Medication Management
from the Geriatric
Perspective
Jennifer Tjia, MD, MSCE, Division of Geriatric Medicine
What are we doing here today?
Very few of you will be geriatricians…
But many of you will care for geriatric patients, and
the most common intervention you will be doing is
prescribing..
The “Don’t Kill Granny List”

A minimum set of standards that every medical
student should be able to demonstrate before
graduating and caring for elderly patients.
“…Often even experienced doctors are unaware that 80-yearolds are not the same as 50-year-olds. Pneumonia in a 50-yearold causes fever, cough and difficulty breathing; an 80-year-old
with the same illness may have none of these symptoms, but
just seem “not herself” — confused and unsteady, unable to get
out of bed.
She may end up in a hospital, where a doctor
prescribes a dose of antibiotic that would be right for a woman
in her 50s, but is twice as much as an 80-year-old patient
should get, and so she develops kidney failure, and grows
weaker and more confused. In her confusion, she pulls the tube
from her arm and the catheter from her bladder.”
http://www.nytimes.com/2009/07/02/opinion/02leipzig.html
“Instead of re-evaluating whether the tubes are needed,
her doctor then asks the nurses to tie her arms to the bed so
she won’t hurt herself. This only increases her agitation and
keeps her bed-bound, causing her to lose muscle and bone
mass. Eventually, she recovers from the pneumonia and her
mind is clearer, so she’s considered ready for discharge — but
she is no longer the woman she was before her illness. She’s
more frail, and needs help with walking, bathing and daily
chores.
This shouldn’t happen.”
“All medical students are required to have clinical
experiences in pediatrics and obstetrics, even though after they
graduate most will never treat a child or deliver a baby. Yet
there is no requirement for any clinical training in
geriatrics, even though patients 65 and older account for 32
percent of the average doctor’s workload in surgical care
and 43 percent in medical specialty care, and they make up
48 percent of all inpatient hospital days. Medicare, the
national health insurance for people 65 and older, contributes
more than $8 billion a year to support residency training, yet it
does not require that part of that training focus on the
unique health care needs of older adults.”
The “Don’t Kill Granny List”
1.
2.
3.
4.
5.
6.
7.
8.
Medication Management
Cognitive and Behavioral Disorders
Self-Care Capacity
Falls, Balance, Gait Disorders
Health Care Planning and Promotion
Atypical Presentation of Disease
Palliative Care
Hospital Care for Elders
Use of all medications*
*Prescription medications, over-the-counter drugs, vitamins/minerals, and
herbals/supplements, during the preceding week, by sex and age.
Adapted. from Kaufman (2002)
Treatment regimen for a 79
year-old woman with HTN,
DM, osteoporosis, OA, and
COPD:
12 meds
5 dosing times
Boyd C, et al. JAMA 2005; 294:716-724.
Medication Management
1.
Understand how age affects the metabolism and
manifestation of the desired (and undesired)
effects of the drug
Medication Management
1.
2.
Understand how age affects the metabolism and
manifestation of the desired (and undesired)
effects of the drug
Understand that some medications should be
avoided in the elderly
Medication Management
1.
2.
3.
Understand how age affects the metabolism and
manifestation of the desired (and undesired)
effects of the drug
Understand that some medications should be
avoided in the elderly
Do a medication review and write it down
“…Often even experienced doctors are unaware that 80-yearolds are not the same as 50-year-olds. Pneumonia in a 50-yearold causes fever, cough and difficulty breathing; an 80-year-old
with the same illness may have none of these symptoms, but
just seem “not herself” — confused and unsteady, unable to get
out of bed.
She may end up in a hospital, where a doctor
prescribes a dose of antibiotic that would be right for a woman
in her 50s, but is twice as much as an 80-year-old patient
should get, and so she develops kidney failure, and grows
weaker and more confused. In her confusion, she pulls the tube
from her arm and the catheter from her bladder.”
http://www.nytimes.com/2009/07/02/opinion/02leipzig.html
Pharmacokinetics in Older Persons
Absorption
 Neuro & GI disease: impaired swallowing
 Diabetes, anticholinergics: delayed gastric emptying
 Frail: decreased subcutaneous fat affecting topical
absorption
Distribution (Volume of distribution ∝ half-life)


