PRINSIP TERAPI PADA

PASIEN GERIATRI

FITA RAHMAWATI, Ph.D, Sp.FRS, Apt

Fakultas Farmsi UGM
 Obyektif
 Populasi elderly dan penggunaan obat pada
geriatri
 Perubahan fisiologi pada geriatri
 Problem penggunaan obat pada geriatri
 POPULASI LANJUT USIA

 US 100 yll --- 2 % populasi lanjut usia (> 65 th) Th

1991 -- 12,6 % (> 31 juta jiwa) diperkirakan
Th 2050 -- 20%
 Jumlah lansia meningkat 22 % th 1980 - 1990
Lansia > 85 tahun meningkat 38 % pada waktu sama
dan diperkirakan 2 x pada abad 21
(Cusack et al, 1997).
 Guatemala 357
Singapore 348
Mexico 324
Philippine 310
Indonesia 301
Brazil 292
India 264
China 236
Hongkong 219
Bangladesh 201 PERCENT INCREASE
Canada 136
Australia 125 ELDERLY POPULATION
Poland 122
Japan
Israel
121 1985-2025
116
United States 105
New Zealand 99
France 67
Bulgaria 65
Luxemborg 56
Hungary 51
Italy 51
Belgium 49
Greece 48
Uruguay 47
Denmark 38
Germany 38
Austria 36
Noorway 36
United Kingdom 23
Sweden 21
Year Number of elderly Percentage of total
population population (%)
1971 5,306,874 4.48
1980 7,998,543 5.45
1985 11,277,557 6.29
1990 12,778,212 6.56
1995 13,298,588 6.83
2000 17,767,709 7.97
2005 19,936,895 8.48
2010 23,992,553 9.77
2020 28,822,879 11.34

Elderly population in Indonesia, 1971 – 2020

(Do-Le and Raharjo, 2002)
Elderly people and Chronic Pathologies (data
ISTAT 2005)
61,0
MEN WOMEN
52,2 48,0
45,5
38,9
36,1

17,2 21,7
13,2 13,1 14,3
10,3

People w ith no People w ith People w ith one People w ith no People w ith People w ith one
chronic disease three or more or more serious chnoic disease three or more or more serious
chronic chronic chronic chronic
diseases diseases diseases diseases

Population People aged 65 years and over

64,9

51,9
45,2 46,4
37,9 38,0
34,9
28,6
18,9 21,3 18,8
16,7
12,2 12,9 12 12,8
8,1
3,9
6,9 6,8
3,9 6,4 8,7 4,1

diabetes hypertension arrythmia, osteoarthritis heart disease nervous diseases

arthritis (women only)
60-64 65-74 75 and over Average, total population
 DRUG USE IN ELDERLY
 U.S. -- > 65 and older comprise 13% of the
population but consume 30% of all
prescription medications.

 In a survey among 2590 participants, the

highest prevalence of medication use was
among women aged at least 65 years, of whom
12% took at least ten medications and 23%
took at least five prescription drugs (Rehman,
2005).
Use of drugs in Italy by age and sex
2007 (Report OsMed 2007 – Agenzia Italiana del Farmaco)

A patient of 75 years or older takes 17 times

more drugs compared to a young adult of 25-34
years.
 European populations, people over 60 years
old represent around 22%, yet receive nearly
54% of the medication prescribed. Over the
age of 75 the proportion of the population is
14%, this population receive 33% of
prescription (Jackson, 2001).

 England one-fifth of the population is over 60

years of age, and they receive 52% of all
prescriptions with the majority of which are
repeats. A number of 75.36% of those aged are
taking four or more drugs (Rehman, 2005).
 Tn S (75 th) – geriatric inpatient
Diagnosa:  Osteotin
- Diabetes mellitus  Aspirin
- Ngomomg tidak nyambung  CaCO3
- Gagal ginjal terminal  Asam folat
- Susp. Renal osteodystrophy  Diabeton
- Osteoarthritis  Osteocare
- Hypoalbuminemia  Lisinopril
- Hyponatremia  Metformin
- Hypochloremia  Viliron
- Anemia  Cilostazol
- Hematemesis ec Stress ulcer  Pregabalin
 Donepazil
 Furosemide
 Citicholin
 Mecobalamin
 Na Phenytoin
PERUBAHAN FISOLOGI PADA GERIATRI
 Perubahan dengan bertambahnya usia
Anatomi dan fisiologi
Psikologi
Sosiologi

