View
223
Download
0
Category
Preview:
Citation preview
7/25/2019 Caring for the Aging Population Presentation
1/46
10th Annual Mini Medical School
GERIATRICSCaring for our ging Population
7/25/2019 Caring for the Aging Population Presentation
2/46
Pharmacology Considerations in
the Elderly
Common Concerns with the use
of Medications
Roger Hefflinger, Pharm.D.
Associate Professor
Idaho State University
College of Pharmacy
Family Medicine Residency of Idaho
7/25/2019 Caring for the Aging Population Presentation
3/46
Disclosure
I have no fiscal connections to disclose with
any of the manufactures of medications
discussed during this presentation
7/25/2019 Caring for the Aging Population Presentation
4/46
Objectives:
Upon completion of this presentation theaudience member shall be expected to:
Recognize changes in the elderly that may
contribute to medication adverse events Identify classes of medications that are more likely
to have adverse events in the elderly
Organize therapy plans for appropriate
management of various disease states in the
elderly
Modify existing therapy plans for more effective
and potentially safer disease state management
7/25/2019 Caring for the Aging Population Presentation
5/46
The Life-Span
Fetal Development
First Trimester
Second Trimester
Third Trimester
Gestational Issues
Perinatal Issues
Infant
Toddler
Adolescent
Puberty
Adult
Organ System Failure
Renal
Liver
Geriatrics
End of Life
Hospice Care
7/25/2019 Caring for the Aging Population Presentation
6/46
What Factors Most Affected
Pharmacokinetics of Medications:
Dissolution Stomach acid, motility, affect product delivery
Absorption Stomach acid inc/dec effect, concurrent medications
First Pass Metabolism Genetic inc/dec, enzyme inducers, enzyme inhibitors
Distribution Protein binding, albumin stores, fat stores
Elimination Gut, liver, renal function
7/25/2019 Caring for the Aging Population Presentation
7/46
What are realistic goals of
medication administration Stop the disease process
Cancer chemotherapy, Antibiotics
Slow the progression of the disease
High blood pressure, Diabetes, Depression
Minimize the symptoms of the disease
COPD, Pain,
Minimum amount of side effects
In the most cost effective manner
7/25/2019 Caring for the Aging Population Presentation
8/46
What is Acceptable Risk
Food and Drug
Administration
Phase 1 drug trials
Phase 2 drug trials Phase 3 drug trials
Drug approval
Drug release
Post marketing adverse
event reporting
Side Effects: Pick an organ system
Central Nervous System
Cardiovascular System Heart, Blood vessels
Respiratory System
Hepatic (Liver)
Renal (Kidney)
Gastrointestinal
Skin
Bone Marrow
7/25/2019 Caring for the Aging Population Presentation
9/46
Central Nervous System
Drowsiness
Dizziness
Ringing in ears
Confusion
Depression
Psychosis
Elderly:
Altered sleep patterns
More easily sedated
More likely to getdizziness
Underlying vertigo
Changes in brain wire
chemistry as age
Decrease in brain mass
as age
Cerebral atrophy
7/25/2019 Caring for the Aging Population Presentation
10/46
Cardiovascular System
Heart block
Arrhythmias
High blood pressure
Low blood pressure
Angina
Heart Failure
Edema
Elderly more likely to:
Have more medications
that can become
additive in CV SE
Heart becomes more
sensitive to ischemia
Beta receptors decrease
in elderly
Altered sympathetic
nervous system tone
7/25/2019 Caring for the Aging Population Presentation
11/46
Respiratory System
Shortness of breath
Pulmonary scaring
Pulmonary fibrosis
Elderly more likely to:
Have either long
standing asthma or if
smoking history COPD May also have anemia
Decrease in red blood
cells = carry oxygen
around the body
More sensitive to
decrease in oxygen drops
7/25/2019 Caring for the Aging Population Presentation
12/46
Altered Organ System Function
Liver dysfunction
Much more to follow
Long standing alcoholmay affect livers ability
to metabolize and clear
medications
Renal dysfunction
It is a normal part of
aging to have a gradual
decline in the kidneysability to filter and
excrete
Many drugs are
eliminated in the urine
Many drugs affect the
ability to urinate
7/25/2019 Caring for the Aging Population Presentation
13/46
Gastrointestinal System
Nausea
Vomiting
Diarrhea
Constipation
Abdominal Cramping
Peptic ulcer disease
Elderly more likely to:
Have less protective
mucus in stomach
More sensitivity to
medications
Less nerve innervation of
the intestinal tract
= more diarrhea or more
common moreconstipation
More SE if on
medications and get viral
infections
7/25/2019 Caring for the Aging Population Presentation
14/46
Adult Medicine
All medications are formulated for effective
dosing in the Normal adult population
Very general rule- Lower tablet strengths
availability is/are generally acceptable starting
dose for desired action
Citalopram: 10,20, 40 mg- 10 mg HS good start
HCTZ: 12.5, 25, 50 mg- 12.5 mg q d good start
7/25/2019 Caring for the Aging Population Presentation
15/46
At what individual risk?
