Principles of Drug Therapy

for the Elderly.

Aging problems:
The elderly population has a higher prevalence of
chronic and multiple diseases (Alzheimers,
Parkinsons, vascular dementia, stroke, visual
impairement, atherosclerosis, CHD, HF, diabetes,
arthritis, osteoporosis, fractures, cancer, incontinence)
They are vulnerable to adverse health outcome
because of advanced age, compromised functional
status, frailty, and diseases.
Social or economic factors, health habit, and lack of
access to care can exacerbate their illnesses
In elderly persons, the risk is greater for an adverse
drug reaction.

Factors That Interfere with Safe and

Successful Drug Therapy in the Elderly
Barriers to the recognition of the need to obtain care
(cultural, economic, physical, psychological)
Atypical presentation of illness
Multiple illnesses
Dementia.
Diminish vision or hearing
Impairment to compliance (cultural, economic,
physical, physiologic)
Polypharmacy
Increased susceptibility to adverse drug events.
Age-related change in pharmacology (ADME)

Interactions of Many Factors That Contribute to

Adverse Health Outcomes in the Vulnerable Elders:

Drug-aging interactions
Drug-disease interactions
Drug-drug interactions

Inappropriate Polypharmacy in the

Elderly:
Polypharmacy may be inappropriate if
more drugs are prescribed than
necessary, prescription of drugs with
unacceptable side effects, co-prescription
of drugs with harmful drug-drug and
drug-disease interactions.
A major concern about polypharmacy is
the potential for adverse drug reactions
and interactions.

Inappropriate Polypharmacy in the

Elderly
Non-adherence, increased risk of
hospitalizations, medication errors,
and increased cost resulting from
treatment of adverse events or other
potential problems with inappropriate
polypharmacy.
As the number of medications used by
patient increases, the incidence of
ADRs increases exponentially

Inappropriate Polypharmacy in the

Elderly
The potential for an ADR is estimated at 6%
when 2 drugs are taken, at 50% when 5 drugs
are taken, and at nearly 100% when 8 or more
drug are taken.
The risk of a serious ADR also increases with
age; it is 18.5% in adults aged 55-64 years,
30.1% in those 75-84, and 41.8 in those 85
and older.
Physicians may contribute to polypharmacy by
excessive or inappropriate prescribing practice
or through lack knowledge about drug actions
and interactions.

Effects of Aging on
Pharmacokinetics:
Absorption:
- GI motility and blood flow decrease; drug
absorption rate decreases, pH decreases,
intestinal motility decreases. Therefore drug
absorption is quantitatively unaffected by aging
Distribution:
- Vd of water soluble drugs decreases; loading
dose should be decreased.
- Vd of fat soluble drugs increases; t1/2 increases.
-

Free drug concentration in plasma increases.

Effects of Aging on
Pharmacokinetics:
Metabolism:
- Phase I drug metabolism declines; liver size
and hepatic blood flow decrease. Dosage of
hepatically metabolized drugs should be
reduced in elderly
Excretion:
- Half-life of drugs undergoing renal elimination
prolongs; the daily dose should be based on
creatinine clearance. The following formula is
useful in estimating CLcr:
CLcr=(140-Age)xBW/72xCr.
0.85 is a correction factor for women.

Effects of Aging on
Pharmacodynamics
Homeostatic control mechanisms are
blunted, response to drugs may change the
intensity of response.
For example, blood pressure goes up with
age, but the incidence of orthostatic
hypotension also increase markedly.
Polypharmacy is associated with an
increased fall risk. Use of diuretics,
hypnotic-sedatives, 1st antihistamines,
anticholinergics, is associated with
increased falling.

Principles of Geriatric
Prescribing
Evaluate the need for drug therapy.
Take a careful history of habits and drug use.
Know the pharmacology of drug prescribed.
Begin therapy with small doses.
Titrate the dosage with patient response.
Simplify the regimen and encourage
compliance.
Regularly review the treatment plan,
discontinue drugs no longer needed.
Remember that drugs may cause new
problems or exacerbate chronic problems.

10 Steps to Prudent Use of Drugs

in the Elderly:

Disclosing all medications.

Identifying drugs by generic name and class.
Using the right drug for the right indication.
Knowing the side effect profile of the drug being
prescribed.
Understand how drug kinetics and dynamics increase
the risk of ADE
Stop any drug without known benefit.
Stop any drug without a clinical indication.
Attempt to substitute a less toxic drug.
Be aware of prescribing cascade.
As much as possible, use the motto, one disease,
one drug, once-a-day.

Common Drugs with Adverse

Events in the Elderly

NSAIDs
Aminoglycosides.
Anticholinergics
Anticoagulants
Antidepressants
Antipsychotics
Beta blockers
Digoxin

Insulin, OAD
Narcotics
Sedative hypnotics
Muscle relaxants
1st antihistamines
Methyldopa and
reserpine.
Negativeinotropic
antiarrythmias