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Geriatrics and pharmacology
1.
Slide 1
© 2001 By Default! Pharmacologic Considerations Geriatrics
2.
Slide 2
© 2001 By Default! Introduction In the US, the elderly (>65y/o) constitute ~12% of the total population, but account for almost 30% of total drug expenditure Age-related physiologic changes make the elderly susceptible to adverse effects Understanding the influence these changes have on the pharmacokinetics and pharmacodynamics of the elderly is essential to prevent harm
3.
Slide 3
© 2001 By Default! Physiologic Changes of Aging Affecting Absorption Physiologic change – Decreased gastric acidity – Decreased gastrointestinal blood flow – Delayed grastric emptying – Slowed intestinal transit time General clinical effect – None on passive diffusion or bioavailability for most drugs – Decreased active transport: Decreased bioavailability for some drugs – Decreased first-pass effect: Increased bioavailability for some drugs Special considerations – Antacids decrease absorption of acidic drugs: digitalis, phenytoin, tetracycline – Anticholinergics: Slow GI motility and absorption rate
4.
Slide 4
© 2001 By Default! Physiologic Changes of Aging Affecting Distribution Decreased Total body water – Decreased Volume Distribution – Increased Plasma Conc. of water soluble drugs – Lower doses are required: Lithium, digoxin, ethanol, etc Decreased Lean body mass and Increased body fat – Increased Volume Distribution, Longer (t½) of water soluble drugs – Accumulation into fat of lipid soluble drugs: Benzos, etc Decreased Serum Albumin – Increased unbound fraction of highly protein bound drugs – Binds acidic drugs: warfarin, phenytoin, digitalis, etc Decreased Alpha1 Acid glycoprotein – Increased unbound fraction of highly protein bound drugs – -Binds basic drugs: lidocaine and propranolol, etc
5.
Slide 5
© 2001 By Default! Metabolism Determined – Primarily by hepatic function and blood flow – Capacity of the liver to metabolize drugs does not appear to decline consistently with age for all drugs
6.
Slide 6
© 2001 By Default! Elimination Determined – Primarily by renal function – Declines with age and is worsened by co-morbidities – Decline is not reflected in an equivalent rise in serum creatinine since creatinine production is reduced due to lower muscle mass
7.
Slide 7
© 2001 By Default! Physiologic Changes of Aging Affecting Elimination Physiologic change – Decreased GFR – Decreased renal blood flow – Decreased renal mass General clinical effect – Decreased clearance, Increased (t½) of renally eliminated drugs
8.
Slide 8
© 2001 By Default! Pharmacodynamics Pharmacodynamic changes in the elderly have been less extensively studied Evidence of enhanced end-organ responsiveness or “sensitivity” to medications with aging Enhanced “sensitivity” may be due – Changes in receptor affinity – Changes in receptor number – Post-receptor alteration – Age-related impairment of homeostatic mechanisms Example: decreased baroreceptor reflexes
9.
Slide 9
© 2001 By Default! Major Drug Groups Requiring Monitoring CNS drugs – Sedative-hypnotics: Benzodiazepines and barbiturates – Analgesics: Opioids – Antipsychotic, antidepressants: Haloperidol, lithium, TCAs Cardiovascular drugs – Antihypertensives: Thiazides, beta-blockers Antiarrhythmic drugs – Quinidine and procainamide: ↓ clearance and ↑ (t½) Antimicrobial drugs – Beta-lactams and aminoglycosides: ↓ clearance Anti-inflammatory drugs – NSAIDs: GI bleed and irritation
10.
Slide 10
© 2001 By Default! Major Reasons for Adverse Drug Reactions in the Elderly Positive relationship between number of drugs taken and incidence Overall incidence is estimated to be at least twice that in the younger population Prescribing errors – Polypharmacy – Drug interactions with other prescriptions – Unawareness of age related physiologic changes Drug usage errors – “Hidden ingredients”: OTCs
11.
Slide 11
© 2001 By Default! Compliance There are several practical obstacles to compliance that the prescriber must recognize – Forgetfulness – Prior experience – Physical disabilities Recommendations to improve compliance – Take careful drug history – Prescribe only for a specific and rational indication – Define goal of drug therapy – High index of suspicion regarding drug reactions and interactions – Simplify drug regimen
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