Every patient has the right to refuse a
medication if they feel the risk is too great
Back to goals of therapy
If you are going to refuse all medications that are
offeredwhy are you here?- rgh
7/25/2019 Caring for the Aging Population Presentation
16/46
Example Package Insert
7/25/2019 Caring for the Aging Population Presentation
17/46
Adult Medicine
Drugs with a Narrow Therapeutic Window
deserve to be monitored.
Digoxin Lanoxin
Levothyroxine Synthroid, Levoxyl
Warfarin Coumadin
Sodium channel blocker for seizure disorder
Enzyme inducers and inhibitors- look for interactions!
Birth Control lose of efficacy
Monitor for established drug levels
For Bipolar?, Migraine?, Depression?, Psychosis?
Ad lt M di i D I t ti
7/25/2019 Caring for the Aging Population Presentation
18/46
Adult Medicine Drug Interactions
Substrates- metabolized this route
7/25/2019 Caring for the Aging Population Presentation
19/46
Adult Medicine Drug Interactions
Inhibitors- Stop the metabolism
7/25/2019 Caring for the Aging Population Presentation
20/46
Adult Medicine Hepatic Impairment
You need to destroy 95% of your hepatocytefunction before you start to lose medication
clearing ability
Transaminitis:
AST/ALT elevations- Most drugs with transiently
elevate
Liver Function-
INR- synthetic marker of clotting factor production Auto anticoagulated- other drugs contribute bleed risk?
Albumin- synthetic
Alter distribution of protein bound medications
7/25/2019 Caring for the Aging Population Presentation
21/46
Potentially Clinically Significant
Benzodiazepines for etoh withdrawal
Short Acting:
Lorazepam
AtivanOxazepam
Serax
Alprazolam
Xanax
7/25/2019 Caring for the Aging Population Presentation
22/46
Adult Medicine Renal Impairment
Cockcroft and Gault
Normal GFR
100-130
Obligated to look GFR
60
Most drugs need GFR dosing adjustment 30
Most All drugs need renal dosing
15
Metformin
Contraindication:SrCr > 1.5 men
SrCr> 1.4 Women
CrCl
7/25/2019 Caring for the Aging Population Presentation
23/46
Adult Medicine Significant
Interactions
Lithium
Very effective under
used
Short yet significant list
NSAIDs
Diuretics
ACEs, ARBs, Lithium toxicity may be
fatal
MAO-Inhibitors
Parkinsons Selegiline Eldepryl
Transdermal Emsam
Rasagiline Azilect
REFRACTORY Depression Parnate
Nardil Marplan
Anti- MRSA antibiotic Linezolid Zyvox
7/25/2019 Caring for the Aging Population Presentation
24/46
Geriatric Medicine
Lean mass declines
Sarcopenia, decrease
strength, mass
Andropause?
Androgen replacement
therapy males?
