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Geriatric Pharmacology


Geriatric Pharmacology & Polypharmacy Problems for Physical Therapists Marilyn James-Kracke, Ph.D. Associate Professor of Pharmacology University of Missouri ... – PowerPoint PPT presentation

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Title: Geriatric Pharmacology

Geriatric Pharmacology Polypharmacy
Problemsfor Physical Therapists
  • Marilyn James-Kracke, Ph.D.
  • Associate Professor of Pharmacology
  • University of Missouri - Columbia Medical School

Lecture outline
  • 1. Why physical therapists benefit from knowing
    some basic pharmacology.
  • 2. Why elderly people experience more adverse
    drug reactions.
  • 3. Which medications can cause problems that
    affect the work of physical therapists.

Physical Therapy and Pharmacology
  • Ovid search since 1966 13 papers - most from an
    Australian group G. Lansbury et al.
  • Hypothesis Physical therapists often have limited
    knowledge and little formal training in
    pharmacology, yet they frequently advise their
    clients on the use of over-the-counter (OTC)
    medications and administer these in the course of
  • The Lansbury et al approach was to perform a
    survey of 25 of all PTs in Australia to see if
    their hypothesis was correct.
  • J. of Allied Health. 2002
  • Conclusions
  • A substantial proportion of practicing physical
    therapists in Australia advised and administered
    OTC medications despite their limited training
    and knowledge in the area.
  • In their opinion, this practice adds occupational
    risk - either teach pharm or stop prescribing.

My conclusion -this pharmacology class for PT
students is unusual and beneficial
Attitude of the elderly towards PT and medications
  • Older people are more likely to prefer physical
    means than medications to feel better.
  • Why
  • Elderly distrust medications they dont
  • too many medications prescribed for them -
  • afraid of choking on medications.
  • Physicians are always changing and rushing them.
  • for the elderly, PT provides social interaction
    as well as health care - they enjoy being with
    healthy fun therapist.
  • Elderly trust personal contact - like hands on
  • nuturing approach - encouragement - humor
  • side effects of the medications often make them
    feel worse - disoriented, sleepy, weak, stomach
    ulcers, hearing impairment, etc
  • For the elderly, medication risk is greater and
    benefit is less than in younger people.
  • In contrast, physical therapy has little risk and
    definite benefits in both the old and the young.

The physical therapist is trusted. Older
patients want your advice on everything including
their medications. This could be good or bad.
This is probably true for younger people also!
Adverse Drug reactions more common in the elderly
of people taking a drug
authors of studies
Bounce back time - If an elderly person is
started on a new medication and 2 to 3 days later
they are taken to the emergency room, suspect a
drug reaction.
If a older patient seems very different than at
your last PT session, ask them if they are taking
any new medications.
Magnitude of the Medication problems in the
  • Patients gt65 years old were 13 of the population
    by 2000.
  • Patients greater than gt85 years old are the
    fastest growing segment of the population.
  • This 13 of the population consumes 30 of all
  • Elderly population is expected to triple from
    1985 to 2060.
  • Elderly are the most physiologically
    heterogeneous category - state of health varies
    extensively - physical strength, - cardiac
    condition, renal and liver function for clearance
    of drugs.
  • Compliance - misuse and errors - side effects

Factors contributing to adverse drug reactions
in elderly patients
Heart, kidney, liver, thyroid
Orthostatic hypotension, when they standup, blood
goes to their feet - weak sympathetic nervous
system response to constrict veins and increase
heart rate. Low thyroid function causes lower
body temperature, metabolic rate, heart rate.
How many prescription medications are too many?
gt4 or gt6 Many elderly people receive 12
medications per day
Kidney clearance is reduced
Blood flow to all organs like kidney and liver is
reduced - therefore clearance is reduced -
exercise may help them clear more drug by
increasing circulation
Breathing affects clearance of inhaled
anesthetics but may contribute to lower interest
in physical activity - lower clearance of drugs

Note - drug absorption is normal in the elderly
- slow GI tract gives plenty of time for
Biggest errors made in prescribing for elderly
  • Polypharmacy - a drug for every complaint and
    elderly people have lots of aches and pains,
    circulation and breathing difficulties etc
  • Side effects are missed because they are
    misinterpreted as part of getting old -
    particularly senility - hearing loss etc
  • Elderly people often see a different doctor every
    time and the next doctor does not realize that
    the patient was clever and active a week ago.
  • Physicians often assume that the patient is ill
    because they are not taking their medications
    when in fact they are taking them and the amount
    prescribed for them too much.

