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Drug use in elderly and techniques to avoid polypharmacy
The document discusses drug use in the elderly and techniques to avoid polypharmacy. It notes that the elderly population is growing and takes a significant portion of medications while also being more sensitive to drug effects due to physiological changes. Polypharmacy, defined as taking more than 5 medications, is common in the elderly due to multiple comorbidities and providers. This can increase risks of adverse drug reactions, interactions, and non-adherence. The document recommends techniques for optimal prescribing in the elderly like reviewing all medications, simplifying regimens, and eliminating unnecessary drugs to help prevent polypharmacy and its risks.
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Presentation by Dr. Sahil Kumar, focusing on drug use in the elderly and strategies to prevent polypharmacy.
Elderly (65+) make up 13% of the population and account for 33% of prescriptions, with projections showing a rise to 324 million elderly in India by 2050.
Challenges include multiple co-morbidities, polypharmacy, compliance issues, and new drug introductions.
Aging affects pharmacokinetics (absorption, distribution, metabolism, elimination) and pharmacodynamics, impacting drug sensitivity and compliance.
Key drug groups needing monitoring: CNS drugs, cardiovascular drugs, anti-infectives, and anti-inflammatories to avoid adverse effects.
Polypharmacy defined as taking over 5 medications concurrently; it leads to adverse drug reactions and increased healthcare costs.
ADRs contribute to 5-28% of geriatric hospital admissions; many are predictable and preventable.
Explains drug interactions, emphasizing the various types (drug-drug, drug-disease, drug-food) that can affect treatment outcomes.
Examples of drug-drug, drug-disease, and drug-food interactions highlighting potential complications in elderly patients.
Pharmacists must monitor interactions, educate patients on proper medication and dietary precautions.
Best practices to avoid polypharmacy: careful prescribing, regular reviews, simplification of regimens, and patient education.
Introduction of modern pillbox reminders and apps to enhance adherence among elderly patients.
Successful pharmacotherapy in the elderly focuses on correct prescribing to minimize ADRs and polypharmacy effects.
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Drug use in elderly and techniques to avoid polypharmacy
- 1. DRUG USE INELDERLY & TECHNIQUES TO AVOID POLYPHARMACY Dr Sahil Kumar Department of Pharmacology Maulana Azad Medical College New Delhi
- 2. 2 The AgingImperative Challenges of pharmacotherapy in elderly Elderly and Medications: Physiological changes in PK, PD, behavior & lifestyle Drug groups requiring monitoring in elderly Polypharmacy: Causes & Consequences Principles of Optimal prescribing in elderly Preventing Polypharmacy Conclusion Topics Covered
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- 4. The Aging Imperative “Elderly” - 65 years old or older, those from 65 through 74 years old -“early elderly” and those over 75 years old - “late elderly.” Constitute 13% of the population & purchase 33% of all prescription medications. 20% of hospitalizations for those >65 are due to medications they’re taking. 4
- 5. The Aging Imperative India in a phase of demographic transition. Sharp increase in the number of elderly persons between 1991 and 2001 and it has been projected that by 2050, it would rise to about 324 million. India has thus acquired the label of “an ageing nation”. 5
- 6. Challenges of Pharmacotherapy inElderly Multiple co-morbid states Effects of aging physiology Polypharmacy Medication compliance Medication cost New drugs available each year FDA approved, off-label indications expanding Increasing popularity of “nutraceuticals” 6
- 7. ELDERLY AND MEDICATIONS Thephysiologic changes that occur with aging make the body more sensitive to the effects of medications. Pharmacokinetic, Pharmacodynamic , Behavioral changes, lifestyle changes occur in elderly. 7
- 8. Aging and Pharmacokinetics PK- What the body does to the drug. Absorption Distribution Metabolism Elimination 8
- 9. Physiologic Changes ofAging Affecting Absorption Physiologic change ↓ gastric acidity ↓ gastrointestinal blood flow Delayed gastric emptying Slowed intestinal transit time General clinical effect Decreased transport: Decreased bioavailability for some drugs like aspirin. 9