Fat deposits increase
Alterations of fatdeposited medications
Lipophilicity
Altered loading doses
Gastrointestinal PH
changes B-12 deficiency
Folate deficiency Iron deficiency
Drug induced? PPI
Albumin decreases Less protein binding
More free drug = toxicity
Less balance Falls- drug induced dizzy
7/25/2019 Caring for the Aging Population Presentation
25/46
Geriatric Medicine Beers List
http://www.fmda.org/beers.pdf Comprehensive list of every medication that may
cause ADR in elderly patients
http://www.fmda.org/beers.pdfhttp://www.fmda.org/beers.pdf7/25/2019 Caring for the Aging Population Presentation
26/46
Collective Overconsumption-
rgh
2 Distinct different phenomenon
#1- Tipping over the edge
Poly-pharmacy and the latest dosage change ofmedication addition causes the patient adverse
events
Make small dosing changes and only 1 drug
change at a time
#2- Oh my goodness- Loved one is on TOO
MANY medications
When you break it down individually- they are not
7/25/2019 Caring for the Aging Population Presentation
27/46
Geriatric Medicine
Fixed income concerns: If you have a sample in your office- it is not
inexpensive
Co-pay waivers Actual costs health plan
What disease can you not manage
generically?
Price matching education Every chain will price match if the PATIENT asks
Does not work if they have insurance
Less than co-pay?
7/25/2019 Caring for the Aging Population Presentation
28/46
Elderly Medicine: Bone Health
Bisphosphonates
Alendronate Fosamax PO
Abandronate Boniva PO
Risedronate Actonel PO
Zoledronic Acid Reclast IV
Women are 4 times
more likely to developosteoporosis than men 77% of women who are
osteoporotic are
undiagnosed 1 in 3 women will
develop a fracture
1 in 8 men will develop
a fracture
Dont forget the Calcium 1500 mg a day
And the Vitamin D- 400-800 units a day!
7/25/2019 Caring for the Aging Population Presentation
29/46
Elderly Medicine Arthritis = Pain
Osteoarthritis
Wear and tear
Knees, Hips, Feet
Decrease in the
softness of the
meniscus resulting in
thinning, tearing of
tissue
Treatment:
Analgesics
Rheumatoid Arthritis
Inflammatory disorder
characterized by the bodyattacking itself and eating
up the meniscus, cartilage,
and eventually bone
Treatment: Analgesics
Disease Modifying Agents
Immune modulating agents
7/25/2019 Caring for the Aging Population Presentation
30/46
How do we measure efficacy?
Drug A Better than Drug B
TOPAR
Total Pain Reduction 4 hours, 8 hours, 12 hours
7/25/2019 Caring for the Aging Population Presentation
31/46
How do we measure functionality
Range of motion
With or without pain Specific disease state
assessments
RA
Osteoarthritis
Back Pain
Neuropathic
Quality of Life
7/25/2019 Caring for the Aging Population Presentation
32/46
First Line Therapy:
Acetaminophen
= Tylenol
Scheduled improves
pain
Does not relieve
swelling
Hepatic Toxin
NMT 4 Grams Total/day
Blood Pressure?
Overdose
Propionic Acid Fenamates: Indene acetic acid
7/25/2019 Caring for the Aging Population Presentation
33/46
Propionic Acid
Ibuprofen
Motrin et al
Fenprofen
Nalfon
Ketoprofen
Orudis
Oruvail
Naproxen HCL
Naprosyn
EC Naprosyn
Naproxen Sodium
Anaprox RR
Naprelen SR
Flurbiprofen
Ansaid
Oxaprosin Daypro
Fenamates:
Mefanamic Acid
Ponstel
Meclofenamate Meclomen
Oxicams:
Piroxicam
Feldane Meloxicam Mobic
Pyranocarboxylics
Etodolac
Lodine Etodolac XR
Napthylakanones:
Nabumetone
Relafen
de e acet c ac d
Sulindac
Clinoril
Indole acetic acid Indomethacin
Indocin
Pyrole acetic acid Tolmentin
Tolectin
Phenylacetic acids Diclofenac Sodium
Voltaren,
Arthrotec Diclofenac Potassium
Cataflam
Miscellaneous
Ketorolac Toradol
7/25/2019 Caring for the Aging Population Presentation
34/46
COX-2 Inhibitors Pain
Rofecoxib: Vioxx
Osteoarthritis:
12.5-25 mg q day
Acute Pain:
25-50 mg q day
> Celecoxib
= to Ibuprofen
Celecoxib: Celebrex
Osteoarthritis: 100-200 mg q day
Rheumatoid Arthritis:
100-200 BID
(400 BID)
Meloxicam: Mobic
Osteoarthritis:
7.5-15 mg q day
Is it selective?