 Perubahan fisiologi
Peningkatan PH asam lambung
Penurunan motilitas gastrointestinal
Reduksi luas permukaan total absorpsi
Reduksi aliran darah jaringan
Reduksi ukuran hati
Reduksi aliran darah hati
Reduksi filtrasi glomerulus
 Table Effect of ageing on drug disposition (Cussack, 2001)

Pharmacokinetic Physiologic changes of Clinical significance

parameter ageing

Absorption Elevated gastric pH; Little change in absorption with age

Reduced small bowel surface
area
Distribution Reduced total body water;
Reduced lean body mass;
Increased body fat
Reduced serum albumin
Increasedα1-acid
glycoprotein
Hepatic Reduced hepatic mass;
metabolism Reduced hepatic blood flow;
Often decreased
metabolizing isoenzyme
activity
Renal elimination Reduced renal plasma flow;
Reduced glomerular
filtration rate
(no clinical significance)
Higher concentration of drugs that
distribute in body fluids;
Increased distribution and often
prolonged elimination half-life of fat-
soluble drugs
Increased free fraction in plasma of
some highly protein-bound acidic
drugs
Small decreases in free fraction of
basic drugs bound to α1-acid
glycoprotein
Often decreased first-past
metabolism;
Decrease rate of biotransformation
of some drugs;
Marked interindividual variation in
rate of hepatic metabolism
Decrease renal elimination of drugs
and metabolites;
Marked interindividual variation
Absorbtion is influenced by:

 Gastric pH
 Gastrointestinal motility changes
 Blood flow in the
 Active membran transport elderly
process
as well as
changes in the hepatic drug metabolism during the first
pass of the drug through the liver
DISTRIBUTION
Factors influence the distribution:

 Body composition
(changes in the elderly, lead to decreased Volume of
distribution)

 Proteins binding drug (reduced in the elderly)

 Blood flow (decreased in the elderly)

CHANGE IN BODY COMPOSITION
with AGING
25 YEARS OLD 19%
6% CELL SOLID
61% BONE MINERAL
14% FAT
H2O

12% 5%
CELL SOLID
53% 30% BONE MINERAL
FAT
H2O
70 YEARS OLD Brocklehurst & Allen, 1987
 Biochemical changes in old age

Biochemical Young adult Elderly

Albumin 37.00 – 51.00 g/l 33.00 – 49.00 g/l

Globulin 19.00 – 23.00 g/l 20.00 – 41.00 g/l
Urea 3.20 – 7.20 mmol/l 3.90 – 9.90 mmol/l
Creatinin 62.00 – 123.00 umol/l 52.00 – 159.00 umol/l
Potassium 3.60 – 4.70 mmol/l 3.60 – 5.20 mmol/l
Urate (men) 0.24 – 0.46 mmol/l 0.19 – 0.31 mmol/l
Calcium (women) 2.18 – 2.55 mmol/l 2.18 – 2.68 mmol/l
Phosphat (men) 0.79 – 1.40 mmol/l 0.66 – 1.27 mmol/l
Phosphat (women) 0.82 – 1.37 mmol/l 0.94 – 1.56 mmol/l
PROTEIN BINDING DRUG

Available
drug

Protein
bound
drug

More protein available Less protein available

Less active drug available More active drug available

 PHARMACOKINETICS
IN THE ELDERLY
 ABSORBTION
 DISTRIBUTION
 METABOLISM
 CLEARANCE

DRUG IN CIRCULATION
 An example of typical concentration-vs-time data from
which pharmacokinetik parameters can be estimated
DRUG METABOLISM
In the Elderly

 Blood flow 
 Liver function  Drug metabolism
 Congestive Heart in the Liver
failure (+)
 Renal elimination of most drugs is closely
correlated with the endogenous creatinine
clearance. CLcr (in mg/dl) as a function of age and
serum creatinine concentration, it may be
calculated from the Cockroft and Gault equation
(Turnheim, 2004):

(140 – age) x bodyweight (kg)

 CLcr =
72 Ccr
 Pharmacodynamics
 Increased drug sensitivity
 Changes in blood-brain barrier
 Alteration in receptor properties
 Increased Adverse Drug Reactions
(ADRs)
 GERIATRIC PROBLEMS

1.Immobility (keterbatasan gerak)

2.Instability (tidak stabil)
3.Intelectual impairment (gangguan intelektual)
4.Impairment of vision and hearing
5.Isolation (depression)
6.Inanition (malnutrition)
7.Irritable colon (gangguan BAB)
 GERIATRIC PROBLEMS (cont.)