- 10. Physiologic Changes ofAging Affecting Distribution Decreased Total body water Increased Plasma Conc. of water soluble drugs Lower doses are required: Lithium, digoxin, ethanol, etc Decreased Lean body mass Accumulation into fat of lipid soluble drugs: BZDs. Decreased Serum Albumin Increased unbound fraction of highly protein bound drugs Binds acidic drugs: warfarin, phenytoin, digitalis, etc Decreased Alpha1 Acid glycoprotein Increased unbound fraction of highly protein bound drugs Binds basic drugs: lidocaine and propranolol, etc 10
- 11. Physiologic Changes ofAging Affecting Metabolism11 Aging ↓ liver mass/ hepatic blood flow Delayed/reduced metabolism of drugs Higher plasma levels Examples: diazepam, barbiturates, lidocaine. Decline in liver ability to recover from injury Lower serum protein levels Loss of protein binding
- 12. Physiologic Changes ofAging Affecting Elimination Physiologic change Decreased GFR Decreased renal blood flow Decreased renal mass General clinical effect Decreased clearance, Increased (t½) of drugs eliminated from the kidney. Eg. atenolol, gabapentin, ranitidine, digoxin, allopurinol, quinolones 12
- 13. Aging and Pharmacodynamics PD- What the drug does to the body. ⇑ sensitivity to sedation and psychomotor impairment with benzodiazepines ⇑ level and duration of pain relief with narcotic agents ⇑ drowsiness with alcohol ⇑ sensitivity to anti-cholinergic agents ⇑ cardiac sensitivity to digoxin 13
- 14. Aging and Behavioralchanges Cognitive changes associated with vascular and other pathologies. Age related dementia leads to problems in compliance. Death of a closed one can be a trigger for depression. 14
- 15. Aging and LifestyleChanges Economic stresses associated with reduced income or increased expenses due to illness. May have to choose OTCs instead of expensive doctor visits Use of outdated medications Use of home remedies Share medications Nutritional status may affect how body metabolizes medications 15
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- 17. Major Drug GroupsRequiring Monitoring in Elderly CNS drugs Sedative-hypnotics: Benzodiazepines and barbiturates Analgesics: Opioids Antipsychotic, antidepressants: Haloperidol, lithium, TCAs Cardiovascular drugs Antihypertensives: Thiazides, beta-blockers Antiarrhythmic drugs Quinidine and procainamide: ↓ clearance and ↑ (t½) Antimicrobial drugs Beta-lactams and aminoglycosides: ↓ clearance Anti-inflammatory drugs NSAIDs: GI bleed and irritation 17
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- 20. Polypharmacy Taking >5medications at the same time. At any given time, an elderly patient takes, on average, four or five prescription drugs and two over-the-counter (OTC) medications. 20
- 21. Causes of Polypharmacyin Elderly Presence of several chronic disorders. Receiving health care from several physicians. Purchasing medications from more than one pharmacy. “The prescribing cascade”. The discovery of a broad range of pharmaceuticals for a wide variety of conditions. In addition, complementary and alternative medicines, such as herbal therapies, are becoming increasingly popular among all patients, including the elderly. 21
- 22. Consequences of Polypharmacy Adverse drug Reactions (ADRs) Medication Errors Drug interactions Duplication of drug therapy Decreased quality of life Unnecessary cost Medication non-adherence 22
- 23. Adverse Drug Reactions (ADRs) Responsible for 5-28% of acute geriatric hospital admissions. Greater than 95% of ADEs in the elderly are considered predictable and approximately 50% are considered preventable. New or sudden-onset GI distress is often caused by medication. Most common ADEs among elderly patients - nausea, vomiting, diarrhea, constipation, and abdominal pain. 23
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- 25. DRUG INTERACTIONS DR. UMATEKUR DRUG INTERACTIONS
- 26. Drug Interaction isdefined as the pharmacological activity of one drug being altered by the concomitant use of another drug or by the presence of some other substance. DEFINITION 26
- 27. Watch for Drug-Drug,Drug-Disease,Watch for Drug-Drug, Drug-Disease, and Drug-Food Interactionsand Drug-Food Interactions 27
- 28. Drug-Drug Interactions Absorptionmay be ⇑ or ⇓. Drugs with similar effects can result in additive effects. Drugs with opposite effects can antagonize each other. Drug metabolism may be inhibited or induced. 28
- 29. Common Drug-Drug Interactions CombinationRisk ACE inhibitor + potassium Hyperkalemia ACE inhibitor + K sparing diuretic Hyperkalemia, hypotension Digoxin + antiarrhythmic Bradycardia, arrhythmia Digoxin + diuretic Antiarrhythmic + diuretic Electrolyte imbalance; arrhythmia Diuretic + diuretic Electrolyte imbalance; dehydration Benzodiazepine + antidepressant Benzodiazepine + antipsychotic Sedation; confusion; falls CCB/nitrate/vasodilator/diuretic Hypotension 29
