1. School of Pharmacy, Jimma University
Clinical pharmacy and Pharmacy practice Course team
Drug therapy in specific patient groups
By: Tsegaye Melaku
[B.Pharm, MSc, Clinical Pharmacist]
November, 2016tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.et
+251913765609
Chapter 3
Geriatrics

2. Introduction
† Pharmacotherapy for older adults can cure or palliate disease as well as
enhance HRQOL.
† HRQOL considerations:
Physical functioning (e.g., activities of daily living),
Psychological functioning (e.g., cognition, depression),
Social functioning (e.g., social activities, support systems),
Overall health (e.g., general health perception).
† Despite the benefits of pharmacotherapy, HRQOL can be compromised
by DRPs.
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3. Cont’d…
† The prevention of drug-related adverse consequences in older adults
requires that 
Health professionals become knowledgeable about a number of age-
specific issues.
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4. Polypharmacy Defined
† Treatment with multiple medications (> 5 medications per regimen)
for a variety of conditions and symptoms that include excessive or
unnecessary medications that place the patient at risk for an
adverse drug reaction
*Balance between avoiding excessive or unnecessary use of
medications and providing beneficial therapies
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5. Causes of Polypharmacy
† Aging population
† Complex drug therapies
† Multiple prescribers
† Multiple pharmacies
† Psychosocial factors
† Adverse drug reactions (prescribing cascade)
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6. Multiple Prescribers
† Multiple providers prescribe medications for patients with chronic disease
† Poor communication between patient and all providers
† Stronger tendency for drugs to be added than discontinued
† Drug regimens are not regularly monitored for potential problems
Medications with no apparent indication
Duplicate therapy
Drug interactions
Inappropriately high or low doses
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7. Psychosocial factors
† Self-medicating (OTCs, herbals, supplements)
† Direct to consumer advertising
† Off-label marketing campaigns
Eli Lilly’s “Viva Zyprexa” campaign in 1999-2000 encouraged doctors
to prescribe olanzapine to older patients with symptoms of dementia
Zyprexa is not approved to treat dementia or dementia-related
psychosis
 FDA Black Box warning due to increased risk of death in older adults with
dementia-related psychosis
 Eli Lilly fined $1.4 Billion for off label marketing Jan 15, 2009
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8. ADRs and the Prescribing Cascade
Rochon and Gurwitz, BMJ 199720-Nov-16 8

9. Examples of the Prescribing Cascade
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10. Aging Population
† Increased incidence of chronic conditions as the population ages
Diabetes
Hypertension
Heart Failure
Ischemic Heart Disease
Asthma/COPD
Arthritis
Alzheimer’s Disease
Urinary problems
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11. Drug Use in Older Adults
† Comprise 12% of the U.S. population
† Consume 33% of all prescription drugs
91% regularly use at least one Rx medication
29% regularly use 5 or more Rx medications
† Consume 40% of all over-the-counter medications
46% concurrently use OTC and Rx medications
52% concurrently use dietary supplements and Rx
† Big consumers of Rx, OTC and dietary supplements
† Vulnerable to ADE and drug interactions
Qato, JAMA 200820-Nov-16 11

12. Complex Drug Therapies
† Drugs commonly used for patients with diabetes
Diabetes Blood Pressure Lipids Thrombosis
Sulphonylurea diuretics Statins Aspirin
Metformin Beta blockers Ezetimibe Clopidogrel
Glitazones ACEI Bile acid sequestrants Warfarin
Insulin ARB Nicotinic acid Heparins
Gliptins Calcium blockers Fibrates
Prandial glucose regulators Alpha Blockers
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13. Consequences of Polypharmacy
† Adverse drug events
† Drug interactions
† Decreased adherence
† Decreased quality of life
† Increased costs
Budnitz, JAMA 2006
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14. The Geriatric Patient at Risk
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15. Altered Pharmacokinetics
† Age-related changes in physiology and organ function result in
altered pharmacokinetics
Absorption
Distribution
Metabolism (hepatic)
Elimination (renal clearance)
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16. Absorption
† Primarily unchanged: Overall amount absorbed
(bioavailability) is unchanged
† Little clinical significance for commonly used drugs
† Iron, calcium, zinc chelate with quinolones,
levothyroxine and L-dopa decreasing absorption
Intestinal
Motility
Splanchnic
Blood Flow
Gastric pH
Gastric
