol, lithium Digoxin Diazepam, trazodone Diazepam, valproic acid, phenytoin, warfarin Quinidine, propranolol, erythromycin, 18 amitriptyline

Vd for hydrophilic drugs Lean body Vd for for drugs mass that bind to muscle Fat stores Vd for lipophilic drugs Plasma protein % of unbound or (albumin) free drug (active) Plasma protein % of unbound or free drug (active) (1-acid glycoprotein) 7/7/2012 Departement pharmacology UNAYA

Aging Effects on Hepatic Metabolism

Hepatic
enzyme function blood flow

Drugs are metabolized more slowly and less completely. Examples: morphine, meperidine, metoprolol, propranolol, verapamil, amitryptyline, nortriptyline

Aging Effects on Excretion Estimating GFR in the Elderly

Renal:
function nephrons GFR (glomerular filtration rate) blood flow

Poor excretion of drugs

Aging Effects on Excretion Estimating GFR in the Elderly

Creatinine clearance (CrCl) is used to estimate glomerular rate Serum creatinine alone not accurate in the elderly lean body mass lower creatinine production glomerular filtration rate Serum creatinine stays in normal range, masking change in creatinine clearance

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Estimation of Creatinine Clearance

Estimate Cockroft Gault equation (140-Age) x (IBW in kg) ------------------------------ x (0.85 for females) 72 x (Scr in mg/dL)

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Measurement of creatinine clearance

Time consuming Requires 24 hr urine collection U Creat (mg/dL) x 24 h Urine Vol (ml) --------------------------------------------S Creat (mg/dL) X 1440

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Polypharmacy
More common in geriatric clients :
Multiple healthcare providers Herbal therapy OTC drugs Discontinued prescribed drugs

Pharmacokinetics
Absorption
cardiac output causes 40-50% gastric blood flow.
Absorption slowed.

GI motility (peristalsis)
Delays onset of action

Reduced gastric emptying

Delays transport of drugs to tissues

Distribution
Dehydrated elderly clients
concentration of water soluble drugs

Increase in body fat

Fat soluble drugs stored, less effect in circulation

Decreased serum protein

free circulating drug

Metabolism
Decreased hepatic enzyme production, hepatic blood flow, total liver function. Decreased liver size with age
Decreases metabolism Risk of toxicity

Monitor liver enzyme levels

Elimination
35 - 40 % decreased renal blood flow; GFR -elimination = drug toxicity Monitor kidney function - GFR

 Creatinine clearance indicates true renal function

Consists of 24 hr urine sample, along with serum creatinine level Normal adult level=80-130 ml/min

Elimination
Creatinine level not always a good indicator of renal function in geriatrics d/t muscle mass in elderly clients
Creatinine is a byproduct of muscle metabolism muscle mass can serum creatinine Even when renal function is declining, serum creatinine level can be normal

Drug Groups
Hypnotics: insomnia common in elderly
Low dose benzodiazepines, with short half lives Take 1 hr before bedtime
Restoril (temazepam) Serax (oxazepam) Ativan (lorazepam) *recent literature not supportive

Short term therapy preferred

Drug Groups
Diuretics / antihypertensives:
Treatment of CHF, HTN Caution: electrolyte imbalances Prefer ACE I, ARBs, ca channel blockers
Altace (ramipril) Vasotec (enalapril) Cardizem (diltiazem) Norvasc (amlodipine)

Drug Groups
Cardiac Glycosides: increase contractility, slow heart rate; used to treat CHF, AF, atrial tachycardia.
Digoxin

Monitor closely narrow therapeutic range Half life doubles on > 80 age group
Dig toxicity

Monitor apical rate prior to each dose Monitor serum dig levels, & cr clearance

Drug Groups
Anticoagulants: prevent clotting
Caution: risk for falls, bleeding, bruising, frailty, CVA, orthopedic procedures Risk of toxicity d/t hypoalbuminemia (warfarin 99% protein bound) Monitor INR regularly with warfarin (Coumadin) therapy

Drug Groups
Antibacterials: decrease dose if client known to have decreased renal function.
Recommended: penicillins, cephalosporins, tetracyclines, sulfa drugs
Amoxicillin, keflex, cefuroxime, septra, tetracycline

Aminoglycosides / quinolones: not considered safe over age 75, unless dose reduced
Gentamycin, tobramycin, Cipro, Avelox, Levofloxacin

Drug Groups
Gastrointestinal: H2 blockers (histamine) Cimetidine (Tagamet) not safe any more for older adults d/t multiple drug interactions
Zantac (ranitidine) preferred

Laxatives: 75% LTC residents use daily.

Caution: elyte imbalances, drug interactions.

Drug Groups
Antidepressants: dose for geriatric client is 30-50% of young adult dose.
Start low, slowly increase Tricyclic / bicyclic antidepressants work well
Elavil (amitriptyline), Prozac (fluoxetine)

MAO inhibitors avoided except Remeron (mirtazipine)

Drug Groups
Narcotic analgesic use:
Risk of dose related adverse reaction

Monitor vital signs closely

Non-Adherence
Attributing Factors:
Frequency of med Limitations in vision/hearing Literacy Too many meds at different times Impaired memory Financial situation Side effects Ability to open container Not understanding purpose

Suggestions to Improve Adherence

Simplify Process:
Calendar Pill organizer Convenient med refills Easy to open containers Reduce number of daily doses when possible Tailor regime to lifestyle

Comprehensive Medication Assessment

Med names, doses, frequency Diagnosis associated with each Beliefs regarding meds OTC/herbals taken & reason Side-effects Financial ability to pay Ability to obtain Persons involved in decision making Use of other drugs/alcohol/caffeine Drugs obtained from others Leftovers or recently discontinued

Comprehensive Medication Assessment

Allergies Strategies used to remember drug regime Nutrition/hydration status Recent drug levels (if appropriate) Liver/kidney function Frequency of visits to provider Level of sensory, memory, and physical ability

Nursing Diagnosis
Constipation Risk for injury Imbalanced nutrition: less than body requirements Confusion /acute or chronic Deficient Knowledge Noncompliance Hyper / hypokalemia

Hit list of the medications to be avoided in the elderly?

1. Beers Criteria 2. Canadian Criteria 3. START-STOPP Criteria
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Opioid analgesics NSAIDs Anticholinergics Benzodiazepines Also: CVS, CNS, musculoskeletal agents
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Example of Beers Criteria

Drug Concern Severity
GIT Highly anticholinergic and High Antispasmodics uncertain efficacy & should be avoided for long-term use Anticholinergic All non-prescription and many High & Antihistamine prescription antihistamines have (Phenergan, potent anticholinergic effects, Avil Benedril, sedative effetcs, cognitive hydroxyzine) impairment non-anticholinergic antihistamines are preferred Barbiturates Highly addictive and more side High effects than sedative and hypnotics pharmacology UNAYA 7/7/2012 Departement

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START-STOPP Criteria
START = Screening Tool to Alert doctors to Right Treatment STOPP = Screening Tool of Older Persons potentially inappropriate Prescriptions

More comprehensive and gives therapeutic alternatives

May work better than Beers to identify meds that result in negative outcome but there is no evidence that it reduces morbidity, mortality or cost.

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