- 30. Drug Disease Interaction Drug – Condition interaction occurs when a drug worsens or exacerbates an existing medical condition. Nasal decongestants + Hypertension … BP↑ NSAIDs + Asthmatic Patients … Airway obstr. Nicotine + Hypertension … Heart Rate↑ Metformin + Heart failure … Lactate level↑ 30
- 31. Drug Food Interactions GARLIC when combined with diabetes medication could cause dangerous decrease in blood sugar. ORANGE JUICE increases the absorption of aluminum and leads to severe constipation. MILK contains elements like Mg and Ca which chelate antibiotics like tetracycline and hence decrease its absorption and effect. GRAPEFRUIT JUICE inhibits CYP3A4; increasing levels of antidepressants (sertraline), benzodiazepines, verapamil. 31
- 32. Role of Pharmacist Be vigilant in monitoring for potential drug interactions. Advising patients regarding proper use. Educate the patient on foods and beverages to avoid when taking certain medications. Advising patients in disease conditions. Keep up-to-date on potential drug-drug and drug-food interactions of medications to counsel the patients. (ASHP Guidelines American Society of Health-System Pharmacists) 32
- 33. Newer Approaches tocheck interactions Free Online Drug Interaction Checking Software: https://www.drugs.com/drug_interactions.p hp (Drugs.com) http://reference.medscape.com/drug- interactionchecker (Medscape) http://desktopindia.com/Drug-inter.aspx (Doctor’s Desktop: Medical Practice Software - Indian) 33
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- 36. Android App– “MICROMEDEX Drug Interactions” 36
- 37. Principles of optimal prescribingin elderly & Preventing Polypharmacy 37
- 38. Principles of optimal prescribingin elderly Knowing which drugs frequently cause problems. Ask about drug allergies, adverse reactions, alcohol. Investigate and document all medications the patient is taking, including OTC and herbal products. “Brown bag" method. Choose a drug that can be given once or twice, rather than three times a day. Simplify the patient's regimen as much as possible by, for example, prescribing a single agent rather than multiple drugs to treat a condition. 38
- 39. Avoiding Polypharmacy Avoid“a pill for every ill”. Always consider non-pharmacologic therapy. Start low and go slow but treat adequately. Maximize dose before switching to another drug. Avoid starting two drugs at the same time. Review medications regularly and each time a new medication started or dose is changed. Eliminate duplicate medications—those prescribed by different healthcare providers for the same problem—and drugs with no therapeutic benefit or clinical indication. 39
- 40. Encourage clientto use one pharmacy. Find out how often and in what doses the patient has been taking all medications, and compare that with what the prescription calls for. About 40% of elderly patients fail to take their drugs as instructed. Be aware of conditions that might increase the risk of certain drug-drug interactions. 40 Avoiding Polypharmacy
- 41. Substitute safermedications whenever possible. Avoid treating an adverse reaction caused by one drug with a second drug; if possible, discontinue the drug that's causing the problem or reduce the dosage. Maintain accurate medication records (include vitamins, OTCs, and herbals). Suggest using innovative pill box reminders for correct adherence and avoid confusion when taking many pills. 41 Avoiding Polypharmacy
- 42. Innovative pill boxreminders Medminder® : $40-65. Looks like traditional pill boxes, 7 day (qid) boxes that lock. Flashing light/audible/text message/phone calls for reminders. Also, caregivers can get reports via text/emails/internet. Locked medication systems (eg e-pill): $200-500. Dispensers that lock/alarm. iPhone apps: Free-$3.99. Virtual pillbox. Can set medications, dosages and times a dose is needed. Alarms, reminders, etc. 42
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- 44. Conclusion Successful pharmacotherapymeans using the correct drug at the correct dose for the correct indication in an individual patient. Age alters PK and PD. Polypharmacy is prescribing more than 5 drugs at the same time. ADRs and Drug Interactions are common among the elderly because of polypharmacy. These can be minimized by appropriate prescribing and avoiding polypharmacy. 44
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Editor's Notes
- #5 India is in a phase of demographic transition. There has been a sharp increase in the number of elderly persons between 1991 and 2001 and it has been projected that by the year 2050, the number of elderly people would rise to about 324 million. India has thus acquired the label of “an ageing nation”.