Transit Time
† Rate of absorption may be
delayed
 Lower peak concentration
 Delayed time to peak
concentration
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17. Volume of Distribution(Vd)
† Decreased Vd for water soluble drugs, increased drug plasma
concentration (e.g., digoxin)
† Increased Vd for fat soluble drugs, increases half life (e.g.,
diazepam)
† Decreased protein binding, increased bioavailability (e.g., warfarin,
phenytoin, aspirin, digoxin)
Total Body
Fat
Muscle
Mass
Total Body
Water
Serum
Albumin
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18. Effects of Aging on Vd
Aging Effect Vd Effect Examples
 body water  Vd for hydrophilic
drugs
ethanol, lithium
 lean body mass  Vd for for drugs that
bind to muscle
digoxin
 fat stores  Vd for lipophilic
drugs
diazepam, trazodone
 plasma protein
(albumin)
 % of unbound or
free drug (active)
diazepam, valproic acid,
phenytoin, warfarin
 plasma protein
(1-acid glycoprotein)
 % of unbound or
free drug (active)
quinidine, propranolol,
erythromycin, amitriptyline
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19. Metabolism
† Metabolic clearance by the liver may be reduced (enzyme activity is
unpredictable)
† Drugs with a high rate of extraction by the liver may have
bioavailability (e.g., warfarin, TCAs, propranolol)
Liver mass
Liver blood
flow ~40%
Phase I
CYP P450
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20. Metabolic Pathways
Pathway Effect Examples
Phase I: oxidation,
hydroxylation,
dealkylation, reduction
Conversion to
metabolites of lesser,
equal, or greater
diazepam, quinidine,
piroxicam, theophylline
Phase II: glucuronidation,
conjugation, or
acetylation
Conversion to inactive
metabolites
lorazepam, oxazepam,
temazepam
** NOTE: Medications undergoing Phase II hepatic metabolism are generally
preferred in the elderly due to inactive metabolites (no accumulation)
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21. Elimination
† Decreased renal function (40-50%) may lead to higher serum drug
levels and longer drug half-life
† Reduced renal clearance of active metabolites may enhance
therapeutic effect or risk of toxicity (e.g., digoxin, lithium,
aminoglycosides, vancomycin) Renal mass
Renal
blood flow
GFR and
tubular fxn
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22. † Need to reduce dose and/or increase dosing interval
† Serum creatinine not a reliable predictor of renal function in older
adults due to decreased muscle mass
*Values based on serum creatinine measurement of 1.3 mg/dl in a 70-kg man
Age (years) Creatinine Clearance (ml/min)
30 82
40 75
50 67
60 60
70 52
80 45
Elimination…
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23. Altered Pharmacodynamics
† Age-related changes resulting in sensitivity to certain classes of drugs
place the elderly at risk for adverse drug reactions.
CNS depressants (e.g., benzodiazepines) resulting in delirium,
confusion, agitation and sedation
Anticoagulants and hemorrhage (e.g., in combination with NSAIDs,
salicylates)
Alpha-blockers and various antihypertensive medications resulting
in orthostatic hypotension
Anticholinergic medications resulting in dry mouth, constipation,
urinary retention, blurred vision, confusion
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24. Examples of Important Drug
Interactions in the Elderly
† Warfarin and aspirin/NSAIDs, ABX   bleeding risk
† ACEIs and potassium supplements   K+ levels
† Digoxin and quinidine or diazepam   digitalis toxicity
† Combinations of drugs with excess anticholinergic effects
† Combinations of drugs with excess sedation
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25. Examples of Drug-Disease Interactions
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26. Examples of Drug-Food Interactions
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27. Suboptimal Prescribing in the Elderly
† Polypharmacy
† Drug-drug Interactions
† Drug-disease Interactions
† Inadequate Dosing and/or Duration
† Inadequate Monitoring
† Drugs to Avoid (e.g., anticholinergics, Beers’ criteria)
† Underuse of Effective Medications (e.g., beta blockers, diuretics, ACEIs,
aspirin, statins, bisphosphonates, calcium, vitamin D, MVI)
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28. The Beer’s Criteria
High Potential for Severe ADE High Potential for Less Severe ADE
amitriptyline
Chlorpropamide
digoxin >0.125mg/d
disopyramide
GI antispasmodics
meperidine
methyldopa
pentazocine
Ticlopidine
antihistamines
diphenhydramine
dipyridamole
ergot alkaloids
indomethacin
muscle relaxants
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29. Strategies to
Optimize Drug Therapy
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30. Strategies to Optimize Drug Therapy
† Thorough Medication History (risk/benefit)
Is there a clear indication for each drug?