Reasons why elderly have compliance problems for
taking medications
  • opening pill containers(weak/arthritis
  • fear of choking while swallowing large pills
  • reading the labels and information
  • depression - sleepy - poor concept of time for
  • cognitive impairment - cant recall a few moments
  • cost of medications are prohibitive -- food vs.
  • adverse drug reactions limit benefit of
  • Bottom line - youre never sure whether they are
    taking too much or too little.

Elderly are more likely to tell their PT than
their doctor whether they are taking their
medications or not because they are too polite to
tell a doctor that his pills make them feel
sicker. You are in a position to make a
Medication problems that affect the physical
therapists work
  • Deafness - problem communicating
  • visual acuity - problem seeing demonstration
  • drowsiness /or mental status - remembering
  • balance, fainting, strength,
  • cardiovascular strength
  • respiratory ability-oxygenation -ability to use
  • abdominal discomfort
  • joint pain, range of motion
  • bruising
  • skin rashes - skin thinning, cracking, bleeding

Beta2 agonist relax bronchioles albuterol
Dizziness, Fainting and Weakness
  • Inner ear disturbances, nauseants, low blood
    pressure, anemia and hypoxia, electrolyte
    imbalances like hypokalemia, dehydration.
  • Antihypertensive medications - beta blockers, Ca
    channel blockers, diuretics, ACE inhibitors,
    nitrates, clonidine, alpha blockers -
    orthostatic hypotension - side effect is an
    extension of the desired blood pressure lowering.
  • Antianginal therapy - nitrates, beta blockers, Ca
    channel blockers
  • Certain antiarrythmic drugs - bretylium,
  • Drugs that cause anemia - NSAIDs can cause
    bleeding of the GI tract which can lead to severe
  • Cytotoxic agents used to treat cancers or
    arthritis or autoimmune diseases like lupus
    erythematosis, and to prevent transplant
    rejection also inhibit the bone marrow from
    making red blood cells
  • methotrexate
  • cyclophosphamide
  • azathioprine
  • cyclosporine

Drugs that cause drowsiness and loss of mental
  • antihistamines (some are used as sleep aids)
  • Pain medications
  • muscle relaxants
  • antinauseants
  • some beta blockers - like propranolol
  • drugs that cause insomnia - prevent a good night
    sleep (caffeine, aminophylline, albuterol) -
    eventually cause daytime drowsiness. Low
    concentration of antidepressant are sleep aids,
    amitryptiline in patients with Parkinsons while
    higher concentrations for depression can cause

Abdominal discomfort
  • Constipation, inability to void the bladder
    completely, stomach and gastric ulcers, inflamed
    bowel disease.
  • drugs that cause these problems are
  • pain medications containing narcotics - inhibit
    GI motility
  • antimuscarinic agents - inhibit motility - slow
    transit through GI tract.
  • antihistamines have antimuscarinic side effects
  • NSAIDs - inhibit prostaglandin synthesis in the
    gut leads to ulcers
  • cytotoxic agents for chemotherapy - epithelial
    cells lining the GI tract slough off
  • antibiotics disturb the normal flora and allow
    pathogenic bacteria to grow - causes diarrhea and
    flatulence - solved by taking antibiotics with
    yogurt - called probiotics.

Drug induced muscle wasting catabolism,
anorexia, cachexia
  • Glucocorticoid steroids used as antiinflammatory
    agents - body burns glucose and protein (in
    muscle) but not fat - causes muscle wasting - fat
    body thin limbs
  • Beta2 agonists - increase blood flow to muscles
    but high doses cause tremor and low K.
  • beta blockers - intermittent claudication - pain
    in muscles causing limping - 4 to 7 of patients
    have this effect
  • digoxin - hypokalemia low K - causes muscle and
    cardiac weakness
  • diuretics - low K - should receive K
    supplement or change to K sparing diuretics -
    spironolactone - old people call these water
  • Angiotensin Converting Enzyme inhibitors ACE
    inhibitors (captopril, enalopril) lower blood
    pressure but can also cause rhabdomyolosis
  • Bromocriptine - Parkinsons patients - dopamine
    stimulates the chemoreceptor trigger zone in the
    brain - anorexia
  • Methylphenidate - stimulant to treat narcolepsy
    or attention deficit disorder - amphetamine like
    - similar to agents used in diet pills to
    suppress appetite.
  • Chemotherapy - cytotoxic agents cause extreme
  • Cachexia - increased tumor necrosis factor alpha
    causes the body to become insensitive to insulin
    - starvation in the midst of plenty.
  • Muscle wasting is more likely due to disease
    rather than drug induced lack of appetite.