- #7 Co-morbidities: 1) Decreased Visual Acuity Due To Cataract and Refractive Errors In 57% of the Elderly 2) Pain in the Joints And Joint Stiffness In 43.4% 3) Dental and Chewing Complaints In 42% 4) Hearing Impairment In 15.4% 5) Hypertension (14%) 6) Diarrhea (12%) 7) Chronic Cough (12%) 8) Skin Diseases (12%) 9) Heart Disease (9%) 10) Diabetes (8.1%) 11) Asthma (6%) 12) Urinary Complaints (5.6%) 13) Type 2 Diabetes 14) Stroke 15) Alzheimer’s Disease 16) Osteoarthritis, Osteoporosis 17) Prostatic hypertrophy, Urinary Incontinence 18) Anorexia/Malnutrition/Weight Loss Decubitus Ulcers, 19) Sleep Disorders, Delirium, Cognition Impairment (Dementia) MORTALITY According to the Government of India statistics Cardiovascular disorders account for one third of elderly mortality. Respiratory disorders account for 10% mortality while infections including TB account for another 10%. Neoplasm accounts for 6% accidents, poisoning and violence constitute less than 4% of elderly mortality with more or less similar rates for nutritional, metabolic, gastrointestinal (GI) and genitourinary infections.
- #22 Compared to the general population, a patient over 65 is more likely to have several chronic disorders, each requiring at least one medication. Elderly patients with more than one health condition are likely to receive care from several healthcare providers, each of whom may prescribe a different medication to treat the same symptoms. Additionally, patients may purchase medications from more than one pharmacy, and each pharmacy checks for potential problems only on those medications that its pharmacist knows the patient is, or is supposed to be, taking. Drug-related problems are less likely to occur when one physician oversees the patient's medication regimen. The prescribing cascade: An elderly patient develops side effects from a medication he's taking; however, his healthcare provider interprets the symptoms not as side effects of the drug but as symptoms of a disease. The healthcare provider then prescribes yet another drug, creating the potential for even more side effects.
- #23 An elderly patient is also more likely to be taking a medication that has been prescribed inappropriately—one that's unnecessary, ineffective, or potentially dangerous—and to suffer an adverse drug event (ADE). In a study of more than 150,000 elderly patients, 29% had received at least one of 33 potentially inappropriate drugs. Most ADEs are the result of drug interactions; the more drugs a patient takes, the higher the risk of interactions. The estimated incidence of drug interactions rises from 6% in patients taking two medications a day to as high as 50% in patients taking five a day. Medication errors : Wrong drug, time, route
- #39 One effective way to take a drug history is with what's called the "brown bag" method. Rather than relying solely on the patient's medical record, ask the patient to bring all of his medications with him to the hospital or office visit. A recent study found that this method produces a more accurate list of the drugs an elderly patient takes. Be sure to tell your patient to bring in all the medications he takes, including prescription and OTC drugs, topical preparations, herbal products, vitamins, and other supplements. Also ask if he is using any medications he gets from family or friends.
- #40 To reduce your elderly patients' risk of an ADR, heed the adage to "start low and go slow." Although requirements vary considerably from patient to patient, doses often must be reduced for elderly patients by one-third to one-half of the recommended adult dose.