Inactive, frail:  Fat mass
 Longer half life of lipophilic agents
 Higher serum concentration of water soluble agents
CNS penetration
Age
Volume of Distribution
Pharmacokinetics in Older Persons
Metabolism

Healthy older persons




No change in hepatic glycosylation
No definite change in P450 enzymes
 Hepatic mass and blood flow: less first-pass effect and increased serum levels of
unmetabolized drug
Comorbid disease


Further decrease in hepatic mass and blood flow
Concomitant medications that induce or inhibit P450 enzymes
Clearance

Healthy older persons


Renal: small decrease in GFR
Comorbid disease


Renal: Significant decrease in GFR, underestimated by serum creatinine
GI: decreased transit time
Creatinine Clearance
Renal Function
Changes with Aging
Age
What happens to drug half life?
t1/2 ~ ↑Vd/↓Clearance
 Prolonged t1/2
And it takes less drug to get an effect…

Pharmacodynamics

Classic age-related pharmacodynamic change is increased
benzodiazepine sensitivity at the receptor level
Summary of PD/PK
“a dose of antibiotic that would be right for a woman
in her 50s might be twice as much as an 80-yearold patient should get…”
Antihypertensive Drug Therapy and
Quality of Life
Physician’s Assessment
100
80
60
40
20
0
Improved
No Change
Worse
Jachuck et al, 1982
Antihypertensive Drug Therapy and
Quality of Life
Patient’s Assessment
100
80
60
40
20
0
Improved
No Change
Worse
Jachuck et al, 1982
Antihypertensive Drug Therapy and
Quality of Life
Relative’s Assessment
100
80
60
40
20
0
Improved
No Change
Worse
Jachuck et al, 1982
Inappropriate Prescribing Cascade
77 yo woman with urgency; gets nifedipine for HTN
Edema, constipation,
impaired bladder emptying
Nocturia,  urgency, some UI
OAB!
Add antimuscarinic
 constipation
Add laxative....
Inappropriate Prescribing Cascade
77 yo woman with urgency; gets nifedipine for HTN
Edema, constipation,
impaired bladder emptying
Nocturia,  urgency, some UI
OAB!
Add antimuscarinic
 constipation
Add laxative....
Clinical Pearl
“In evaluating virtually any symptom in an
older patient, the possibility of an adverse
drug event should be considered in the
differential diagnosis.”
Medication Management
1.
2.
Understand how age affects the metabolism and
manifestation of the desired (and undesired)
effects of the drug
Understand that some medications should be
avoided in the elderly
Inappropriate Prescribing



12 - 25% outpatients receive at least one
inappropriate medicine
92% of frail elderly VA inpatients received at least
one inappropriate medicine
Risk factors
Number of medications
 Comorbidity
 Poor self-rated health


50% of ADRs linked to inappropriate meds
Examples of Drugs to Avoid in the Beers Criteria




Propoxyphene
Pentazocine
Meperidine
NSAIDs
 Indomethacin
 Ketorolac
 Naproxen
 Oxaprozin
 Piroxicam

Short-acting benzos






Lorazepam 3 mg
Oxazepam 60 mg
Alprazolam 2 mg
Temazepam 15 mg
Triazolam 0.25 mg
Long-acting
 Chlordiazepoxide
 Flurazepam
 Diazepam
Fick DM Arch Intern Med 2003;163:2716-2724
Beers MH Arch Intern Med 1997;157:1531-1536
Medication Management
1.
2.
3.
Understand how age affects the metabolism and
manifestation of the desired (and undesired)
effects of the drug
Understand that some medications should be
avoided in the elderly
Know why you’re prescribing, do a medication
review and write it down
What and Why in Prescribing
Treatment Targets




Acute illness
Chronic disease
Symptoms
Risk factors
Goals of Care







Primary prevention
Secondary prevention
Slow disease progression
Prolong life
Prevent morbidity
Prevent decline
Comfort
Sachs, GA. JAGS 1998; 46: 782-3.
Factors in Management - Ease of Use
Do these drugs work in
older persons?
Are there differences in
adverse effects?
Tolerability
Efficacy
Polypharmacy
Impact on target
disease, symptoms,
quality of life
Aging
Comorbidity
Pathophysiology
Pathophysiology
Pharmacology
The right drug at the right time for the
right person…
A pill for all…