OTC medications, vitamins, supplements, herbals
Allergies, adverse reactions to medications
Use of alcohol, tobacco, recreational drug use
Immunizations (e.g., flu, pneumococcal)
† Maintain active medication list
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31. Cont’d…
† Discontinue unnecessary therapy
† Consider non-pharmacologic approaches: Avoid “a pill for every ill”
† Avoid or minimize drug interactions
† Simplify regimen (once or twice daily, combo pills)
† Appropriate dosing
† New medications: ‘’Start Low & Go Slow’’
† Suspicious of new complaints/cognitive changes, ADR?
† Continuous monitoring
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32. Frequency of dosing Vs adherence
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33. Predictors of Poor Adherence to Medication
† Complexity of treatment
† Poor provider-patient communication or relationship
† Cognitive impairment
† Psychological problems, particularly depression
† Treatment of asymptomatic disease
† Patient’s lack of belief in benefit of treatment
† Side effects of medication
† Inadequate follow-up or discharge planning
† Cost of medication, copayment, or both
Osterberg, NEJM 2005
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34. Assessing Adherence in the Elderly
† Do they take their medications??
† Do they take their medications correctly??
Who is responsible?
How do you take your drugs
“Show and Tell” technique
Physical and cognitive limitations
 Phonetic confusion
 Flip-flopping errors
 Once daily, twice daily, as needed
 With or without food
 Pill visual-cue errors
 Similar looking pills
 Frequently changing generic
forms
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35. † Identify barriers
Understanding what the medication is for
Motivation (e.g., ease of use, incentive, side effects)
Access, cost
Physical or cognitive limitations
† Identify success
Who or what helps them take their medications correctly
Cont’d…
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36. Strategies to Improve Adherence in the Elderly
† Individually tailor regimen to the patient’s preference
† Minimize barriers, maximize success
Simplify regimen (once or twice daily dosing)
Consolidate medications
Use of blister packs, pill boxes, calendars, watches, other
reminders
Functional assistance (e.g., large labels, language)
Reduce costs (e.g., generics, pill splitting)
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37. † Provide drug information and education to patients/caregivers
using “teach back” methods to check understanding of benefits
and side effects of medications
† Improve motivation and build on the patient’s strengths and
confidence
† Be supportive and non-judgmental (positive communication)
† Multiple strategies work best
† Continue follow-up and reinforcement
Cont’d…
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38. 20-Nov-16 38

39. Case 1
A 73 y/o woman is seen for a routine visit:
 Blood pressure is 134/84 mmHg and HgbA1c is 8.1%
 Metformin is increased to 500mg bid and other daily medications
are continued: amlodipine 5mg qd, timolol ophthalmic 1 drop bid,
aspirin 81mg qd, and calcium citrate 500mg qd
 At 6 month follow-up, blood pressure is 130/82 mmHg, finger stick
BS is 93 mg/dL, and HgbA1c is 9.2%
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40. Case 1…
Which of the following is the most likely explanation for the
increase in HgA1c?
A. Incorrect choice of anti-diabetic medication
B. Inadequate dose of anti-diabetic medication
C. Long-term non-adherence with medication
D. Altered pharmacokinetics
E. Altered drug absorption
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41. Case 2
A 68 y/o woman has a hx of Parkinson’s disease, hypertension, and
osteoarthritis
 Daily medications are carbidopa 25mg/levodopa 100mg tid,
selegiline 5mg bid, losartan 50mg, celecoxib 200mg qd, and MVI
qd
 In the past 3 weeks, she has taken diphenhydramine at bedtime for
insomnia
 The patient now reports the onset of urinary incontinence
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42. Case 2…
Which of the following is the most appropriate intervention?
A. Discontinue Celecoxib
B. Discontinue diphenhydramine
C. Discontinue losartan
D. Substitute fosinopril for losartan
E. Begin tolterodine
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43. Case 3
An 83 y/o woman is brought to the ER because of dizziness on
standing, followed by brief LOC; the patient now feels well
 She has hypertension but is otherwise healthy
 Daily medications: metoprolol 50mg/d, captopril 25 mg/d, and
nitroglycerin 0.4mg SL prn
 BP is 130/70 mmHg sitting and 100/60 standing; PE is otherwise
normal; CBC, BUN, ECG, are all normal
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44. Case 3…
Which of the following is the most likely cause of this syncopal episode?
A. Sepsis
B. Drug-related event
C. Hypovolemic hypotensive episode
D. Cardiogenic shock
E. Unidentifiable cause
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45. Thank you
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