The use of drugs among the elderly: the role of pharmacists

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• The use of drugs among the elderly the role of
  pharmacists
• THEORY

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Proportion of citizens aged 65 years in Europe
Source European Health For All Database,
WHO/Europe, various years (1997-2004)
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Use of drugs in Italy by age and sex 2007 (Report
OsMed 2007 Agenzia Italiana del Farmaco)
A patient of 75 years or older takes 17 times
more drugs compared to a young adult of 25-34
years.
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The paradox of drugs
Medication is probably the single most important
healthcare technology in preventing injury,
disability and death in the geriatric
population. (Avorn J. Medication use and the
elderly current status opportunities. Health
Aff, 1995)
Any symptom in an elderly patient should be
considered a drug side effect until proved
otherwise. (Gurwitz et al. Long-term Care
Quality Letter - Brown University, 1995)
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Limits to pharmaceutical therapies for the
elderly
Physiological alterations
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Problems related to drug therapy for elderly
people
Elderly people have a risk of developing adverse
effects almost double that of younger people (Br
J Clin Pharmacol, 2002)
20 of older people in Europe receive at least
one inappropriate drug (JAMA, 2005)
30 of hospital admissions among elderly people
are caused by adverse effects of drugs, which is
considered the fifth leading cause of death in
hospitals (J Am Geriatr Soc, 2001)
It has been estimated that in 1994, in the USA
alone over 100,000 people died due to an adverse
reaction to a drug (JAMA, 1998)
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Which drugs?(Pirmohamed M et al. Adverse drug
reaction as cause of admission to hospital. BMJ,
2004)
Admissions ADRs/tot 1,225/18,8206.5 (16 pharmaceutical interactions) Drug which caused the admission FANS (29.6) Diuretics (27.3) Warfarin (10.5)
Deaths caused by ADRs ADRs/tot 28/1,2252.2 Deaths caused by FANS 67.8 WarfarinFANS 10.7
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More than 2/3 of adverse reactions to drugs are
FORESEEABLE and AVOIDABLE (Ger and Soc, 2002
BMJ, 2004 Pharmacotherapy, 2006).
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Physiologcal changes in elderly people (Mangoni
AA, Jackson SH Age-Related Changes in
Pharmacokinetics Basic Principals Practical
Applications. Br J Clin Pharmacol, 2004)

• Reduced gastric motility
• Reduced secretion of acid/enzymes

• Change in numbers of hepatocytes
• Reduced production of albumen

• Reduced number of functioning glomeruli
• Reduced blood flow

• Alterations in neurochemical transmission
• Reduced cognitive capacity and ability

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Physiological alterations in elderly people what
to do?

• Consider
• the use of well-known drugs about which enough
  is known regarding the risk/benefit balance for
  elderly patients.
• the presence of organ insufficiencies.
• recourse to non pharmacuetical treatments (diet
  advice, smoking cessation, physical activity).

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Some medicines are absoutely to be avoided

• Flurazepam (Dalmadorm?) and Diazepam (Valium?) ?
  prolonged sedation and higher rates of falls and
  femoral fractures.

• Ketoralac (Toradol?, Lixidol?) ? risk of
  gastrointestinal bleeding even in the short term.

• Naprossene and Piroxicam ? risk of
  gastrointestinal bleeding, renal insufficiency
  and hypertension if used oved the long term.

• Ticlopidina (Tiklid?) ? risk of neutropenia.

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or with particular conditions

• Gastrointestinal disturbances
• Constipation
• Avoid anticolinergics, antidepressants
  tricyclics
• Ulcers
• Avoid FANS, aspirin, K integrators
• Endocrine Disturbances
• Diabetes
• Avoid corticosteroids, ?-blockers

• Cardiovascolar Disturbances
• Cardiac arrhythmia
• Avoid antidepressants tricyclics
• Urinary Disturbances
• Incontinence
• Avoid ?-blockers
• Respiratory Disturbances
• Athsma o COPD
• Avoid ?-blockers

¼ of elderly surgery patients, and 40 of those
in care homes receive inappropriate drugs
according to the Beers criteria. (Willcox SM et
al JAMA, 1994 Dhall J et al
Pharmacotherapy, 2002Hamilton H - BMC
Geriatrics, 2009)
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Inappropriate drugs what to do?
avoid prescribing drugs which appear on the
Beers list
Favour other, safer, therapies
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Polytherapy possible causes

• Presence of pluripathologies.
• Expectations of the patient and medical
  prescription.
• Fragmentation of cures.
• Recourse to self-medication.
• Adverse reactions treated as pathologies.

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Elderly people and Chronic Pathologies (data
ISTAT 2005)
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Fragmentation of cures (Viktil K et al. The Janus
face of polypharmacy overuse vs underuse of
medication. Norsk Epidemiol, 2008)

1. In 2000, in the USA, elderly patients made more
   than 200 million visits to the dotor

- 1/3 of visits ? no prescription - 1/3 of visits
? 1-2 drugs prescribed - 1/3 of visits ? 3 or
more drugs prescribed

1. The number of drugs increases as the number of
   doctors looking after the same patient increases.

...but not only this!!!
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Every day I take pills for my blood pressure,
drops to help me sleep, happy pills and I stuff
myself with vitamins and Im still getting
older!!!
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The iceberg effect
Known drugs
Over the counter medicines
Herbal products
Particular foods
Alcohol
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The prescription snowball
For the collateral effects of the last drug I
gave you, take this other one, and then if there
are any side effects Ill prescribe you a third
to help with them
Cant I just have my old illness back?!
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Some examples of the prescription snowball
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Always remember
Any symptom in an elderly patient should be
considered a drug side effect until proved
otherwise. (Gurwitz et al. Long-term Care
Quality Letter - Brown University, 1995)