8. Incontinence (gangguan BAK)

9. Impecunity (merasa miskin)
10. Infection (Infeksi)
11. Iatrogenesis (gangguan karena obat)
12. Insomnia (sulit tidur)
13. Immune deficiency (penurunan sistem imun)
14. Impotence (lemah syahwat)
 The paradox of drugs:
“Medication is probably
the single most important
healthcare technology in
preventing injury, disability
and death in the geriatric
population.”
(Avorn J. Medication use
and the elderly: current
status & opportunities.
Health Aff, 1995)
“Any symptom in an elderly
patient should be considered a
drug side effect until proved
otherwise.”
(Gurwitz et al. Long-term Care
Quality Letter - Brown University,
1995)
BENEFIT
RISK
 PROBEM PENGGUNAAN OBAT
PADA GERIATRI

 Sekitar 25 % obat tidak efektif/tidak diperlukan

 Obat sekunder untuk mengatasi ESO obat lain
 Masalah pada pengobatan usia lanjut:
Interaksi obat-obat
Duplikasi terapi
Frekwensi, interval at kekuatan dosis yg tdk
tepat
Petunjuk yg tidak memuaskan
Item yg sebenarnya sudah tidak diperlukan
Problems related to drug therapy
for elderly people

Elderly people have a risk of developing adverse

effects almost double that of younger people (Br J
Clin Pharmacol, 2002)

20% of older people in Europe receive at least one

inappropriate drug (JAMA, 2005)

30% of hospital admissions among elderly people are

caused by adverse effects of drugs, which is
considered the fifth leading cause of death in
hospitals (J Am Geriatr Soc, 2001)
 Factors that Predispose Elderly to ADRs

 Drug accumulation secondary to reduced

renal function
 Polypharmacy
 Greater use of drugs with a low therapeutic
index ( i.e. digoxin)
 Inadequate supervision of long-term therapy
 Poor patient adherence
 Measures to Prevent ADRs
 Complete drug history including OTC and herbals
Anamnesis/History taking
 According to INDICATION
 Account for pharmacokinetic and pharmacodynamic
changes that occur with aging
 Initiate therapy with low doses
 Monitor clinical response and plasma drug levels
 Employ simplest regime possible
 Monitor drug-drug interactions
 Periodically review drug regime
 Encourage patient to dispose of old medications
 Promote adherence to drug regime
MANAGEMENT OF ADR

 Cease suspected drugs

 Tapering off the drug dose
 Manage the emergency
 Monitoring the conditions
 Recording
BEBERAPA HAL YANG PERLU DIPERHATIKAN

 Tujuan dari terapi obat

Kualitas hidup
 Yang perlu diperhatikan :
Hindari terapi yang tidak diperlukan
Mengobati penyebab bukan sekedar gejala
Mengetahui riwayat pengobatan/penyakit
pasien
Titrasi dosis
Pemilihan obat dan bentuk sedian yg cocok
 Physiological alterations in elderly people:
what to do?

Consider…
 …the use of well-known drugs
about which enough is known
regarding the risk/benefit
balance for elderly patients.

 …the presence of organ

insufficiencies.

 …recourse to non
pharmacuetical treatments
(diet advice, smoking
cessation, physical activity).
 Polytherapy: possible causes

 Presence of pluripathologies.
 Expectations of the patient
and medical prescription.
 “Fragmentation of cures”.
 Recourse to self-medication.
 Adverse reactions treated as
pathologies.
Fragmentation of cures
(Viktil K et al. The Janus face of polypharmacy: overuse vs underuse of medication.
Norsk Epidemiol, 2008)

1. In 2000, in the USA, elderly patients made

more than 200 million visits to the dotor:
- 1/3 of visits  no prescription
- 1/3 of visits  1-2 drugs prescribed
- 1/3 of visits  3 or more drugs prescribed

