GUIDELINE FOR GERIATRIC PATIENTS.pptx

The presentation “Guideline for Geriatric Patients” by Syed Mubasheer Ali, MIPM, Raikal, Shadnagar provides a comprehensive overview of safe and effective drug use in elderly populations. It discusses the physiological changes that occur with aging and how they affect pharmacokinetics and pharmacodynamics. The presentation highlights the increased risk of adverse drug reactions (ADRs), drug interactions, and medication errors among older adults. It emphasizes rational prescribing principles, careful medication review, dose adjustments, and monitoring to improve therapeutic outcomes. Common drug classes such as NSAIDs, hypnotics, diuretics, and anticoagulants are reviewed with specific cautions for geriatric use, supported by a real-life case study illustrating clinical application.

1. General  prescribing guidelines for geriatric patients Presented By: - Syed Mubasheer Ali MIPM , Raikal,Shadnagar,RR

2. Topics  Introduction Why is guidelines required for geriatric patients Aging Pharmacokinetics (younger/elder) Pharmacodynamics (younger/elder) General prescribing guidelines for elders Principle of drug prescribing in  hospitalized elderly patients Medication Case study 2

3. a branch of medicine that deals with the problems and diseases of old age and the medical care and treatment of aging people. Older patients have a higher prevalence of chronic and multiple illness and physiological changes associated with ageing may masquerade as illness. They are thus more likely to be prescribed medication by their doctors and to take multiple agents. ` THIS PUTS THEM AT A HIGHER RISK OF SUFFERING ADVERSE DRUG REACTIONS(ADRS), ADVERSE DRUG EVENTS AND DRUG-DRUG INTERACTIONS Definition  

4. Why guideline required for geriatric patients 4 Elderly patient are at higher risk of adverse events. Adverse drug reaction are 2 to 3 times greater compared to younger patient. Studies shows that 1/5 of all patients above 65 years experiences an adverse drug reaction. 30% of admissions due to drug related problems 2/3 of nursing facility residents have ADR over 4 years. 5 th cause of death

5. Predictors of adverse drug events > 4 prescription medication. Length of stay in hospital > 14 days. > 4 active medical problems. Admission to general medical unit. History of alcohol use. Lower mean mini-mental state examination score. 2-4 new medications added during hospitalization. 5

6. ageing Aging refer to the inevitable ,irreversible decline in organ function that occurs over time in the absence of injure, illness, environmental risk, or poor life style choices (Eg:Unhealthy Diet , lack of exercise, substance abuse) 6

7. ageing

8. Organ system manifestation 8 Body composition Cardiovascular system Decrease in total body water Decrease in lean body mass Increase body fat Decrease serum albumin Increase in alpha – acid glycoprotein (increased by several disease states ) Decrease in myocardial sensitivity to beta – adrenergic stimulation. Decrease in baroreceptor. Decrease in cardiac output Increase in total peripheral resistance

9. 9 CNS Endocrine system GIT Decrease in weight and volume of the brain Alternations in several aspects of cognition. Cerebral blood flow decrease with aging and blood brain barrier (BBB) may become more permeable Secondary memory may be diminished Thyroid gland atrophies with age Increased incidence of DM ,thyroid diseases Menopause Increased in gastric ph. Decreased in GIT blood flow. Delayed gastric emptying. Slowed intestinal transit.

10. 10 Genitourinary Immune Liver Oral Atrophy of the vagina due to decreased estrogen Prostatic hypertrophy due to androgenic hormonal changes Age – related changes may predispose to incontinence. Decrease in cell mediated immunity Decrease in liver size Decrease in liver blood flow Decrease in ability to taste sweetness, sourness and bitterness Altered dentition

11. 11 Pulmonary Renal Sensory Skeletal Skin/hair Decreased in muscle strength, chest wall complain , total alveolar surface vital capacity maximal breathing capacity. Decreased in GFR, renal blood flow, renal mass, tubular secretion function. Increased in filtration fraction. Decreased in accommodation of the lens of the eye , causing farsightedness presbycusis (loss of auditory acuity ). Decreased in conduction velocity. Loss of skeletal bone mass (osteopenia). Skin dryness, wrinkling and change in pigmentation, epithelial thinning, loss of dermal thickness. Decreased in number of hair follicles and melanocytes in the hair bulbs.

