PHAR44002: Care of the Elderly

Why is there a need for high quality evidence-based healthcare for the elderly?

• Growing elderly population

• Rise in multimorbidity (e.g. obesity, type 2 diabetes, CVD)

• Increased complexity of pharmaceutical interventions (e.g. cancer)

• Increased need for rationing in the NHS

• Increased need for clinically skilled pharmacists

What challenges do the elderly face?

• Lack of advice from professionals about self-care

• Lack of service coordination and poor communication between professionals

• Lack of information about available services and pathways

What should pharmacists consider when caring for the elderly?

• Look for the evidence, don’t assume

• Work with the MDT to account for all comorbidities/impairments/social context

• Older people are a heterogenous group - make decisions on an individual patient basis and include the person

• Communicate your interventions, making it clear who will do what

What are the common cardiovascular disease states in the elderly?

• Congestive heart failure (CHF)

• Ischaemic heart disease (e.g. angina, MI)

• AF and other arrhythmias

• Hypertension

• Peripheral vascular disease

Metabolic/Endocrine Disorders

• Type 2 diabetes

• Thyroid dysfunction (hypothyroidism/hyperthyroidism)

• Electrolyte imbalances (e.g. hyponatremia, hyperkalemia)

Renal Disorders

• CKD

• AKI

GI Issues

• Constipation or faecal impaction

• GI bleeding

• Diverticulitis

• Malnutrition

What are common respiratory conditions in the elderly?

• COPD

• Pneumonia (common reason for hospital admission)

• Pulmonary embolism

What are common neurological disorders in the elderly?

• Stroke/TIA

• Parkinson’s disease

• Alzheimer’s disease and other dementias

• Seizures (especially new-onset seizures)

What are common musculoskeletal disorders in the elderly?

• Osteoarthritis

• Osteoporosis (increased fracture risk)

• Hip fractures or other fragility fractures

• Sarcopenia (loss of muscle mass)

What are common metabolic/endocrine disorders?

• Type 2 diabetes

• Thyroid dysfunction (hypothyroidism/hyperthyroidism)

• Electrolyte imbalances (e.g. hyponatremia, hyperkalemia)

What are common renal disorders in the elderly?

• AKI

• CKD

What are common GI issues in the elderly?

• Constipation or fecal impaction

• GI bleeding

• Diverticulitis

• Malnutrition

What are common infectious diseases in the elderly?

• UTIs (often with atypical presentation like confusion)

• Sepsis

• Skin infections (e.g., cellulitis, pressure ulcers)

What are common haematologic and oncologic conditions in the elderly?

• Anaemia of chronic disease or iron deficiency

• Malignancies (e.g. colorectal, lung, prostate, breast cancer)

• Lymphomas and leukemias

What are common psychiatric conditions in the elderly?

• Depression

• Anxiety

• Delirium (especially during hospital admissions)

• Late-onset psychosis

What are the main categories of natural consequences of aging?

• Sensory decline

• Cognitive decline

• Mobility and balance issues

• Bladder and bowel changes

• Sleep disturbances

• Immune senescence

• Skin changes

• Decreased bone density

• Thermoregulatory changes

What is involved in sensory decline?

• Presbyopia (age-related farsightedness)

• Presbycusis (age-related hearing loss)

• Reduced contrast sensitivity and night vision

• Loss of taste and smell

What is involved in cognitive decline?

Mild cognitive impairment (not always progressing to dementia)

What is involved in mobility and balance issues?

• Increased risk of falls

• Slower gait and reaction time

What is involved in bladder and bowel changes?

• Urinary incontinence

• Decreased bowel motility

What is involved in sleep disturbances?

Changes in sleep architecture (less deep sleep, early waking)

What is involved in immune senescence?

Reduced immune response to infections and vaccinations

What is involved in skin changes?

• Thinning of skin

• Increased susceptibility to bruising and tears

What is involved in decreased bone density?

Without necessarily meeting criteria for osteoporosis

What is involved in thermoregulatory changes?

Reduced ability to maintain body temperature in extreme weather

What drug-related problems can occur in Parkinson’s disease?

• Manual dexterity issues due to tremor, insomnia, dysphagia, postural hypotension leading to falls

• Antipsychotics (e.g. haloperidol) → worsen parkinsonism

• Levodopa interactions with high-protein diets or MAO inhibitors

What drug-related problems can occur in reduced renal function?

• Reduced clearance of drugs, increased risk of accumulation (and therefore toxicity)

• Decreased effectiveness of diuretics

• Reduced treatment of UTI (less AB in the bladder due to worse clearance)

• ACE inhibitors/ARBs, diuretics → hyperkalemia

What drug-related problems can occur when pain is experienced in osteoarthritis?

• If using opioids - increased risk of falls, drowsiness, danger with driving, constipation, risk of unintentional overdose

• If using NSAIDs - increased risk of GI bleed, CV events, precipitation of AKI

What drug-related problems can occur in hypertension?

• Oedema

• Dry cough

• Hypotension

• Altered electrolytes

• Target BP increases with age (go in aggressive = increased responses)

• Older patients have a higher risk of white coat hypertension so may need to use ambulatory monitoring

What drug-related problems can occur in UTI?

• Possible confusion

• Poor renal function - antibiotic can’t enter bladder

What drug-related problems can occur in mental health problems?

• Drowsiness/falls risk with antidepressants/anti-anxiety (Increased anti-cholinergic burden)

• Confusion can occur due to leaky BBB which allows meds, toxins, microbial organisms to pass through and damage the brain

What drug-related problems can occur in depression?