2. The number of drugs increases as the

number of doctors looking after the same
patient increases.
The iceberg effect

Known drugs

Over the
counter
medicines
Herbal
products Particular
foods

Alcohol
The prescription ‘snowball’

For the collateral effects of

the last drug I gave you, take
this other one, and then if
there are any side effects I’ll
prescribe you a third to help
with them… Can’t I just
have my old
illness back?!
 Some examples of the prescription ‘snowball’

FANS HYPERTENSION ANTI-

HYPERTENSION
DRUG

HCT FANS HYPERTENSION

GOUT

MACROLIDE ARRYTHMIAA ANTI-

ARRYTHIMIA
DRUG
 Always remember:

“Any symptom in an elderly patient should be considered a drug

side effect until proved otherwise.”
(Gurwitz et al. Long-term Care Quality Letter - Brown University,
1995)
Numerous syndromes in old age are actually consequences of
pharmacological therapies:
 delirium  use of SNC drugs (eg. Anticolinergic drugs,

opiates)
 falls and fractures  benzodiazepins, anti-hypertension

drugs
 urinary incontinence  eg. diuretics
 Polytherapy and interactions between drugs

“An interaction between drugs becomes important for the

patient and the doctor when it interferes with the expected
efficacy or diminishes the safety of a treatment”

At the moment of the commercial authorisation of the drug, the safety

profile for elderly people is limited.

The risk of potential interactions alomst

exponentially as age and the number of
drugs used increase.
(Karas S - Ann Emerg Med, 1981; Sloan RW – Am Fam Physician, 1983)

The risk of interaction triples in patients

who receive prescriptions from two
doctors simultaneously.
(Recalde J.M., Aten Prim, 1998)
 Common interactions between drugs and foods

 Foods rich in K+: bananas,

oranges, leafy greens
 ACE-inhibitors
 Diuretics
 Sartans
 K+ savers
 Foods rich in Ca2+: milk,
yogurt, cheese
 Digossin  Foods rich in vitamin K:
apples, spinach, nuts, kiwis,
 Diuretics broccoli, cabbage
 Thyroid Hormones  Warfarin
 Some antibiotics
 Food and Drugs:
the case of grapefruit juice…
(Stump AL, et al. Management of grapefruit-drug
interactions. Am Fam Physisican 2006)

benzodiazepine
 AUC,  Cmax  strengthens the effects of BDZ
Calcium channel
blockers Immune-
 Haematic levels 
(headaches, hypotension,
supressants
 Adverse
tachycardia )
effects 
statins nefrotoxicity,
 AUC (16 times)  cefalea, liver disease
myopathy

Antidepressants
arrythmia,
antihistamines tricyclics
 Levels of liver  Levels of liver
disease disease
 Prolonged QT
 Berikut Pharmacist ’s guide terkait dengan
penurunan polifarmasi (Terie, 2004):
 Determine all medications being taken
 Identify the indication for all medications
 Identify any potential for adverse effects for
each medication
 Recommend eliminating all medications with
no therapeutic benefit, goal, or indication
 Recommend substituting medications with
a lesser side-effect profile, when possible
 When possible, select agents with an
infrequent dosing schedule
 Avoid utilizing another medication to threat a
side effect of another agents
 Berikut Pharmacist ’s guide terkait dengan
penurunan polifarmasi (Terie, 2004):

 Keep drug regimens as simple as possible

 Recommend starting at the lowest dosage and
increase slowly, if necessary
 Review all medication profiles routinely
 Encourage patients to follow up with a
physician regularly, particularly if they are
experiencing side effects
 Educate patients to keep a list of all
medication taken, including OTC and
alternative medication
 Polytherapy and interactions:
what to do?
 Treat the pathologies in order of
priority.
 Use drugs when strictly necessary
to reduce risk.
 Ask the patients if they are using
over the counter medicines or
herbal medicines.
 Inform the patient about foods to
avoid.
 Monitor the response periodically
and compare the appearance of
adverse reactions.
 Review treatment periodically.
The Beer’s criteria covered 2 types of statements:
(1)Medications or medication classes that should
generally be avoided in persons 65 years or older
because they are either ineffective or they pose
unnecessarily high risk for older persons and a safer
alternative is available and
(2)Medications that should not be used in older persons
known to have specific medical conditions.