12. pharmacokinetics 12 ABSORPTION :The fraction of a drug dose reaching the systemic circulation . DISTRIBUTION :Locations in the body a drug penetrates expressed as volume per weight( e.g. L/Kg ) METABOLISM : Drug conversion to alternate compounds which may be pharmacologically active or inactive. ELIMINATION : A drug’s final route of exist the body expressed in terms of half-life or clearance

13. Effects of aging on absorption Rate of absorption may be delayed lower peak concentration ,delayed time to peak concentration. FACTORS AFFECTING ABSORPTION : Route of administration What it taken with the drug Divalent cation (ca , mg , fe ) Food, enteral feedings Drugs that influence gastric ph. Drugs that promote or delay GI motility. Comorbid conditions 13

14. 14 Increased GI ph. Decreased gastric emptying Dysphagia EFFECT OF AGING ON VOLUME OF DISTRIBUCTION (Vd) In aging it deceased body water it leads to deceased distribution for hydrophilic drugs EX: Ethanol, lithium In elder the deceased lean body mass leads to deceased the volume of distribution for drugs that bind to muscle EX : Digoxin. The aging effect increased of fat stores that leads to increased vd for lipophilic drugs EX:Diazepam, trazodone. It deceased plasma protein (albumin ) leads to increased % of unbound or free drug (active) in vd EX :Diazepam, valporic acid, warfarin. It also effect the increased plasma protein ( alpha -1 acid glycoprotein) leads to vd deceased% of unbound or free drug (active) EX: Propranolol, Erythromycin.

15. Aging effect on hepatic metabolism 15 Metabolic clearance of drugs by the liver may be reduced due to decreased in hepatic blood flow and also decreased liver size and mass. EX: Morphine, meperidine propranolol. METABOLIC PATHWAYS OTHER FACTORS AFFECTING DRUG METABOLISM Gender Smoking Diet Drug interactions Weakness in character

16. EXCRETION 16 When compared to 10 years, at the age of 40 years GFR reduced by 10%and 6-10%is reduced in every 10 years after this age. At the age of 90 years about 30-40% reduction in GFR occurs. Decreased in renal plasma flow and secretion . Decreased in excretion of renally cleared drugs ( digoxin,penicillin,amino glycosides) Coexisting diseases like HT,DM Include renal compromise. Creatinine clearance (ml/min): For male =140 – age (years) × weight(kg)/ 72 × serum Cr (mg/dl) For female = 140 – age (years) × weight(kg)/ 85 × serum Cr(mg/dl).

17. pharmacodynamics Pharmacodynamics ` The older patient's central nervous system is often more sensitive to agents such as antipsychotics ,  opioids, benzodiazepines and anti-Parkinsonian agents.   Drugs which have toxic gastrointestinal (GI) side-effects, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids, must be used with caution.

18. SUMMARY OF PK AND PD. Pk and pd changes generally result in decreased clearance and increased sensitivity to medications in older adults. Use of lower doses, longer interval, slower titration are helpful in decreasing the risk of drug intolerance and toxicity. Careful monitoring is necessary to ensure successful outcomes RISK FACTORS FOR DRUG RELATED PROBLEM IN THE ELDERLY Suboptimal prescribing. Medication errors. Medication non adherence. pharmacodynamics

19. General prescribing guidelines for the elderly when prescribing new medication review the following issues Is medication is necessary ? Determine therapeutic endpoint? Asses : risk vs benefits Can one medication treat more than one condition ? Administration times matches existing medicines? Identify all drugs by generic name and drug class All drugs prescribed should have clinical indication Known the side effect profile of drugs you prescribe Understand aging pharmacokinetics and how to decrease ADE’S Stop all drugs without clinical indication 19

20. Stop all drugs without clinical indication Always attempt to substitute less toxic drug Avoid negative prescribing cascade ( treating one ADE with another drug). BROWN BAG INVENTORY ( ANNUAL OR BIANNUALLY ) 20

