GERIATRIC PHARMACOLOGY Prof. M. Kršiak Department of Pharmacology, Third Faculty of Medicine, Charles University in Prague Cycle II, Modul NURG (nephrology, urology, rheumatology a geriatry– CVSE4P0023 Charles University in Prague, Third Faculty of Medicine Academic year 2012- 2013 GENERAL MEDICINE 6-YEAR MASTER‘S STUDY PROGRAMME http:// vyuka.lf3.cuni.cz CVSE4P0023 TU 531
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GERIATRIC PHARMACOLOGY Prof. M. Kršiak Department of Pharmacology, Third Faculty of Medicine, Charles University in Prague Cycle II, Modul NURG ( nephrology,
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GERIATRIC PHARMACOLOGYProf. M. Kršiak
Department of Pharmacology, Third Faculty of Medicine, Charles University in Prague
Cycle II, Modul NURG (nephrology, urology, rheumatology a geriatry–
CVSE4P0023
Charles University in Prague, Third Faculty of Medicine
Academic year 2012-2013
GENERAL MEDICINE 6-YEAR MASTER‘S STUDY PROGRAMME
http://vyuka.lf3.cuni.cz CVSE4P0023 TU 531
1. Drugs can significantly increase life excpectancy and quality of life in old age
2. However, they can also produce the opposite
OLD AGE MAY HAVE A HIGH VALUE
How to realize the first possibility and avoid the second one?
1. Factors affecting drug effects in older adults
2. Inappropriate pharmacotherapy in the elderly („Beers criteria“)
3. Analgesics in older adults
„older adults“ or the ‚elderly‘ = > 65 yers old
age of 65 years is accepted as a definition of 'elderly' or older person
Do you agree with this dosage? YES / NO / DON‘T KNOW
Case Study No. 1 - contd:
3. Six days later, the man was brought back to the hospital. There he complained of nausea and vomiting . He was disoriented. The serum digoxin concentration was 2.7 ng/ml
SPC and Beers criteria: do not give more than 0.125 mg/day in the old age (>65 years of age)
2. Pharmacodynamic changes –due to ageing e.g. in targets for drug actions
consequences e.g.
confusion, cognitive impairment, delirium
Factors influencing drug effects in older adults (>65y):
CONFUSION
can be caused by various drugs in the old age,
particularly by:
benzodiazepines, drugs with anticholinergic effects (e.g. some antidepressants, antipsychotics), opioids, levodopa,
but also by:
metoprolol (or other betablockers), ranitidin (or other H2 antagíonists), corticoids, digoxin, lithium, anticonvulsants, and others
3. Less robust homeostasis e.g.
antihypertensives –orthostatic hypotension more likely
and other changes in the old age e.g.
prostatic hypertrophy – anticholinergic drugs -micturition problems (urinary retention or too frequent needs to urinate during night, etc)
Factors influencing drug effects in older adults (>65y):
4. Concomitant diseases e.g.
- NSAIDs 10x risk of hospitalization due to cardiac insufficiency in patients with preceding/concomitant cardiac disorders
- cardiac insufficiency lower blood flow in the liver
lower 1st-pass effect halflife of morphine
Factors influencing drug effects in older adults (>65y):
5. Polypharmacy (↑drug interactions)
e.g.
SSRI + NSAIDs 13x risk of GIT bleeding
SSRI + warfarin risk of bleeding
Factors influencing drug effects in older adults (>65y):
How to improve pharmacotherapy in older adults?
1. Withdraw unnecessary drugs or reduce doses if appropriate
2. Determine whether „manifestations of the old age“ such as confusion, urination problems, dizzines, insomnia, etc are not due to drugs
3. In general, begin therapy with low doses
4. If possible avoid administration of drugs inappropriate (more risky) in the old age („Beers criteria“) . Instead select more appropriate alternative drugs.
5. Simplify use of drugs and encourage of compliance- try to avoid intermittent schedules; once daily dosage is ideal
- give clear instructions, best in a written form
“Manifestations of the old age” that might be caused (or increased) by drugs
• desorientation, confusion[e.g. benzodiazepines and many other drugs (see above)],
Beers criteria:Potentially Inappropriate Medication Use in Older Adults - Beers List
Fick D.M. et al.: Archives of Internal Medicine 163: 2716-2724, 2003*
examples:
Benzodiazepines
Drugs with anticholinergic effects
Nonsteroid Antiinflammatory Drugs (NSAIDs)
Some cardiovascular drugsmethyldopa, amiodaron, digoxin > 0,125 mg/d,
Some opioids pethidin, pentazocin
Miscellanea cimetidine, androgens, estrogens
*Several upgrades of the list have been published since that time in several countries. Recently by Topinková et al. Praktický lékař 92 (1): 11-22, 2012 indicating also alternative more appropriate drugs.
Beers criteria:Potentially Inappropriate Medication Use in Older Adults
Medications to be avoided in older adults with these conditions
Fick D.M. et al.: Archives of Internal Medicine 163: 2716-2724, 2003
examples:
Urination problems Drugs with anticholinergic effects
*541 persons > 75 y **18 394 pers. > 65y Kubešová et al. 2001 Won et al. 2003
SUMMARY I:
1. In older patients we shoud take into account:
• lower elimination of drugs,
• higher probability of some adverse effects,
• concomitant diseases,
• polypharmacy
2. In older patients we shoud apply „Beers criteria“, i.e. we should try to avoid inapproriate drugs and select more appropriate alternatives if possible
3. In older patients there are more appropriate analgesics containing
paracetamol alone or in combination with opioids (than NSAIDs)
4. If NSAIDs are necessary, it is advisable to administer them with proton pump inhibitors or, if possible, locally