Advanced Therapeutics: Cancer / Special Patient Groups - Notes on Elderly Patients

Pharmaceutical Care Needs of Elderly Patients

Aims and Objectives

• Improve understanding of the pharmaceutical care needs of elderly patients.
• Understand the pharmacist’s role in caring for elderly patients.
• Describe the extent of adverse drug reactions and drug interactions in the elderly.
• Discuss pharmaceutical care issues for older people and strategies to minimize drug-related problems (DRPs).

Adverse Drug Reactions and Drug Interactions

• Elderly patients are more susceptible to adverse drug reactions (ADRs) and drug interactions due to:
  • Age-related physiological changes
  • Multiple comorbidities
  • Polypharmacy

Commonly Encountered Disease States in Elderly Patients

• Osteoarthritis
• Type 2 diabetes
• Infection risk
• Reduced renal function / Chronic Kidney Disease (CKD) / Acute Kidney Injury (AKI)
• Mental health issues (depression, loneliness)
• Weaker immune systems
• Parkinson’s disease (PD)
• Liver failure/cirrhosis
• Fall risk (contributing factors include muscle atrophy, sensory deterioration, and polypharmacy)
• Hypertension
• Urinary Tract Infection (UTI)
• Osteoporosis
• Loss of hearing
• Rheumatoid arthritis (RA)
• Skin changes (thinner skin, age spots, risk of skin cancers)
• Loss of eyesight
• Cancer
• Dental issues (including poorly fitting dentures)
• Heart failure
• Delirium (due to “leaky” Blood-Brain Barrier (BBB))
• Muscle atrophy (decreased muscle mass and increased fat, affecting drug distribution)
• Dementia (vascular, often due to existing cardiovascular disease (CVD))
• Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) (due to acute immobility, dehydration, and other risk factors from multimorbidity)
• Pain (often complex and multifactorial)
• Alzheimer's disease
• Coronary heart disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Stroke
• Atrial fibrillation
• Increased stomach pH (leading to less protection and increased GI infection risk)
• Hypotension
• Oedema (heart failure and/or positional oedema)
• Dehydration (often diuretic-induced or due to poor oral intake)
• Myocardial infarction
• Bleed risk (related to clotting factors from the liver, antiplatelet/anticoagulant therapy)
• Pressure sores (especially in care homes)
• Malnutrition
• Constipation (decreased peristaltic movements, decreased fluid intake, and low dietary fiber)
• Incontinence
• Glaucoma
• Swallowing issues

Drug-Related Problems (DRPs) in Elderly Patients

Parkinson's Disease

• Manual dexterity issues due to tremor.
• Insomnia.
• Dysphagia.
• Postural hypotension leading to falls.
• Parkinson's disease dementia.

Reduced Renal Function

• Reduced clearance of drugs, increasing the risk of accumulation and toxicity.
• Decreased effectiveness of diuretics.
• Reduced treatment of UTIs (less antibiotic concentration in the bladder).

Pain (Osteoarthritis)

• Opioids:
  • Increased risk of falls and drowsiness.
  • Danger with driving.
  • Constipation.
  • Risk of unintentional overdose.
• NSAIDs:
  • Increased risk of GI bleed.
  • Cardiovascular events.
  • Precipitation of acute kidney injury.

Hypertension

• Calcium Channel Blockers (CCBs), ACE inhibitors, thiazide-like diuretics can cause:
  • Oedema.
  • Dry cough.
  • Hypotension.
  • Altered electrolytes.
• Target BP increases with age; aggressive treatment can lead to increased adverse responses.
• Higher risk of white coat hypertension, possibly requiring ambulatory monitoring.

Urinary Tract Infection (UTI)

• Increased risk of infection (e.g., sepsis).
• Possible confusion.
• Impaired renal function affects antibiotic effectiveness (e.g., nitrofurantoin, trimethoprim).

Mental Health

• Drowsiness/falls risk with antidepressants/anti-anxiety medications (increased anticholinergic burden).
• Confusion due to a leaky BBB.
• Drowsiness with some antidepressants (e.g., TCAs).
• Care with antidepressants with long half-life.
• Low sodium with SSRIs.
• Social isolation exacerbates depression; drug treatment alone may not be effective.

Dementia / Alzheimer’s

• Inability to manage own medications.
• Consideration of patient's ability to provide informed consent.
• Potential for non-adherence or accidental overdose.
• Distrust of medications/healthcare professionals.
• Advocate anticholinesterase for mild/moderate cases with increased social support.

