Geriatric%20 Medicine%20 %20 Dr.%20 Cefalu

1. Clinical Pharmacological Issues in the Elderly Charles A. Cefalu MD, M Professor and Chief, Section of Geriatric Medicine Department of Fam. Med, LSUHSC, New Orleans, La.

2. Evaluation for Possible Polypharmacy

85 yr. olds and older; average 5-8 drugs per patient

Association exists between increased number and severity of illnesses and increased number of adverse drug reactions

Ref: Lesar, Briceland, and Stein, JAMA, 277,1997, p. 312-317.

3. Increased Medication Use and Perceived Health in the Oldest Old

Increased medication use associated with poorer ratings on health self report

Not associated with increased mortality except for use of digoxin

Ref: Hershman DL et al. Drug utilization in the old and old and how it relates to self-perceived health and all-cause mortality: results from the Bronx Aging Study. J Am Geriatr Soc. 43(4), Apr 1995, p. 356-60.

4. Factors Related to Adverse Drug Drug Reactions

Chronicity and Multiplicity of Disease

Increased Disease-Drug Interactions

Increased Drug-Drug Interactions

Lanoxin and Quinidine

Theophylline and Erythromycin

Visiting Multiple Prescribers

Visiting Multiple Pharmacies

Ref: Schwartz JB. Clinical Pharmacology. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4 th Ed., 2000, p. 326.

5. Factors Related to Increased Number of Adverse Drug Reactions, Contd

Multiple Diseases

CHF

COPD

PVD

CRF

Chronic liver disease

Dementia

ASHD

Diabetes Mellitus

Osteoporosis

DJD

Others

6. Normal Changes of Aging

Increased Fat

Decreased Bone

Decreased Muscle

Decreased Water Content

Ref: Cefalu CA. Clinical Pharamcology. In: Burke MM & Laramie JA. Primary Care of the Older Adult. 2000, p. 90.

7. Normal Physiological Changes of the Organ Systems

Liver- decreased blood flow; Decreased Phase I Metabolism

Kidney- decreased creatinine clearance with advanced age

CNS-increased risk of confusional states primarily secondary to anti-cholinergic agents

Intestinal tract-- malabsorption-- not clinically significant in absence of disease

8. Normal Changes of Aging-Hepatic

Phase I Metabolism-rate of metabolism slows (oxidation, reduction, hydroxylation)

Phase II Metabolism-rate stays the same (conjugation or deactivation process-sulfonuralidation, methylation, acetylation)

Examples-benzodiazepines

Short acting-Phase II only-appropriate

Long acting-Phase I and II-inappropriate, long half-lives

Reference: Beers MH. Medication Use in the Elderly. In: Calkins, Ford & Katz, 1992, p. 40.

9. Pharmaceutical Agents That Require Hepatic Metabolism

NSAIDs; Aspirin Ca channel blockers

Acetaminophen Alpha blockers

Erythromycin Statins

Ketoconazole Dilantin

Tetracyclines Valproic acid

Lidocaine Carbamazepine

Metoprolol Tricyclic Antidepres

SSRIs Neuroleptics

10. Pharmaceutical Agents That Require Hepatic Metabolism

Benzodiazepines

Cimetidine

Ranitidine

Famotidine

Terfenadine

Proton pump inhibitors

Schwartz JB. Clinical Pharmacology. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4 th Ed., 2000, p. 309-319.

11. The Cytochrome System

CYP1A2

CYP2C

CYP2D6

CYP3A

Involves Model Compounds, Drug Substrates, Inducers, and Inhibitors

Ref: Schwartz JB. Clinical Pharmacology. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4 th Ed., 2000, p. 308.

12. Particular Agents of Concern in the Elderly-highly bound to protein

Phenytoin

Carbamazepine

Barbiturates

Warfarin

Malnutrition or hypoproteinemia is associated with increased free fraction of drug and increased toxicity

Ref: Physicians Desk Reference, Medical Economics-Thomson Healthcare,55 th Edition, 2001, p. 2427.

13. Normal Changes of Aging-Renal

Age-related reduction in renal blood flow and creatinine clearance in the face of a normal BUN and serum creatinine:

Implications-

Adjust dose of renally excreted drugs with age according to the following formula

14. Creatinine Clearance Calculation

Cr Clearance= ( 140-age) x weight (kg)

____________________________

serum creatinine x 72

(serum cr adjusted to 1, multiplied x .85 for female)

Ref: Ref: Cefalu CA. Clinical Pharmacology. In: Burke MM & Laramie JA. Primary Care of the Older Adult. 2000, p. 92.