Joint pain, range of motion
  • 30 drugs are listed to cause this - but most are
    low incidence
  • injections of microcrystalline steroids into
    joints relieves pain, lasts for a month,
    shorter relief each time because more rapid
    destruction of the joint - greater pain after
    effect wears off.
  • Beta blockers betaxolol pindolol - 7 to 10
    experience myalgia
  • Cholesterol lowering agents - fenofibrate
  • clozapine - used for abnormal movement disorders
    and aggressive behaviors - neuroleptic
  • danazol - androgenic steroid
  • droloxifene - nonsteroidal antiestrogen
  • rifampin - used to treat tuberculosis - first
    week of therapy
  • losartan valsartan- to lower blood pressure,
    uncommon side effect.
  • Ca channel blockers - uncommon

Analgesics - nonsteroidal antiinflammatory drugs
  • Old arthritic people take more of these but they
    are also prone to stomach/intestinal ulceration
    due to cycloxygenase inhibition of the synthesis
    of protective prostaglandins in the gastric
  • chronic slow blood loss causes anemia
  • look for very pale weak patient
  • can be sudden onset - severe hemorrhage
  • platelet activity is slowed by NSAIDS
  • patients taking these meds should be asked if
    they have abdominal discomfort before starting
  • activity increases blood pressure - may
    precipitate a bleed
  • longer term use of high dose NSAIDs can cause
    kidney damage and loss of erythropoeitin made by
    the kidney which is a hormone that stimulates red
    cell production and without it there is anemia.

Bruising - hematomas
  • Vit K is important for making clotting factors -
    malnutrition causes bruising -lack of green leafy
    vegetables in diet containing Vit K
  • Anticoagulant dose too high (warfarin-coumadin
    competes with Vit K)
  • NSAIDs - inhibit platelets - causes longer
    bleeding times
  • antibiotics killed bacteria in the gut that make
    Vit K
  • Steroid use - Cushing syndrome - weakens blood
  • drugs causing dizziness - orthostatic hypotension
    cause falls
  • diuretics (dehydration)
  • blood pressure lowering medications
  • Ineffective Parkinsons treatment - excessive
  • cancer chemotherapy - reduces platelets for
    clotting and makes a person weak enough to fall
    more frequently.
  • Intramuscular injections - for people on
  • Elder abuse

Muscle Relaxants - many mechanisms - not well
understood - all of them cause drowsiness as a
side effect
  • GABAB agonist BACLOFEN, less drowsiness than
  • GABAA agonists Benzodiazepines DIAZEPAM
  • GABA and glycinergic receptors agonist
  • Spinal reflex blockers, MEPROBAMATE CARISOPRODOL
  • Imidazo receptor blocker and alpha2 receptor
    blocker CLONIDINE, TIZANIDINE - also used to
    lower blood pressure, ease drug addiction
    withdrawal - for smoking and alcohol cessation.
  • Blocker of Ca release from Sarcoplasmic Reticulum
    in muscles DANTROLENE
  • Neuromuscular Cholinergic receptor blockade
    mainly to produce muscle paralysis in surgery
  • Acetylcholine agonist depolarizing blockers
    SUCCINYLCHOLINE used in surgery

Drug induced ototoxicity (deafness)at plasma
levels above therapeutic level
  • Aminoglycoside antibiotics cause irreversible
    deafness - like gentamicin, tobramycin, amikacin
  • antidepressants
  • loop diuretics - furosemide (lasix)
  • erythromycin azithromycin
  • NSAIDs and salicylates aspirin causes tinnutis -
    ringing of the ears but acetominophen does not -
    this type of hearing loss is reversible
  • quinine - tinnutis
  • vancomycin

Drug Induced oculotoxicity (vision impairment)
  • Allopurinol - used to treat gout - can cause
  • amatadine - antiparkinsons antiviral - corneal
  • amiodarone - antiarrythmic corneal microdeposits
  • - 10 of patients - high incidence of
    hypothyroidism too!
  • anticholinergics - ipratropium atrovent blurred
    vision and glaucoma
  • antidepressants - anticholinergic side effects
  • antihistamines - anticholinergic side effects
  • anticonvulsants - diplopia (double vision),
  • ? -adenergic blocker - reduced tears
  • bromocriptine - myopia blurred vision
  • corticosteroids - glaucoma cataracts
  • digoxin - colored halos - sign of toxicity
  • methotrexate 25 conjunctivitis
  • - reduced tears photophobia
  • phenothiazines - deposits in lens
  • tamoxifen - antiestrogens, fine retinal opacities