 The Beers criteria have been used to survey clinical

medication use and evaluate intervention studies to
decrease medication problems in older adults.
Previous studies have shown these criteria to be useful
in decreasing problems in older adults.
 Some medicines are absoutely to be
avoided…

 Flurazepam (Dalmadorm) and

Diazepam (Valium): 
prolonged sedation and higher
rates of falls and femoral
fractures.
 Ketoralac (Toradol,
Lixidol):  risk of
gastrointestinal bleeding
even in the short term.

 Naprossene and Piroxicam :  risk of gastrointestinal

bleeding, renal insufficiency and hypertension if used oved
the long term.
 Ticlopidina (Tiklid):  risk of neutropenia.
 … or with particular conditions

 Gastrointestinal  Cardiovascolar
disturbances Disturbances
 Constipation  Cardiac arrhythmia
 Avoid:  Avoid:
anticolinergics, antidepressants
antidepressants tricyclics
tricyclics
 Ulcers  Urinary Disturbances
 Avoid: FANS,  Incontinence
aspirin, K+  Avoid: -blockers
integrators
 Respiratory Disturbances
 Endocrine Disturbances  Athsma o COPD
 Diabetes  Avoid: -blockers
 Avoid:
corticosteroids, -
blockers
Inappropriate drugs: what to do?

avoid prescribing drugs which

appear on the Beers list,
STOP/START

Favour other, safer,

therapies
 Medication Appropriateness
 Overuse of a Medication
– Antibiotics
– GI Medications
– Sleep medications
 Misuse
– Wrong dose and/or frequency
 Underuse
– Chronic disease
– Preventative medications- vaccines
Polytherapy and therapy adherence: a real problem

Adherence = “match between the behaviour of the

patient and the medical prescription”

Change in timing or frequency

Mistaken
of doses by the patient
consumption

40-60% of elderly patients do not follow their

prescription properly
(Vik SA et al. Ann Pharmacoter, 2004)
 KEPATUHAN PENGGUNAAN
OBAT PADA GERIATRI
Kepatuhan
 Berkurang tu pada regimen yg rumit
 Kegagalan pengobatan
 Memperpanjang waktu pengobatan
 Kerugian finansial

Peran farmasis meningkatkan kepatuhan

 Memotivasi pasien
 Informasi tentang obat
 Aturan pemberian obat yg sederhana
KEPATUHAN PENGGUNAAN OBAT PADA
GERIATRI

Penyebab ketidak patuhan :

 Tidak memahami tujuan pengobatan
 Hanya sedikit memperoleh atau tidak
memperoleh manfaat dari terapi sebelumnya
 Kemungkinan ESO tidak dijelaskan dan
sangat mengganggu px
 Aturan dosis rumit
 Kesulitan membaca, bahasa , mendengar
 Ketidakmampuan membuka kemasan
 Reasons for not following a prescription correctly

 …the number of drugs taken  Polytherapy

 …the frequency of doses
 …the cost of the medicine
 …the relationship between doctor and patient
 Factors Attributing to Poor Drug
Adherence in the Elderly Patient
 Multiple chronic disorders
 Multiple prescribers
 Multiple prescriptions
 Multiple doses
 Change in daily drug regime
 Cognitive or physical impairment
 Living alone
 Recent Hospital discharge
 Inability to pay for drugs
 Presence of side effects
 Factors that Promote
Drug Adherence
 Simplify regime
 Clearly explain treatment plan
 Choosing appropriate dosage form
 Label containers clearly
 Suggest a calendar, diary or pill counter
 Assure patient’s access to a pharmacy
 Assure affordability of medication
 Involve a family member or friend
 Monitor therapeutic responses, adverse
reactions and plasma drug levels
Polytherapy and adherence to treatment
what to do ?
 Polytherapy and adherence to treatment : what to
do?

time 7 8 9 11 12 13 16 19 20 21 22 23 24

drug
Pantoprazol 1
cpr
Gliclazide 1 1 1
cpr cpr cpr
Furosemide 1 1
cpr cpr
Ramipril 1
cpr
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Jakarta, 2003
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O’Mahony D, Gallagher P, STOPP & START criteria: A new approach to
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