15. Pharmaceutical Agents Primarily Eliminated In the Kidneys Requiring Dosage Adjustment

Penicillins Procainamide

Aminoglycosides Atenolol

Fluroquinolones Clofibrate

Lithium Ace Inhibitors

Digoxin Metformin

Fluconazole Bisphosphonates

Thiazides Nizatidine

Ref: Schwartz JB. Clinical Pharmacology. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4 th Ed., 2000, p. 309-319.

16. Inappropriate Prescribing of Renally Excreted Agents in LTC

One in three renally excreted drugs prescribed in Ontario nursing homes was inappropriately dosed based on the calculated creatinine clearance.

Renal function is often overlooked when prescribing renally excreted drugs to older long-term care residents and emphasizes the need for consideration of creatinine clearance when prescribing such drugs in this population.

Ref: Papaioannou A et al. Assessment of Adherence to renal dosing guidelines in long-term care facilities. J Am Ger Soc. 48(11), Nov. 2000, p. 1470-3.

17. Aminoglycoside Dosing in the Elderly With Impaired Renal Function

Once daily dosing of aminoglycosides associated with reduced risk of morbidity (ototoxicity and renal failure) in patients with reduced creatinine clearance (usually below 50 ml/minute). Also alleviates the need for expensive peak and trough testing.

Ref: Cefalu CA & Agcaoli D. Preventing antibiotic misuse in older patients. Hospital Medicine, December 1998, p. 39-43.

18. Good Rule of Thumb

Reduce by half the dose of the particular renally excreted agent with a creatinine clearance of 50 ml/minute or less.

19. Physiological changes of the GI Tract

Stomach- little change in gastric acidity with aging. In presence of dsyphagia and H2 blocker therapy, may increase risk of morbidity and mortality from pneumonia (bacteria more viable after aspiration due to reduced acidity)

Decreased GI motility and blood flow-- increased frequency of constipation

Ref: In: Hall KE, Wiley JW. Age-Associated Change in Gastrointestinal Function. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4 th Ed., 2000, p. 835-842.

20. CNS Changes with Aging

Reduced numbers of receptors

Subtle structural and physiological changes consistent with Alzheimer's and Vascular Dementia

Increased susceptibility to drugs with anti-cholinergic properties resulting in: urinary retention; constipation; dry mouth; blurred vision; sedation; cognitive dysfunction

Ref: Cefalu CA. Clinical Pharmacology. In: Burke MM & Laramie JA. Primary Care of the Older Adult. 2000, p. 90.

21. Anticholinergic Agents

Phenothiazine major tranquilizers (promethazine, thorazine, chlorpromazine, haloperidol)

Tricyclic anti-depressants (imipramine, amitriptyline, nortriptyline, desipramine)

Narcotics-demerol, codeine, morphine

Anti-spasmotics-oxybutynin, diclomine, tolterodine, probanthine, atropine, hyoscyamine, probanthine, belladonna alkaloids

22. Anti-cholinergic Agents-continued

Anti-histamines

Diphenhydramine

Cyproheptadine

OTC cold medications

OTC sleep agents

Trihexyphenidyl

Benztropine

23. Common Clinical Conditions Necessitate Adjustment of Dosage in the Elderly:

Liver- cirrhosis, malnutrition, malignancy, hepatitis with resultant decreased albumin and total protein levels (ex: sodium warfarin and phenytoin

Kidney- chronic renal insufficiency, renal failure

Brain-dementia, delirium

Intestinal tract- malabsorption syndrome

stomach- gastritis, malignancy

24. Anorexia and Aging

Reduced thirst and appetite with normal aging

Reduced thirst and appetite is associated with depression and/or dementia

Ref: Singh MAF & Rosenberg IH. Nutrition and Aging. IN: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4 th Ed., 2000, p. 88.

25. Anorexia-Drug Induced:

Theophylline

Macrodantin

Pronestyl

Digoxin

Thyroxin

SSRIs

Ref: Thompson MP, Morris LK. Unexplained Weight Loss In the Ambulatory Elderly. J Am Geriatr Soc. 39, 1001, p. 497-500.

26. Specific High Risk Drug Categories

27. Screening for potential toxicity of prescription drugs-H2 Blockers:

Confusion at high doses- Creatinine clearance below 50/ml/min.= reduce dose, except famotidine (below 20 ml/min)

Nonspecific use associated with inadequate healing of gastric and duodenal ulcerations and greater chance of recurrence

Nonspecific use for prophylaxis when used with NSAIDs

Only two specific indications for prophylaxis to prevent gastrointestinal bleeding in the ICU setting: respiratory failure or coagulopathy

28. H2 Blockers-continued

Very common to use these agents in nursing home without specific indications

Ref: Cefalu CA. Clinical Pharmacology. In: Burke MM & Laramie JA. Primary Care of the Older Adult. 2000, p. 93.

