1. Polypharmacy in the Elderly
Marc Evans M. Abat, M.D., FPCP, FPCGM
Internal Medicine-Geriatric Medicine
Head, Center for Healthy Aging, The Medical City
Clinical Associate Professor, Section of Adult Medicine,
Department of Medicine, UP-PGH

2. Objectives
• Definition of polypharmacy
• Prevalence
• Consequences
• Pharmacology and Aging
• Specific Examples
• Interventions

3. Question: How many drugs must an older
person take to make him at risk for
polypharmacy???
A. 2
B. 5
C. 10
D. A gazillion

4. • Polypharmacy
– The use of more than 5 medications,
some of which may be clinically
inappropriate

5. Prevalence
• As much as 25% of the overall population
(Chumney et al., 2006)
• For those >65 years old, prevalence
increases to 50%
• Prevalence may also be dependent on
comorbidity
– More drugs among diabetics than age or sex
matched non-diabetics (Good, 2002)
– Other predictors include number of starting
drugs, CAD, diabetes, and use of medications
without indications (Veehof et al. 2000)

6. Question: Any substance may have an
interaction with the following EXCEPT:
A. Another drug
B. food
C. disease
D. None of the above

7. Consequences
Adverse Drug Reactions (ADRs) which may
include:
– Drug-drug interactions
– Drug-disease interactions
– Drug-food interactions
– Drug side effects
– Drug toxicity
• May increase from 7% in those using 2 drugs
to 50% in those using 5 and 100% in those
using > 10 (Lin 2003; Brazeau 2001)

8. Quality of Life
• In ambulatory elderly: 35% of experience
ADRs and 29% require medical
intervention
• In nursing facilities: 2/3 of residents
experience ADRs and 1in 7 of these
require hospitalization
• Up to 30% of elderly hospital admissions
involve ADRs
• Linked to preventable geriatric syndromes
Fick 2003. Arch Int Med.

9. Economic
• In 2000: ADRs caused 10,600 deaths
• Annual cost of $85 billion
• $76.6 billion in ambulatory care
• $20 billion in hospitals
• $4 billion in SNF
Fick 2003. Arch Int Med.

10. Pharmacokinetics and Aging
• characterization and mathematical
description of the absorption,
distribution, metabolism, and
excretion of drugs, their by-products,
and other substances of biologic interest
as affected by the elderly body

11. Question: In which of the following
situations is drug absorption decreased in
the elderly?
A. Amoxicillin taken with food
B. Vitamin B12 in patients with atrophic gastritis
C. Calcium carbonate taken with food
D. Ferrous sulfate taken while on omeprazole

12. Absorption
• Age-related gastrointestinal tract and skin
changes seem to be of minor clinical
significance for medication usage
– Decrease in small intestine surface area
– Increase in gastric pH
• Medical conditions (e.g. achlorhydria), other
medications or feedings may modify absorption
– vitamin B12 in atrophic gastritis
– PPIs with sucralfate
– Amoxicillin with food

13. Distribution
• Age-related changes
– Decrease in lean body weight
– Decrease in total body water(10-15%)
– Increased percentage body fat (~15-30%)
– Increased fat:water ratio
– Decreased plasma proteins, especially albumin
• Occurrence of heart failure, kidney disease with
resulting water retention

14. Question: Drugs that are lipophilic tend to
have:
A. Shorter half-lives
B. Shorter effects
C. Longer effects
D. None of the above

15. • Increase in volume of distribution for
lipophilic drugs
– sedatives that penetrate CNS
– Leads to longer half-lives (Linjakumpu 2003)
• Metabolic capacity of phase I reactions
decrease
• Phase II reactions are largely unaffected
• Greater, active, free concentration in
highly protein-bound drugs

16. Metabolism
• some overall decline in liver metabolic
capacity due to decreased liver mass and
hepatic blood flow
– Highly variable, no good estimation algorithm
– Minimal clinical manifestations
• Concurrent drug use may affect
metabolism in both directions
• No formula to estimate this effect

17. Renal Elimination
• Age-related decrease in renal blood flow
• GFR decreases by 8 mL/min/1.73
m2/decade
• Decreased lean body mass leads to
decreased creatinine production
– Serum creatinine not reliable
– Need to estimate creatinine clearance and
adjust medications accordingly (i.e. use
Cockroft-Gault or MDRD)

