Managing Medicine in Older People
The evidence base in elderly care
- Clinical trials involve older people, but they cut off at around 75-80 – lack of evidence for interventions for older people typically age over 75
Contrasted with the need for high quality evidence-based healthcare for the elderly
- Growing elderly population
- Rise in multimorbidity (e.g. obesity, T2Diabetes, CVD)
- Increased complexity of pharmaceutical interventions (e.g. cancer)
• Increased risk of toxicity + ADRs – requiring more monitoring
• BBB not as competent = increased CNS effects
- Increased need for rationing in the NHS – services are stretched + treatments are not cheap
• Require new funding models – ie gene therapy is very expensive but will increase the QoL
INCREASED NEED FOR CLINICALLY SKILLED PHARMACISTS
Who are older people?
Entering old age – mixed group, biological age ceases to be of importance -> based on functional capacity + social connections
Transitional
Frail older people
Challenges
- Older people want to remain independent and cope with their illnesses
- The challenges they face include:
• Lack of advice from professionals about self-care -> tailor lifestyle advice for older people
• Lack of service coordination and poor communication between professionals
• Lack of information about available services and pathways – signposting older people to the services -> links to the aim of older people independently manging their illness
Summary
• Look for the evidence... don’t assume
• Work with the MDT to take full account of the interacting nature of all comorbidities / impairments / social context
• Older people are a heterogenous group - make decisions on an individual patient basis and include the person
• Consider if the benefits outweigh the risks for the pt -> consider the number to treat and the number to cause harm
• COMMUNICATE your interventions, making it clear who will do what
Commonly encountered disease states / the aged body
Osteoarthritis | Type 2 diabetes | Infection risk |
Reduced renal function / CKD / AKI | Mental health (depression, loneliness) | Weaker immune systems |
Parkinson’s disease (PD) | Liver failure/cirrhosis | Fall Risk (risk of fractures) |
Hypertension | UTI | Osteoporosis |
Loss of hearing | Rheumatoid arthritis (RA) | Skin changes |
Loss of eyesight | Cancer | Dental issues |
Heart failure | Delirium | Muscle atrophy – decreased muscle mass (weaker) and increased fat - affects distribution of drugs |
Dementia + leaky blood brain barrier | DVT/Pulmonary embolism | Pain |
Alzheimer's | Coronary heart disease | COPD |
Stroke | Atrial fibrillation | Stomach pH goes up – weaker – less protection – GI infection risk |
Hypotension | Oedema | Dehydration |
Myocardial infarction | Bleed risk | Pressure sores (care homes) |
Malnutrition | Constipation | Incontinence |
Glaucoma |
| Swallowing issues |
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Drug related problems (DRPs) in elderly patients
Osteoarthritis | Type 2 diabetes | Infection risk |
Reduced renal function / CKD / AKI | Mental health (depression, loneliness) | Weaker immune systems |
Parkinson’s disease (PD) | Liver failure/cirrhosis | Fall Risk (risk of fractures) |
Hypertension | UTI | Osteoporosis |
Loss of hearing | Rheumatoid arthritis (RA) | Skin changes |
Loss of eyesight | Cancer | Dental issues |
Heart failure | Delirium | Muscle atrophy – decreased muscle mass (weaker) and increased fat - affects distribution of drugs |
Dementia + leaky blood brain barrier | DVT/Pulmonary embolism | Pain |
Alzheimer's | Coronary heart disease | COPD |
Stroke | Atrial fibrillation | Stomach pH goes up – weaker – less protection – GI infection risk |
Hypotension | Oedema | Dehydration |
Myocardial infarction | Bleed risk | Pressure sores (care homes) |
Malnutrition | Constipation | Incontinence |
Glaucoma |
| Swallowing issues |
Drug related problems (DRPs) in elderly patients
Condition | Drug-related problem |
Parkinsons Disease | Manual dexterity issues due to tremor, insomnia, dysphagia, postural hypotension leading to falls |
Reduced renal function | Reduced clearance of drugs, increased risk of accumulation (and therefore toxicity), decrease effectiveness of diuretics with reduced function, reduced treatment of UTI (less AB in the bladder due to worse clearance) |
Pain (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 acute kidney injury |
Hypertension – (CCB use, ACE I, thiazide-like diuretics) | 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 |
UTI | (increased risk of infection eg sepsis), possible confusion Poor renal func antibiotic cant enter bladder due to poor renal function |
Mental health | 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 |
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 |
Dementia / Alzheimer’s | May not be able to manage own medications, must consider patients 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 |
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. Be aware of things such as DOLs (and difference bwn this and section), capacity and work w MDT |
Constipation | Reduced intestinal motility movement in elderly – May be worsened by drugs such as codeine, morphine, poor fluid intake also contributes. 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 |
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 vs DOACs! |
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 |
Osteoporosis | Bisphosphonates = GI irritation, ONJ RANK-L inhibitors = immunosuppressive Anabolic therapies = increased risk of osteocarcinoma, Hypercalcaemia Consider vitamin D and calcium deficiencies, diet, exercise Loss of mobility Reduce 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 ppl |
Infection | Leaky BBB --> toxins get into the brain and cause delirium Hospital itself is an infection risk– keep ppl in community |
Decreased muscle mass | Weaker and increased fat – affects Vd of drugs, harder to get back up if fallen |
Cancer – chemotherapy /RT | There is risk of secondary cancers / tumours – radio or chemo induced. Rebound side effects later in life |
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. Cant read written instructions |
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. |
Malnutrition | Decreased body fat = different distribution of drugs Lower body weight – different dosing required |
Atrial fibrillation | Increase the risk of stroke and bleeding Think about toxicity – amiodarone (narrow therapeutic range) can affect thyroid function, and LFTs Mainly on beta blockers later in life |
Swallowing issues | Incorrectly prescribed oral medications – ppl cannot take these medicines to help... Lack of alternative formulations for certain drugs. |
Diabetes | Sulfonylureas – increase hypoglycaemia risk – so increased risk of falls in pt 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 Fall risk with peripheral neuropathy/ other complications Administering insulin becomes trickier... small errors lead to big consequences |
COPD | Increased frequency of exacerbations --> more use of oral corticosteroids which increases the risk of immunosuppression, osteoporosis Increased use of abx --> risk of dysbiosis Use of inhaled corticosteroids --> increased risk of oral thrush especially is patient doesn’t rinse their mouth out after use Manual dexterity decreases – using inhalers becomes trickier Ensure proper inhaler techniques |
Dental issues | Background pain without treatment, infection risk |
Incontinence |
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Skin changes | Adherence to emollients, steroid over use, risk of infections, itchy rashes, bleeding, blisters, patch applications, changing plasters, pressure sores Risk of benign melanoma increases |
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 |
Decreased hepatic function | Decreased plasma proteins altering distribution |