29. High Risk Drugs-Beta Blockers

B-Blockers (propranolol)-side effects of:

Precipitation of or exacerbation of CHF

Masking of hypoglycemia

Development of hypotension

Masking of symptoms of endocrine disease (hypothyroidism)

Reduction in exercise capacity

Exacerbation of chronic lung disease or bronchospasm

Depression

Memory loss

Production of arthropathy

Ref: Cahill et al: Beta-adrenergic activation and memory for emotional events, Nature, 371, P. 702-704.

Newbern et al. Cautionary Tales on Using Beta Blockers. Geriatric Nursing. 12(3); 1991, p. 119-122.

.

30. Beta Blockers-continued

use selective ones: atenolol and metoprolol

Less side-effect profile

Better compliance-once or twice daily

Use associated with reduced cardiovascular morbidity and mortality in high risk patients

Ref: Mangano DT et al. Effect of atenolol on mortality and cardiovascular morbidity after non-cardiac surgery. N Engl J Med, 335, 1996, p. 1713-20.

Australia/New Zealand Heart Failure Research Collaborative Group, 1997

31. Antihypertensives that cause Postural Hypotension or Sedation:

Alpha-methyl-dopa

Clonidine

Alpha-blocking agents: useful for combined hypertension and prostatic hyperplasia

Reserpine

Ismelin- same as reserpine

Physicians Desk Reference, 2003

32. Diuretics

Once daily dosing increases compliance

Inexpensive

First line agents effective in reducing risk of stroke and CV disease

Doses above 50 mg ineffective in achieving blood pressure control

Thiazides generally not effective in the presence of renal insufficiency

May cause hypercalcemia

Contribute to or cause incontinence

Use not associated with adverse effects on lipids

33. Diuretics-continued

Use in older caucasian women associated with reduced risk of hip fracture

Adverse reactions

Dehydration; postural hypotension; K loss (especially during the summer and sweating)

Consider discontinuing in elderly when possible, especially advanced, demented, or depressed elderly (reduced thirst and appetite drive)

34. Diuretics-References

Ref: SHEP (Systolic Hypertension in the Elderly) Cooperative Research Group, 1991

Heidrich et al. Diuretic drug use and the risk of hip fracture Ann Intern Med., 115, 1991, p. 1-6.


Gurwitz MM et al. The impact of thiazide diuretics on the initiation of lipid-reducing agents in older people: a population-based analysis. J Am Geriatr Soc., 45(1), Jan. 1997, p. 71-5.

35. Major and Minor Tranquilizers* and Hypnotics:

Worsen dementia and delirium

Cause hip fractures and falls

Cause postural hypotension

Risk of tardive dyskinesia with phenothiazines

*Especially long acting minor and sedating, highly anti-cholinergic major ones

Ref: Cefalu CA. Clinical Pharmacology. In: Burke MM & Laramie JA. Primary Care of the Older Adult. 2000, p. 100-101.

36. Oral Hypoglycemics:

Cause Hypoglycemia-- chlorpropamide

SIADH more frequent with aging (idiopathic 30%)

37. Lanoxin

(Few indications currently for use except for rate control or congestive heart failure to improve function). Side-effects:

Confusion

Anorexia

Nausea

Yellow Green Colors

Agitation

Depression

Ref: Physicians Desk Reference, 2003; Geriatrics Review Syllabus, 5 th Ed., 2002-2004, p. 260

38. NSAIDs*:

Can Worsen HBP- removal of NSAID can affect mean blood pressure control

Fluid retention

Worsen CHF

Cause confusion

GI bleeding

Newer Cox-2 agents, gastric sparring

Less risk of Alzheimer's and cognitive decline

*In big doses or used chronically

Ref: Carson JL & Strom BL. Use of Nonsteroidal Anti-Inflammatory Drugs. In: Hazzard WR et al. Principles of Geriatric Medicine and Gerontology, 4 th Ed., 2000, p. 1113-1119; Stewart WF et al. Risk of Alzheimers disease and duration of NSAID use. Neurology, 48, 1997, p. 626-632.