• Numerous syndromes in old age are actually
  consequences of pharmacological therapies
• delirium ? use of SNC drugs (eg. Anticolinergic
  drugs, opiates)
• falls and fractures ? benzodiazepins,
  anti-hypertension drugs
• urinary incontinence ? eg. diuretics

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Polytherapy and interactions between drugs
An interaction between drugs becomes important
for the patient and the doctor when it interferes
with the expected efficacy or diminishes the
safety of a treatment
At the moment of the commercial authorisation of
the drug, the safety profile for elderly people
is limited.
The risk of potential interactions alomst
exponentially as age and the number of drugs
used increase. (Karas S - Ann Emerg Med, 1981
Sloan RW Am Fam Physician, 1983)
The risk of interaction triples in patients who
receive prescriptions from two doctors
simultaneously. (Recalde J.M., Aten Prim, 1998)
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Drugs and Herbs principal herbal products which
cause interactions between drugs
ST JOHNS WORT warfarin, digossin,
antidepressants, ansiolitici, oestrogen,
antivirals, immunesuppressants, anti-tumorals,
anaesthetics, teofilin. CRANBERRIES
warfarin GINKGO warfarin, calcium channel
blocker, anti-inflammatories, antidepressants,
salicylics. GARLIC warfarin, ACE inhibitors,
antivirals, anti-inflammatories. GINSENG
warfarin, anti-platelets, anti-depressives,
anti-epileptics. GREEN TEA warfarin.
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Common interactions between drugs and foods

• Foods rich in K bananas, oranges, leafy greens
• ACE-inhibitors
• Diuretics
• Sartans
• K savers

• Foods rich in Ca2 milk, yogurt, cheese
• Digossin
• Diuretics
• Thyroid Hormones
• Some antibiotics

• Foods rich in vitamin K apples, spinach, nuts,
  kiwis, broccoli, cabbage
• Warfarin

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Food and Drugs the case of grapefruit juice
(Stump AL, et al. Management of grapefruit-drug
interactions. Am Fam Physisican 2006)
benzodiazepine
? AUC, ? Cmax ? strengthens the effects of BDZ
Calcium channel blockers
Immune-supressants
? Haematic levels ? (headaches, hypotension,
tachycardia )
? Adverse effects ? nefrotoxicity, liver disease
statins
? AUC (16 times) ? cefalea, myopathy
Antidepressants tricyclics
arrythmia,antihistamines
? Levels of liver disease ? Prolonged QT
? Levels of liver disease
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Polytherapy and interactions what to do?

• Treat the pathologies in order of priority.
• Use drugs when strictly necessary to reduce risk.
• Ask the patients if they are using over the
  counter medicines or herbal medicines.
• Inform the patient about foods to avoid.
• Monitor the response periodically and compare the
  appearance of adverse reactions.
• Review treatment periodically.

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Polytherapy and therapy adherence a real problem
Adherence match between the behaviour of the
patient and the medical prescription
Change in timing or frequency of doses by the
patient
Mistaken consumption
40-60 of elderly patients do not follow their
prescription properly (Vik SA et al. Ann
Pharmacoter, 2004)
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Reasons for not following a prescription correctly
AGE DOESN'T COUNT but...

• the number of drugs taken ? Polytherapy
• the frequency of doses
• the cost of the medicine
• the relationship between doctor and patient

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Polytherapy and adherence to treatment (1) what
to do ?
For Mary Smith 1 pill after meals for 7 days
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Polytherapy and adherence to treatment (2) what
to do ?
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• PRACTICAL PART

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Polytherapy and adherence to treatment (3) what
to do?
time 7 8 9 11 12 13 16 19 20 21 22 23 24
drug 7 8 9 11 12 13 16 19 20 21 22 23 24
Pantecta (pantoprazolo) 1 cpr
Diamicron cpr (gliclazide) 1 cpr 1 cpr 1 cpr
Lasix cpr (furosemide) 1 cpr 1 cpr
Triatec cpr (ramipril) 1 cpr
...









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Exercise
An 87-yar old woman suffers from arterial
hypertension, atrial fibrilation and has worn a
pacemaker for two years. The patient comes to
the pharmacy periodically to buy the following
drugs

• gliclazide 1 pill before meals 3 times a day
• ramipril 5 mg 1 pill after breakfast
• digoxin 0,125 mg 1 pill at 4pm
• furosemide 25 mg 1 pill at breakfast and 1 at
  4pm
• pantoprazolo 20 mg 1 pill before breakfast (on
  an empty stomach)
• amlodipina 5 mg ½ pill after lunch
• warfarin 5 mg 1 pill after dinner
• metoprolol 100 mg ½ pill before breakfast ½
  before dinner
• simvastatina 20 mg 1 pill after dinner
• triazolam 0,25 mg 1 pill before bed

1. Using the diary, help the patient to plan her
   intake of prescribed drugs and give relevant
   advice on food/products to avoid while taking
   these drugs.
2. The patient asks for advice regarding the sudden
   appearance of a pain in her knee despite the
   topical use of NSAID. What drug/advice can be
   given to the patient?

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Diary
TIME 7 8 9 11 12 13 16 19 20 21 22 23 24
Drug 7 8 9 11 12 13 16 19 20 21 22 23 24
(pantoprazolo) 1 cpr
(gliclazide) 1 cpr 1 cpr 1 cpr
(furosemide) 1 cpr 1 cpr
(ramipril) 1 cpr
(metoprololo) ½ cpr ½ cpr
(amlodipina) ½ cpr
(digossina) 1 cpr
(warfarin) 1 cpr
(simvastatina) 1 cpr
(triazolam) 1 cpr