Non-Specific CNS Symptoms

• Difficulty differentiating serious mental health diagnosis from dementia/Alzheimer's/delirium/ADRs.
• Inappropriate prescribing of sedatives can worsen cognition and increase falls risk.
• Be aware of DOLs (Deprivation of Liberty Safeguards), capacity, and work with multidisciplinary teams (MDTs).

Constipation

• Reduced intestinal motility.
• Worsened by drugs such as codeine, morphine.
• Poor fluid intake.
• Stimulant laxatives are less effective; osmotic laxatives are often preferred.

DVT/PE

• Heparins to warfarin/DOACs increase bleeding risk.
• Warfarin: adherence, DDIs hard to manage; dietary restrictions.
• Warfarin is easier to reverse vs DOACs.

Hearing Loss

• Caution with ototoxic drugs like gentamicin and loop diuretics.
• Ensure patients can hear and understand instructions; provide written instructions and ask them to repeat.

Osteoporosis

• Bisphosphonates: GI irritation, ONJ (osteonecrosis of the jaw).
• RANK-L inhibitors: immunosuppressive.
• Anabolic therapies: increased risk of osteosarcoma, 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 caused by steroids, cancer drugs, hypogonadism, etc.).
• Reduced oestrogen -> reduced bone repair.
• Increased sensitivity to bone-altering drugs; Zolendronic acid IV infusion annually may be easier than oral meds.

Infection

• Leaky BBB allows toxins into the brain, causing delirium.
• Hospital itself is an infection risk; keep people in the community if possible.

Decreased Muscle Mass

• Increased fat - affects Volume of distribution (V_d) of drugs.

Cancer

• Chemotherapy/RT increases risk of secondary cancers/tumours (radio or chemo-induced).
• Increased risk of Tumour Lysis Syndrome (TLS) – increased risk of dehydration.
• Cancer treatment toxicities are often worse/last longer; monitor closely and reduce dose if needed.

Loss of Eyesight

• Can’t see fall hazards, identify drugs, or read written instructions (use large print or colour coding).

Prolonged Hospitalisations

• Increased risk of PE, VTE, DVT, delirium, reduced cognition, infection risk, bed sores, loss of mobility/independence/routine.
• Treat in the community to avoid hospitalisation and complications.

Malnutrition

• Lower body weight requires different dosing.
• Care with 50kg minimum for full dose paracetamol and check Summary of Product Characteristics (SPCs) for weight adjustments for other drugs (e.g., DOACs).

Atrial Fibrillation

• Increased risk of stroke – DOAC indicated but use ORBIT score to assess bleed risk and implement extra monitoring.

Toxicity

• Amiodarone (narrow therapeutic range) can affect thyroid function and Liver Function Tests (LFTs).
• Digoxin (narrow therapeutic range) increases toxicity – monitor plasma levels.

Swallowing Issues

• Lack of alternative formulations for most drugs; use resources to check alternatives.

Diabetes

• Sulfonylureas increase hypoglycaemia risk, increasing fall risk; monitor.
• Metformin should be stopped if estimated Glomerular Filtration Rate (eGFR) <30.
• With metformin, risk of vitamin B12 deficiency (requires monitoring).
• If renal impairment and CVD co-exist, may require a more renoprotective/cardioprotective agent such as SGLT-2i like dapagliflozin or empagliflozin.

Falls

• Fall risk with peripheral neuropathy/retinopathy/other complications.
• Administering insulin becomes trickier; small errors lead to big consequences. Ensure proper administration

COPD

• Increased frequency of exacerbations leads to more corticosteroid use, which increases immunosuppression and osteoporosis risk.
• Increased antibiotic use increases dysbiosis risk.
• Inhaled corticosteroids increase oral thrush risk, especially without rinsing mouth after use.
• Decreased manual dexterity makes using inhalers trickier; ensure proper inhaler techniques.

Dental Issues

• Background pain without treatment and infection risk.
• Poorly fitting dentures can result in poor nutrition.

Incontinence

• Care with inappropriate diuretic and laxative use, which can exacerbate the condition.

Skin Changes

• Adherence to emollients is important; avoid steroid overuse; manage risk of infections, itchy rashes, bleeding, blisters, patch applications, pressure sores.
• Risk of all skin cancers increases; Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) are common and can cause irritation/be unsightly.

Dehydration

• Increased risk of AKI, especially if taking renotoxic drugs or with Heart Failure (HF).
• May avoid fluids at night to avoid nocturia, increasing dehydration and AKI risk.

Decreased Hepatic Function

• Decreased plasma proteins alter drug distribution.
• Decreased clotting factors.
• Decreased enzyme production slows drug metabolism.