Valdicoxib Bextra
10 mg
20 mg
7/25/2019 Caring for the Aging Population Presentation
35/46
Additional Options of Analgesia
Acetaminophen = Tylenol
NSAIDS:
Cox-1 vs Cox-2
Steroids:
Opioids
C-II law
Opioids plus APAP
Dozens Increase Usage
Opioids plus NSAIDS
Empirin, Vicoprofen
Tramadol
Tramadol plus APAP
Muscle Relaxants:
Topical agents
Caine anesthetics
Capsacian
Menthol Camphor
Adjunctive
medications
Anti-depressants
Membrane
Stabilizers
7/25/2019 Caring for the Aging Population Presentation
36/46
Geriatric Medicine:
Parkinsons Disease
Disease that is a functional decline in the
balance between 2 nervous system
transmitters- Dopamine and Acetylcholine
7/25/2019 Caring for the Aging Population Presentation
37/46
Presenting Symptoms:
Initial:
aches, pains, parasthesias,
numbness coldness
Classic: Temor:
Pill rolling, thumb finger,
feet
At rest
Stress makes worse
Usually initial presenting
symptoms
Bradykinesia:
Slowing of movements
Hypokinesia
decreased ability to move
Masked Facies
Emotionless
Walking difficulties
Ridgidity: Cog wheeling
Coordination difficulties
Walking difficulties
O i f M di i
7/25/2019 Caring for the Aging Population Presentation
38/46
Options of Medication
Management:
1. Replace the deficient chemical
2. Normalize relative imbalance of chemicals
3. Stimulate the receptor
4. Stop the normal breakdown of the chemical
5. Stimulate the release remaining chemicals
6. Increase the numbers or sensitivity of
remaining receptors
7/25/2019 Caring for the Aging Population Presentation
39/46
Therapy for Parkinsons
Anticholiniergics:
Diphenhydramine
Benadryl
Trihexylphenadyl Artane Benztropine Cogentin
Increase Dopamine
Carbidopa/Levodopa
Sinemet
Stimulate DA receptor Ammantadine
Pramipaxole Mirapex
Ropinerole Requip
Stop the breakdown
Selegiline Eldepryl
Rasagaline Azilect
Tolcalpone Tasmar
Entacapone Comtan
7/25/2019 Caring for the Aging Population Presentation
40/46
Other increasing elderly disorders
Depression
Weight loss
Weight gain
Anxiety
Psychosis
Dementia
Delirium
Sun Downing
7/25/2019 Caring for the Aging Population Presentation
41/46
End of Life Issues
Can the elderly make decisions for
themselves?
Power of attorney
TALK about it BEFORE elderly is very sick
Get ALL family members on the same page
7/25/2019 Caring for the Aging Population Presentation
42/46
Hospice Concerns
Die with dignity
Treat pain appropriately
Morphine High dose
Morphine 3 Glucuronide is INACTIVE
95% of MSO4 metabolite
Morphine 6 Glucuronide is ACTIVE
M3G ANTAGONIZES M6G and MSO4
May be worth your while to switch to another
phenanthrene opioid
7/25/2019 Caring for the Aging Population Presentation
43/46
Hospice Concerns
The death rattles Air hunger
Inhaled morphine effective
Injectable and oral opioids effective
Constipation
Softeners at minimum, senna, stimulates, Mirilax
Hypersecretions: Glycopyralate Robinul
1-2 mg PO TID-QID, IM or IV 0.1 mg Q 3-4 hours
7/25/2019 Caring for the Aging Population Presentation
44/46
Summary The Life-Span
Fetal Development
First Trimester
Second Trimester
Third Trimester
Gestational Issues
Perinatal Issues
Infant
Toddler
Adolescent
Puberty
Adult
Organ System Failure
Renal
Liver
Geriatrics
End of Life
Hospice Care
7/25/2019 Caring for the Aging Population Presentation
45/46
Questions?
7/25/2019 Caring for the Aging Population Presentation
46/46
roger@otc.isu.edu
Recommended