39. Tips for Safe Traditional NSAID Use

Substitute acetaminophen when possible around the clock instead of NSAID

Use PRN when possible

Use lowest dose possible

Use for acute flare for 7-10 days then d/c

When necessary for chronic use, insist on routine q 3 month BUN and CBC

40. Narcotics:

May cause cognitive dysfunction

Have anti-cholinergic side effects

urinary retention

constipation

dry mouth

sedation

41. Theophylline Adverse Reactions:

Anorexia

Nausea

Arrhythmias

Hypotension

Drug-drug interactions-erythromycin, cimetidine, diazepam, phenytoin

Useful for acute wheezing or asthma, not for COPD

Ref: Physicians Desk Reference, 2003; Cefalu CA. Clinical Pharmacology. In: Burke MM & Laramie JA. Primary Care of the Older Adult. 2000, p. 112.

42. Oxybutynin

Anticholinergic-

Sedation

Cognitive dysfunction

Dry mouth

Blurred vision

Constipation

Urinary retention

Ref: IR Katz et al. Identification of medications that cause cognitive impairment in older people: The case of oxybutynin chloride. J AM Geriatr Soc., 46, 1998, p. 8-13.

43. Muscle Relaxers:

Sedation

Falls

Anti-cholinergic side-effects

Contraindicated in elderly

Ref: Physicians Desk Reference, 2003

44. Ophthalmologic Preparations

Beta blocker preparations-can achieve significant systemic absorption leading to heart block, CHF, bronchospasm.


45. List Of Inappropriate Drugs In Elderly-Journal of American Medical Association-July 27, 1994; Archives of Internal Medicine-July 28, 1997 and 2003

46. Inappropriate Drugs in Elderly:

Diazepam

Chlordiazepoxide- long acting

Flurazepam- long acting

Muscle relaxers- sedation, anticholinergic

Vasodilators- ineffective, cause Steal Syndrome and postural hypotension

Dipyridamole- ineffective

Amitriptyline- sedation, anticholinergic

Propranolol

J of Am Med Assoc , July, 1994, Arch of Int Med , July, 97

47. Inappropriate Drugs in Elderly-Cont,d

Alpha-methyl dopa

Depression

Hemolytic anemia

Drug-induced lupus


Reserpine

Depression

Impotence

Sedation

Orthostatic hypotension


Short-acting Benzodiazepines in excess of the following doses:

Lorazepam- 3mg

Oxazepam- 6mg

Alprazolam- 2mg

Temazepam- 15mg

Zolpidem- 5mg

Triazolam- .25mg


Anticholinergic

Diclomine

Hyoscyamine

Probanthine

Belladonna alkaloids


Chlorpropamide

Indomethacin (neurotoxic)- confusion, bleeding

Propoxyphene- sedation and no more effective than acetaminophen

Trimethobenzamide- extra-pyramidal side-effects and least effective anti-emetic

52. Pain Pill Use by Elders

Lack of adequate pain assessments, little use of nonpharmacologic interventions, and inappropriate use of analgesic medication in the nursing home (Ref: Cramer GW et al. J Am Geriatr Soc, 48(4), March 2001, p. 340-1.

Use of proxyphene in the community dwelling elders is 6.8% and double this in th elong-term setting-15.5%. Ref: Sachin JK et al. J AM Geriatr Soc., 51, 2003, p. 1099-1104.


Pentazocine- sedation, confusion, and hallucinations

Meprobamate- addictive and sedating

Lanoxin (if higher than .125mg)- reduced renal clearance with normal aging

Disopyramide- negative inotropic effect, may cause CHF


Phenylbutazone- excess bleeding

Doxepin- anticholinergic and sedating

Ticlopidine- no more effective than aspirin

Meperidine- addicting, short-acting associated with breakthrough, sedation, anticholinergic

Barbiturates- sedation


Iron in doses greater than 325mg iron sulfate- constipation and no greater absorption at higher dose

56. Screening for Toxicity of OTC Drugs

Laxatives- chronic use associated with development of chronic megacolon, terminal reservoir syndrome, subsequent fecal impaction, and cancer

Vitamins A, C and E- added toxicity with little added benefit

Acetaminophen or aspirin- several different doctors, different brand names

57. Screening for Toxicity-OTC Drugs-Cont.

Especially diphenhydramine-containing OTC agents

Sleep aides

Cold Medications

58. Rules for Prescribing to the Elderly

Start with one-third to one-half the normal starting dose

Use one drug to treat two clinical conditions

PAT and HBP

HBP and angina

59. Rules, contd

Maximize dose of one agent before adding second agent to treat same clinical condition (HBP)

Less confusing for elderly

Less expensive

Less risk of adverse drug reactions

Maximize compliance to no more than once or twice daily

60. Rules, contd

Use cheapest drug possible

Review medications patient brings in at each visit

Discontinue unnecessary drugs and taper psychotropic drugs when possible

Consider drug holidays

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