21. Principles of drug prescribing in hospitalized elderly patient AT THE TIME OF ADMISSION: Review all medication (include relevant OTC, herbal, vitamins, etc ) taken by patient prior to hospitalization. Assess pervious compliance. 2. AVOID UNNECESSARY POLYPHARMACY BY: Using drugs that treat more than one condition (E.g. : Beta-blocker for both hypertension and angina pectoris) when practical. Discontinue drugs unnecessary in hospital (E.g. : urinary antispasmodic when catheter has been placed) 3.SAFE PRESCRIBING HABITIS : When initiating a new medication : Choose agents whose pharmacokinetic properties in elderly patients Begin with a short acting agent but buy discharge convert to an agent that is given once or twice daily in order to enhance patient compliance and reduce caregiver burden at home . If patient require multiple medications avoid whenever possible,drugs that are inhibitor or 21

22. Inducers of cytochrome P450 hepatic metabolism ,or highly bound to albumin .EXAMPLE : Ceftriaxone,diazepam,lorazepam,phenytoin,valproic acid. If in doubt consult a pharmacist When the maintenance dose of a medication is not established “start low and go slow” to allow time to titrate the dose against the desired clinical effect. Use lower than usual maintenance dose of medications that are renal excreted( EX:Digoxin ) ADVERSE DRUG EVENTS - Anytime a patient develops new or unexplained medical problem Consider ADE as a cause EX:Hypotension,arrhythmias,renal failure ,constipation. AT TIME OF DISCHARGE: - Review medication that were taken by patient prior to admission and evaluate which should be renewed on discharge. - Review all discharge medication with the patient and family and provide written instruction. 22

23. Medications  

24. NONSTEROIDAL ANTI - INFLAMMATORY DRUG   NSAIDs ` Gastrointestinal (GI) bleeding is more common and has more serious consequences in older patients. ` NSAIDs can worsen heart failure or aggravate impaired renal function. These effects can be worse in elderly patients. ` They are best avoided, if possible, for simple pain relief in osteoarthritis (OA)  etc. paracetamol should be tried instead and, if this is insufficient, try a low-dose NSAID in addition, with proton pump inhibitor (PPI) or misoprostol cover, or substitute a low-dose opioid.  24

25.           HYPNOTICS Hypnotics with long half-lives are a significant problem and can cause daytime drowsiness, unsteadiness from impaired balance and confusion. ` Short-acting ones may also be a problem and should only be used for short periods if essential. ` In patients prone to falls or dizziness avoid using these agents unless absolutely necessary EX: Ambien, Belsomra, Dayvigo 25

26. Digoxin(drug for heart failure) In the very elderly, the daily maintenance dose should 125 μg. In the renally impaired, the dose should be 62.5 μg. 250 μg/day is likely to cause toxicity 26

27. DIURETICS 27 This class of drugs is often overused in the elderly and should not be used for chronic treatment of gravitational oedema  where measures such as  legraising, increased walking/leg exercises and graduated compression stockings are often sufficient. EX : Aldactone, Amiloride, Lasix

28. DRUGS CAUSING BONEMARROW DEPRESSION   Drugs such as co- trimoxazole and chloramphenicol should only be used if there is no suitable alternative

29. ANTIDEPRESSANTS    Tricyclic antidepressants commonly cause postural hypotension and confusion in the older patient; they should be used carefully.  

30. ANTICOAGULANTS AND ANTIPLATELET DRUGS 30 Beware of GI bleeding and contra-indications such as peptic ulceration which may have occurred a long time ago and been forgotten about. For warfarin, prescribe only when patients have a full understanding of why the drug is being taken, its dangers, correct daily dosing/timing and the importance of regular INR monitoring.

31.   Case study  A Patient her age 82 years of age with a history of congestive heart failure, glaucoma, hypertension and osteoarthritis. Her Current medication are  furosemide, potassium, Lisinopril, metoprolol, aspirin, timololmaleate ophthalmic solution (timoptic) acetaminophen (as needed), multivitamin and a calcium/vitamin D supplement (800 IU daily). She has a appointment with a new orthopedic physician. During the appointment, the patient complains of persistent arthritic pain in her knee. The physician prescribe the NSAID meloxicam (7.5 mg per day) for pain and inflammation. 31

32. Thank you