• If using Duloxetine - drowsiness, sleeping throughout the day which could result in missed meals so increased risk of malnutrition

• Low sodium with SSRIs

• Social side is very important

What drug-related problems can occur in dementia/Alzheimer’s?

• May not be able to manage own medications, must consider patient’s ability to provide informed consent

• May make patient less adherent to other medications

• May make patients distrustful of medications/HCPs - worsen health outcomes of other co-morbidities. Advocate anticholinesterase

What drug-related problems can occur in serious mental illness?

• Can be difficult to differentiate from dementia/Alzheimer's/delirium

• Difficult to choose right medicine

• Problems with adherence

• Distressed patients may be inappropriately prescribed drugs e.g. sedatives to calm down which can worsen cognition and increase falls risk

• DOLs, capacity; work with MDT

What drug-related problems can occur in constipation?

• Reduced intestinal motility movement in the elderly

• May be worsened by drugs such as codeine, morphine, poor fluid intake

• Good diets are harder to get – self-care advice around diet

• Stimulant laxatives not as effective in older age so more likely to use osmotic laxatives

What drug-related problems can occur in DVT/PE?

• Reduced mobility, often lying down a lot especially if very unwell

• Heparins --> warfarin / DOAC – effective but bleeding risk goes up, really bad bruising

• Warfarin: adherence, DDIs hard to manage in older patients and may be harder to stay on top of the dietary restrictions

• Warfarin is easier to reverse than DOACs

What drug-related problems can occur in hearing loss?

• Caution in drugs that may cause ototoxicity like gentamicin

• Loop diuretics, cisplatin can cause ototoxicity

• Can they hear? Can they understand? Do they just nod along... provide written instructions and ask them to repeat

What drug-related problems can occur in osteoporosis?

• Bisphosphonates - GI irritation, ONJ

• RANK-L inhibitors 0 immunosuppressive

• Anabolic therapies - increased risk of osteocarcinoma, hypercalcaemia

• Consider vitamin D and calcium deficiencies, diet, exercise

• Loss of mobility

• Reduced mobility + multiple medicines → increased falls risk, ACB score, drowsiness, hypotension risk

• Progressive bone loss with age (also secondary OP can be caused by steroids, cancer drugs, hypogonadism etc.)

• Reduced oestrogen so reduced bone repair

• Increased sensitivity to bone altering drugs

• Zolendronic acid IV infusion annually

• Annual infusion may be easier than oral meds - many instructions may be tricky for older people

What drug-related problems can occur in infection?

• Leaky BBB → toxins get into the brain and cause delirium

• Hospital itself is an infection risk - keep people in community

What drug-related problems can occur in decreased muscle mass?

• Weaker and increased fat - affects Vd of drugs, harder to get back up if fallen

  monitor statin use, as it breaks down in muscle mass (creatinine clearance)

What drug-related problems can occur in cancer - chemotherapy/RT?

• Rsk of secondary cancers / tumours – radio or chemo induced

• Increased risk of TLS – increased risk of dehydration

• Rebound side effects later in life

What drug-related problems can occur in loss of eyesight?

• Can’t see fall hazards. Can’t see to identify drugs they need.

• Caution use of digoxin as it causes blurred vision.

• Can’t read written instructions.

What drug-related problems can occur in prolonged hospitalisations?

• Increased risk of PE, VTE, DVT, delirium, reduced cognition, infection risk, other complications, bed sores, loss of mobility, loss of independence, loss of routine

• Keep patient out of hospital, treat in community to avoid hospitalisation and complications

What drug-related problems can occur in malnutrition?

• Decreased body fat - different distribution of drugs

• Lower body weight - different dosing required

What drug-related problems can occur in atrial fibrillation?

• Increase the risk of stroke and bleeding

• Think about toxicity - amiodarone (narrow therapeutic range) can affect thyroid function, and LFTs

• Digoxin - (narrow therapeutic range) increase toxicity - monitor plasma levels

• Mainly on beta blockers later in life

What drug-related problems can occur in swallowing issues?

• Incorrectly prescribed oral medications – people cannot take these medicines to help

• Lack of alternative formulations for certain drugs

What drug-related problems can occur in diabetes?

• Sulfonylureas increase hypoglycaemia risk – so increased risk of falls in patient

• Monitor metformin use in elderly - eGFR <30 treatment should be stopped

• With metformin, risk of B12 deficiency (requires monitoring)

• If renal impairment and CVD exists, may require a more renoprotective/cardioprotective agent such as SGLT-2i like dapagliflozin, empagliflozin

• Falls risk with peripheral neuropathy/other complications

• Administering insulin becomes trickier - small errors lead to big consequences

What drug-related problems can occur in COPD?

• Increased frequency of exacerbations -> more use of oral corticosteroids which increases the risk of immunosuppression, osteoporosis

• Increased use of antibiotics -> risk of dysbiosis

• Use of inhaled corticosteroids -> increased risk of oral thrush especially if patient doesn’t rinse their mouth out after use

• Manual dexterity decreases - using inhalers becomes trickier

• Ensure proper inhaler techniques

What drug-related problems can occur in dental issues?

• Background pain without treatment

• Infection risk

What drug-related problems can occur in skin changes?

• Adherence to emollients

• Steroid overuse

• Risk of infection

• Itchy rashes

• Bleeding

• Blisters

• Patch applications

• Changing plasters

• Pressure sores

• Increased risk of benign melanoma

What drug-related problems can occur in dehydration?

• Increased risk of AKI especially if taking renotoxic drugs or patients with HF

• May avoid large volumes of fluid to avoid getting up at night so that can increase risk of dehydration and AKI

What drug-related problems can occur in decreased hepatic function?

Decreased plasma proteins altering distribution