Medication Management from the Geriatric PerspectiveJennifer Tjia, MD, MSCE, Division of Geriatric Medicine

What are we doing here today?

Very few of you will be geriatricians…But many of you will care for geriatric

patients, andthe most common intervention you will be

doing is prescribing..

The “Don’t Kill Granny List”

A minimum set of standards that every medical student should be able to demonstrate before graduating and caring for elderly patients.

“…Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed.

She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.”

http://www.nytimes.com/2009/07/02/opinion/02leipzig.html

“Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won’t hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she’s considered ready for discharge — but she is no longer the woman she was before her illness. She’s more frail, and needs help with walking, bathing and daily chores.

This shouldn’t happen.”

“All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics, even though patients 65 and older account for 32 percent of the average doctor’s workload in surgical care and 43 percent in medical specialty care, and they make up 48 percent of all inpatient hospital days. Medicare, the national health insurance for people 65 and older, contributes more than $8 billion a year to support residency training, yet it does not require that part of that training focus on the unique health care needs of older adults.”

The “Don’t Kill Granny List”

1. Medication Management2. Cognitive and Behavioral Disorders3. Self-Care Capacity4. Falls, Balance, Gait Disorders5. Health Care Planning and Promotion6. Atypical Presentation of Disease7. Palliative Care8. Hospital Care for Elders

Adapted from Kaufman (2002)

*Prescription medications, over-the-counter drugs, vitamins/minerals, and

herbals/supplements, during the preceding week, by sex and age. .

Use of all medications*

Boyd C, et al. JAMA 2005; 294:716-724.

Treatment regimen for a 79 year-old woman with HTN, DM, osteoporosis, OA, and COPD:

12 meds5 dosing times

Medication Management

1. Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug

Medication Management

1. Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug

2. Understand that some medications should be avoided in the elderly

Medication Management

1. Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug

2. Understand that some medications should be avoided in the elderly

3. Do a medication review and write it down

“…Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed.

She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.”

http://www.nytimes.com/2009/07/02/opinion/02leipzig.html

Pharmacokinetics in Older Persons

Absorption Neuro & GI disease: impaired swallowing Diabetes, anticholinergics: delayed gastric

emptying Frail: decreased subcutaneous fat affecting

topical absorption

Distribution (Volume of distribution ∝ half-life) Inactive, frail: Fat mass

Longer half life of lipophilic agents Higher serum concentration of water soluble

agents CNS penetration

Age

Volu

me o

f D

istr

ibu

tion

Pharmacokinetics in Older Persons

Metabolism Healthy older persons

No change in hepatic glycosylation No definite change in P450 enzymes Hepatic mass and blood flow: less first-pass effect and increased

serum levels of unmetabolized drug Comorbid disease

Further decrease in hepatic mass and blood flow Concomitant medications that induce or inhibit P450 enzymes

Clearance Healthy older persons

Renal: small decrease in GFR Comorbid disease

Renal: Significant decrease in GFR, underestimated by serum creatinine

GI: decreased transit time

Renal FunctionChanges with Aging

Age

Cre

atin

ine

Cle

aran

ce

t1/2 ~ ↑Vd/↓Clearance

Prolonged t1/2

What happens to drug half life?

And it takes less drug to get an effect…

Pharmacodynamics Classic age-related pharmacodynamic change is

increased benzodiazepine sensitivity at the receptor level

Summary of PD/PK

“a dose of antibiotic that would be right for a woman in her 50s might be twice as much as

an 80-year-old patient should get…”

Antihypertensive Drug Therapy and Quality of LifePhysician’s Assessment

Improved No Change Worse0

20

40

60

80

100

Per

cen

t

Jachuck et al, 1982

Antihypertensive Drug Therapy and Quality of LifePatient’s Assessment

Improved No Change Worse0

20

40

60

80

100

Per

cen

t

Jachuck et al, 1982

Antihypertensive Drug Therapy and Quality of LifeRelative’s Assessment

Improved No Change Worse0

20

40

60

80

100

Per

cen

t

Jachuck et al, 1982

Inappropriate Prescribing Cascade

77 yo woman with urgency; gets nifedipine for HTN Edema, constipation,

impaired bladder emptyingNocturia, urgency, some UI

OAB!

Add antimuscarinic

constipation Add laxative....

Inappropriate Prescribing Cascade

77 yo woman with urgency; gets nifedipine for HTN

Edema, constipation, impaired bladder emptyingNocturia, urgency, some UI

OAB!

Add antimuscarinic

constipation Add laxative....

Clinical Pearl

“In evaluating virtually any symptom in an older patient, the possibility of an adverse drug event should be considered in the differential diagnosis.”

Medication Management

1. Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug

2. Understand that some medications should be avoided in the elderly

Inappropriate Prescribing

12 - 25% outpatients receive at least one inappropriate medicine

92% of frail elderly VA inpatients received at least one inappropriate medicine

Risk factors Number of medications Comorbidity Poor self-rated health

50% of ADRs linked to inappropriate meds

Examples of Drugs to Avoid in the Beers Criteria

Propoxyphene Pentazocine Meperidine NSAIDs

Indomethacin Ketorolac Naproxen Oxaprozin Piroxicam

Short-acting benzos Lorazepam 3 mg Oxazepam 60 mg Alprazolam 2 mg Temazepam 15 mg Triazolam 0.25 mg

Long-acting Chlordiazepoxide Flurazepam Diazepam

Fick DM Arch Intern Med 2003;163:2716-2724 Beers MH Arch Intern Med 1997;157:1531-1536

Medication Management

1. Understand how age affects the metabolism and manifestation of the desired (and undesired) effects of the drug

2. Understand that some medications should be avoided in the elderly

3. Know why you’re prescribing, do a medication review and write it down

What and Why in Prescribing

Treatment Targets Acute illness

Chronic disease Symptoms Risk factors

Goals of Care Primary prevention Secondary prevention Slow disease

progression Prolong life Prevent morbidity Prevent decline Comfort

Sachs, GA. JAGS 1998; 46: 782-3.

Pathophysiology

Aging

Comorbidity

Pathophysiology

TolerabilityEfficacy

PharmacologyPolypharmacy

Impact on target disease, symptoms, quality of life

Do these drugs work in older persons?

Are there differences in adverse effects?

Factors in Management - Ease of Use

The right drug at the right time for the right person…

A pill for all…