Copyright © 2015 Cengage Learning® Chapter 27 Drugs and Older Adults.

Copyright © 2015 Cengage Learning®Copyright © 2015 Cengage Learning®

Chapter 27Drugs and Older Adults

Copyright © 2015 Cengage Learning®

Introduction• Today, people are living longer and are

taking more medications– Forty percent of people of age 60 years and

older in the U.S. take at least five prescribed medications, and many add OTC medications and supplements• Increased serious complications resulting from

adverse drug reactions

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Introduction (cont’d.)• About 50% of hospitalizations are the

result of adverse drug effects in the elderly– In 2012, an estimated 100,000 deaths

annually were caused by medication-related problems (MRPs)• MRPs can be mistaken for what is often

considered a normal consequence of aging or for progression of disease

• Cognitive impairment and behavioral changes are frequently the result of drug therapy

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Introduction (cont’d.)• The aging process is an individualized

matter– Because of genetic or environmental factors

or good health practices, some older adults may not feel or appear particularly different• However, there are gradual changes in body

composition and organ function as we grow older• These changes can affect the reaction to drugs

and make the individual more sensitive to a wide variety of medications

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Physiological Changes with Age • Complex changes of aging involve both

anatomic and physiological factors – Affect how drugs are processed in the body

• Absorption• Distribution• Metabolism (biotransformation)• Excretion

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Physiological Changes with Age (cont’d.)

• Cumulative effects of drugs in older adults can be due to:– Inadequate absorption– Impaired distribution– Slower metabolism– Impaired excretion

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• Absorption– Gastric motility decreases – Gastric acid production diminishes, increasing the

gastric pH, causing a more alkaline environment– Many older adults also take medication that

reduces gastric acid• Examples: ranitidine (Zantac) or omeprazole (Prilosec) • Antacids are also used frequently

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• Distribution – Once drugs are absorbed and enter the

circulation, many of them bind to proteins• Albumin: principal protein used to bind drugs

– As we age, the liver produces less albumin• Allows more of the drug to be unbound (free) to

reach receptor sites and therefore have a greater than expected response

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– Phenytoin (Dilantin) responds quite noticeably to drops in plasma albumin levels

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• Metabolism– The liver serves as a major site for drug

metabolism• As we age, the mass of functional liver tissue and

blood flow to the liver decreases• Ability of the liver to break down drugs declines,

and drugs remain in the body longer• Repeated dosing can result in the accumulation of

the drug and increases the risk for toxicity

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• Excretion– In the older adult, kidney size, blood flow, and

glomerular filtration all decrease, resulting in a decline in creatinine clearance• Illnesses such as hypertension, heart failure, and

diabetes add to the age-related loss and further reduce creatinine clearance

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– Drug by-products normally eliminated through the kidneys can accumulate• Can lead to toxic effects

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• Seniors and drug development– Pharmaceutical research is frequently

focused on younger individuals– Older adults are often excluded from or

underrepresented in clinical trials• Results may be inappropriately extrapolated to

other populations with negative outcomes

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– Some medicines safe for a 30-year-old may produce unexpected results in a person over age 50 or 60• Example: digoxin (Lanoxin)

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Potentially Inappropriate Medication Use in Older Adults

• The Beers List – Results of a survey conducted to determine

the most inappropriate drugs for ambulatory nursing home residents and adults 65 or older

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Potentially Inappropriate Medication Use in Older Adults (cont’d.)

– Goal to improve care of older adults by reducing their exposure to potentially inappropriate medications (PIMs)• Health care professionals treating older adults

should have ready access to the Beer’s List and recognize common classes of medications that can produce problems

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Drugs to Avoid with Certain Medical Conditions

• Drugs that produce significant anticholinergic effects – Antipsychotic agents– Antidepressants– Antiparkinson agents– Antispasmodics– Antihistamines

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Drugs to Avoid with Certain Medical Conditions (cont’d.)

• Drugs that can cause mental impairment – Anticholinergics– Antidepressants and antipsychotics – Benzodiazepines– Corticosteroids– H2 receptor antagonists

– Meperidine– Phenothiazines– Sedative hypnotics

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• Drugs that can cause or contribute to syncope/falls – Anticonvulsants– Antidepressants – Antipsychotics – Alpha blockers – Benzodiazepines– Nonbenzodiazepine hypnotics

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• Gastrointestinal conditions – Anyone taking NSAIDs should be cautioned

about the real danger of serious complications• In older adults, there may be no warning signs of

pain, and the first symptoms of trouble may be a “silent” bleed that could lead to fatal GI hemorrhage

• Key to avoiding problems with NSAIDs is to use the lowest effective dose for the shortest period of time

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– Avoid prolonged use (no longer than two weeks) of OTC antacids without medical supervision

– Constipation can be worsened by anticholinergics and oral antimuscarinics (e.g., oxybutynin, tolterodine) for urinary incontinence

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• Cardiovascular disease– Studies have indicated increased risk of

cardiovascular problems (thrombotic events, MI, and stroke) with the use of NSAIDs and COX-2 inhibitors

– Older adult patients with heart failure should avoid the calcium-channel blockers diltiazem and verapamil, the antidiabetic glitazones (Actos, Avandia), cilostazol (Pletal), and dornedarone (Multaq)

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Polypharmacy• Individuals, especially older adults, may be

the victims of polypharmacy– Excessive use of multiple drugs

• OTC, herbals, or prescriptions given at one time for the treatment of a patient’s medical conditions

– Polypharmacy becomes problematic when negative outcomes occur• May result in unnecessary prescriptions, increased

risk of dangerous interactions with potentially serious adverse side effects, and possible medication nonadherence

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Polypharmacy

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Polypharmacy (cont’d.)• Helpful guidelines

– Educate yourself, your patients, and their families

– With newly prescribed drugs, note diagnoses, allergies, and other medications

– Monitor long-term drug use– Question any inappropriate medicine or

dosage– Document all adverse side effects, calls to the

physician, and action taken

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Copyright © 2015 Cengage Learning® Chapter 27 Drugs and Older Adults.

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