Chapter 27

Drugs and Older Adults

Copyright 2015 Cengage Learning

 Introduction
Today, people are living longer and are
taking more medications
Forty percent of people of age 60 years and
older in the U.S. take at least five prescribed
medications, and many add OTC medications
and supplements
Increased serious complications resulting from
adverse drug reactions

Copyright 2015 Cengage Learning 2

 Introduction (contd.)
About 50% of hospitalizations are the
result of adverse drug effects in the elderly
In 2012, an estimated 100,000 deaths
annually were caused by medication-related
problems (MRPs)
MRPs can be mistaken for what is often
considered a normal consequence of aging or for
progression of disease
Cognitive impairment and behavioral changes are
frequently the result of drug therapy

Copyright 2015 Cengage Learning 3

 Introduction (contd.)
The aging process is an individualized
matter
Because of genetic or environmental factors
or good health practices, some older adults
may not feel or appear particularly different
However, there are gradual changes in body
composition and organ function as we grow older
These changes can affect the reaction to drugs
and make the individual more sensitive to a wide
variety of medications

Copyright 2015 Cengage Learning 4

 Physiological Changes with Age
Complex changes of aging involve both
anatomic and physiological factors
Affect how drugs are processed in the body
Absorption
Distribution
Metabolism (biotransformation)
Excretion

Copyright 2015 Cengage Learning 5

 Physiological Changes with Age
(contd.)
Cumulative effects of drugs in older adults
can be due to:
Inadequate absorption
Impaired distribution
Slower metabolism
Impaired excretion

Copyright 2015 Cengage Learning 6

 Physiological Changes with Age
(contd.)
Absorption
Gastric motility decreases
Gastric acid production diminishes, increasing the
gastric pH, causing a more alkaline environment
Many older adults also take medication that
reduces gastric acid
Examples: ranitidine (Zantac) or omeprazole (Prilosec)
Antacids are also used frequently

Copyright 2015 Cengage Learning 7

 Physiological Changes with Age
(contd.)
Distribution
Once drugs are absorbed and enter the
circulation, many of them bind to proteins
Albumin: principal protein used to bind drugs
As we age, the liver produces less albumin
Allows more of the drug to be unbound (free) to
reach receptor sites and therefore have a greater
than expected response

Copyright 2015 Cengage Learning 8

Physiological Changes with Age
(contd.)
Phenytoin (Dilantin) responds quite noticeably
to drops in plasma albumin levels

Copyright 2015 Cengage Learning 9

 Physiological Changes with Age
(contd.)
Metabolism
The liver serves as a major site for drug
metabolism
As we age, the mass of functional liver tissue and
blood flow to the liver decreases
Ability of the liver to break down drugs declines,
and drugs remain in the body longer
Repeated dosing can result in the accumulation of
the drug and increases the risk for toxicity

Copyright 2015 Cengage Learning 10

 Physiological Changes with Age
(contd.)
Excretion
In the older adult, kidney size, blood flow, and
glomerular filtration all decrease, resulting in a
decline in creatinine clearance
Illnesses such as hypertension, heart failure, and
diabetes add to the age-related loss and further
reduce creatinine clearance

Copyright 2015 Cengage Learning 11

Physiological Changes with Age
(contd.)
Drug by-products normally eliminated through
the kidneys can accumulate
Can lead to toxic effects

Copyright 2015 Cengage Learning 12

 Physiological Changes with Age
(contd.)
Seniors and drug development
Pharmaceutical research is frequently
focused on younger individuals
Older adults are often excluded from or
underrepresented in clinical trials
Results may be inappropriately extrapolated to
other populations with negative outcomes

Copyright 2015 Cengage Learning 13

Physiological Changes with Age
(contd.)
Some medicines safe for a 30-year-old may
produce unexpected results in a person over
age 50 or 60
Example: digoxin (Lanoxin)

Copyright 2015 Cengage Learning 14

Potentially Inappropriate Medication
Use in Older Adults
The Beers List
Results of a survey conducted to determine
the most inappropriate drugs for ambulatory
nursing home residents and adults 65 or older

Copyright 2015 Cengage Learning 15

Potentially Inappropriate Medication
Use in Older Adults (contd.)
Goal to improve care of older adults by
reducing their exposure to potentially
inappropriate medications (PIMs)
Health care professionals treating older adults
should have ready access to the Beers List and
recognize common classes of medications that
can produce problems

Copyright 2015 Cengage Learning 16

Drugs to Avoid with Certain Medical
Conditions
Drugs that produce significant
anticholinergic effects
Antipsychotic agents
Antidepressants
Antiparkinson agents
Antispasmodics
Antihistamines

Copyright 2015 Cengage Learning 17

Drugs to Avoid with Certain Medical
Conditions (contd.)
Drugs that can cause mental impairment
Anticholinergics
Antidepressants and antipsychotics
Benzodiazepines
Corticosteroids
H2 receptor antagonists
Meperidine
Phenothiazines
Sedative hypnotics
Copyright 2015 Cengage Learning 18
Drugs to Avoid with Certain Medical
Conditions (contd.)
Drugs that can cause or contribute to
syncope/falls
Anticonvulsants
Antidepressants
Antipsychotics
Alpha blockers
Benzodiazepines
Nonbenzodiazepine hypnotics

Copyright 2015 Cengage Learning 19

Drugs to Avoid with Certain Medical
Conditions (contd.)
Gastrointestinal conditions
Anyone taking NSAIDs should be cautioned
about the real danger of serious complications
In older adults, there may be no warning signs of
pain, and the first symptoms of trouble may be a
silent bleed that could lead to fatal GI
hemorrhage
Key to avoiding problems with NSAIDs is to use
the lowest effective dose for the shortest period of
time
Copyright 2015 Cengage Learning 20
Drugs to Avoid with Certain Medical
Conditions (contd.)
Avoid prolonged use (no longer than two
weeks) of OTC antacids without medical
supervision
Constipation can be worsened by
anticholinergics and oral antimuscarinics
(e.g., oxybutynin, tolterodine) for urinary
incontinence

Copyright 2015 Cengage Learning 21

Drugs to Avoid with Certain Medical
Conditions (contd.)
Cardiovascular disease
Studies have indicated increased risk of
cardiovascular problems (thrombotic events, MI,
and stroke) with the use of NSAIDs and COX-2
inhibitors
Older adult patients with heart failure should
avoid the calcium-channel blockers diltiazem
and verapamil, the antidiabetic glitazones
(Actos, Avandia), cilostazol (Pletal), and
dornedarone (Multaq)
Copyright 2015 Cengage Learning 22
 Polypharmacy
Individuals, especially older adults, may
be the victims of polypharmacy
Excessive use of multiple drugs
OTC, herbals, or prescriptions given at one time
for the treatment of a patients medical conditions
Polypharmacy becomes problematic when
negative outcomes occur
May result in unnecessary prescriptions, increased
risk of dangerous interactions with potentially
serious adverse side effects, and possible
medication nonadherence
Copyright 2015 Cengage Learning 23
Polypharmacy

Copyright 2015 Cengage Learning 24

 Polypharmacy (contd.)
Helpful guidelines
Educate yourself, your patients, and their
families
With newly prescribed drugs, note diagnoses,
allergies, and other medications
Monitor long-term drug use
Question any inappropriate medicine or
dosage
Document all adverse side effects, calls to the
physician, and action taken
Copyright 2015 Cengage Learning 25