Prescribing in Elderly

What is the general perception of what elderly is classed as?

Over the age of 65

What is the new definition of elderly?

Over 70

What is the physical changes accompanied with elderly?

How medicines are handled by the body - 40 onwards! 

What % of the UK population are currently classed as elderly?

18% over 65 

Where do a lot of elderly patients live?

Independently at home, with family at home, at home with carer support, sheltered housing, care homes, hospitals/rehab units

Why are the ageing population important?

Many taking 5+ medications per day, higher risk of toxic effects, biggest user of NHS services including prescriptions

What factors may be responsible for ADRs in elderly?

• multiple disease states 

• Increased use of medication

• Over prescribing 

• Changes in sensitivity to certain drugs 

• Alterations in drug handling 

What can pharmacodynamic changes result in in elderly patients?

Alterations in sensitivity to the drug to a patients over-response to a conventional dose

What are 3 main reasons for pharmacodynamic changes in handling of drugs in elderly patients?

• Number of drug receptors decrease and so does their affinity for drug molecules

• Homeostasis changes and postural hypotension and other conditions becomes more prevalent so may need to reduce antihypertensive drugs

• Elderly patients more susceptible to confusion - drugs that produce confusion as a side effect are more likely to do so

What is postural hypotension?

BP decreases when standing after sitting/lying 

What factors may affect drug absorption in elderly patients?

Reduced saliva production affecting buccal preparations, increased gastric pH, delayed gastric emptying, decreased GI motility, decreased GI and regional blood supply 

What is more likely to happen to drug absorption in elderly patients?

Slower, not reduced so just takes more time to get the desired therapeutic effect

Why is VD often increased for lipid soluble drugs in elderly patients?

Increased mass of adipose tissue

What does it mean for a decrease in lean muscle mass in elderly patients for distribution?

Drugs e.g., digoxin are less likely to enter muscle compartment and be stored so more present in serum and dose may need to be reduced 

What happens to VD for water soluble drugs in elderly patients?

Decreased as there is a decrease in total body water

What does a reduced serum albumin level mean in elderly?

Drugs that are extensively albumin bound are now free to exert more of an effect so may need dose reductions

Why are there reduced serum albumin levels in elderly patients?

Liver function naturally decreases 

What are the two other liver related factors that affect drug handling in the body?

Reduced hepatic blood flow and reduced metabolic clearance

What is the effect of a reduced hepatic blood flow in elderly patients?

Reduced first pass metabolism

What is the effect of less first pass metabolism in elderly patients for drugs that are extensively affected by 1st pass metabolism?

Increase in free drug so greater drug effect 

What is the effect of less first pass metabolism in elderly patients for prodrugs?

Not converted so drug effect may be reduced 

What does a reduced metabolic clearance mean for drugs in elderly?

Accumulation of drugs extensively metabolised and prolongs medications duration of action

Why are LFTs not useful to predict deterioration in metabolic function?

Only detect liver damage and not ageing

What happens to the kidneys as we age?

Size decreases - loss of functioning glomeruli and decreases GFR 

What does a reduced GFR mean for renal function?

Accumulation of renally excreted drugs, increases their half life, increases risk of renal disease/drug induced renal damage

Should blanket recommendations to reduce doses of drugs metabolised by the liver be implemented?

No as liver function is only slightly impaired in elderly

Should blanket recommendations to reduce doses of drugs excreted by the kidneys be implemented?

Yes - reduce all doses

What physical problems may need to be considered for adherence in elderly patients?

Onset of arthritis, Parkinson’s disease or decrease in functional capacity, polypharmacy

What preparations/methods should pharmacists consider to help medicines adherence in elderly patients?

Blister packs, clic-loc bottle tops, measuring liquid preparations, sublingual tablets and dry mouths

What is polypharmacy?

Prescription of 5 or more drugs to one patient - patients may be prescribed more drugs than clinically necessary 

What is appropriate polypharmacy?

Prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence

What is problematic polypharmacy?

Prescribing of multiple medicines inappropriately, or where the intended benefit of the medicines are not realised

What are problems with polypharmacy in elderly patients?

• risk of adverse drug reactions increased with more meds used

• Risk of drug-drug interactions increase

• Chronic conditions can be exacerbated by medications for other conditions 

• Medicines adherence may decrease as elderly patients may struggle to take as prescribed 

• Patients may become socially restricted if trying to fit medicine regimes around daily routines 

• Older patients who cannot adhere may need support from carers or residential care

• Drug cost and wastage 

How can pharmacists be involved in medicines optimisation in elderly patients?

• supporting adherence with practical measures following NICE CG76

• Managing polypharmacy with screening tools e.g., STOPP or START tools

• Medication reviews

• Medicines reconciliation

• Structured medication reviews

• Other services may support meds optimisation e.g., pharmacy first

• Deprescribing

What is deprescribing?

Reducing unnecessary tablet/medication burden and conserving risk vs benefit

What should be asked to elderly patients regarding falls?

Ask if they’ve had any falls within the past year and ask about frequency, context and characteristics of the fall 

What should be done with a patient if they have had a fall?

Medication review to eliminate drug causes 

What are two other important considerations for elderly patients in regards to their care?

Frailty and cognitive status - if they have capacity to consent