18. Question: In a bedridden, demented, and
constipated older patient, which agent
may be more appropriate to use
A. Fiber bulking agents (e.g. psyllium)
B. bisacodyl
C. lactulose
D. Commercial enema (e.g. Fleet Enema)

19. Pharmacodynamics and Aging
• Effect of the drug on the body with regard
to aging
• Generally, lower drug doses are required
to achieve the same effect with advancing
age.
– Receptor numbers, affinity, or post-receptor
cellular effects may change.
– Changes in homeostatic mechanisms can
increase or decrease drug sensitivity.

20. Inappropriate Medications: Beers
Criteria
• One of the most, if not the widely used
consensus data for inappropriate
medication use in the elderly
• Latest revision in 2003
• Covers 2 statements regarding drug use
in elderly:
– Those inappropriate for the elderly in general
– Those inappropriate for the elderly with regard
to specific conditions

26. Vitamin and Herbal Use in Older
Adults
• Highly prevalent among older adults
– 77% in Johnson and Wyandotte county
community dwelling elderly
• Generally not reported to the physician
• serious drug interactions possible:
– Warfarin, gingko biloba, vitamin E

28. Non-adherence to Medication
Regimens
• related to both physician and patient factors
– Large number of medications
– Expensive medications
– Complex or frequently changing schedule
– Adverse reactions
– Confusion about brand name/trade name
– Difficult-to-open containers
– Rectal, vaginal, SQ modes of administration
– Limited patient understanding

29. Geriatric Prescribing Principles
• First consider non-drug therapies
• Match drugs to specific diagnoses
• Try to give medications that will treat more than
one condition
• Reduce meds whenever possible
• Avoid using a drug to treat side effects of
another drug
• Review meds regularly (at least q3 months)
• Avoid drugs with similar actions/same class
• Clearly communicate with patient and caregivers
• Consider cost of meds

30. CARE: Avoiding
Polypharmamcy
• Caution and Compliance
– Understand side effect profiles
– Identify risk factors for an ADR
– Consider a risk to benefit ratio
– Keep dosing simple- QD or BID
– Ask about compliance

31. CARE: Avoiding
Polypharmamcy
• Adjust the Dose
– Start low and go slow- titrate
– Consider the pharmacokinetics and
pharmacodynamics of the medication

32. CARE: Avoiding
Polypharmamcy
• Review Regimen Regularly
– Avoid automatic refills
– Look for other sources of medications- OTC
– Caution with multiple providers
– Don’t use medications to treat side effects of
other meds
– Choose drugs to discontinue or substitute
safer medications

33. CARE: Avoiding
Polypharmamcy
• Educate
– All medicines, even over-the-counter, have adverse
effects-report all products used
– Talk to your patient about potential ADRs
– Warn them of potential side effects and report
symptoms
– Educate the family and caregiver
– Ask pharmacist for help in identifying interactions
– Assist your patient in making and updating a
medication list- personal medical record
– Avoid seeing multiple physicians
– Do not use medications from others

34. Personal Health Record
• It will reduce polypharmacy and ADRs
• Multiple specialist involved in care
• Transitions in care from independent
living, hospitals, nursing homes and
assisted living facilities
• Great aid in emergency care
• Provides the patient with more peace of
mind…

35. Personal Health Record
Includes:
• Patient identifying information
• Doctors contacts
• Caregiver contacts
• Past Medical History and Allergies
• List of all medications, dose, reason they
are taking it and whether it is new

36. NAME DOCTOR PHONE: ( )
PHARMACIST PHONE: ( )
DESCRIBE
MEDICATION REASON OR TAPE
WHEN TO TAKE MEDICINE SPECIAL NOTES
NAME FOR USE MEDICINE
HERE
REMEMBER
BRING THIS CHART TO ALL DOCTOR APPOINTMENTS
INCLUDE ALL THE MEDICATIONS YOU ARE TAKING
DO NOT CHANGE THE WAY YOU TAKE THE MEDICATIONS WITHOUT CALLING THE DOCTOR
DO NOT SHARE MEDICATIONS

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gawin….