Geriatric Pharmacology

By dr.absar ullah khan

INTRODUCTION
Physical therapists working with any patient population
must be aware of the drug regimen used in each patient.
Therapists must have a basic understanding of the beneficial
and adverse effects of each medication and must be
cognizant of how specific drugs can interact with various
rehabilitation procedures.
Polypharmacy
polypharmacy typically refers to the excessive or
inappropriate use of medications.
 Changes in Geriatrics
Multipathologies
Reduced organ function
Impaired homeostasis
Multiple subjective symptoms
 tendency of polypharmacy

4
Characteristics of Polypharmacy in Older
Adults
Characteristic
Use of medications for no apparent
reason
Use of duplicate medications
Concurrent use of interacting
medications
Use of contraindicated medications
Use of inappropriate dosage
Use of drug therapy to treat adverse
drug reactions
Patient improves when medications are
discontinued
Example
Digoxin use in patients who do not
exhibit heart failure
Simultaneous use of two or three
laxatives
Simultaneous use of a laxative and an
anti diarrheal agent
Use of aspirin in bleeding ulcers
Failure to use a lower dose of a
benzodiazepine sedative-hypnotic
Use of antacids to treat aspirin-induced
gastric irritation
Withdrawal of a sedative-hypnotic
results in clearer sensorium
Cardiovascular Drug Groups
Drug Group Primary Generic Name Trade Name
Indications
Angiotensin- Hypertension, Captopril Capoten
converting enzyme CHF Enalapril Vasotec
inhibitors Quinapril Accupril
b-Blockers Hypertension Atenolol Tenormin
Angina Metoprolol Lopressor
Arrhythmias Nadolol Corgard
Propranolol Inderal
Calcium channel Hypertension Diltiazem Cardizem
blockers Angina Nifedipine Adalat, Procardia
Arrhythmias Verapamil Calan, Isoptin
Diuretics Hypertension, Chlorothiazide Diuril
CHF Furosemide Lasix
Spironolactone Aldactone
Centrally acting Hypertension Clonidine Catapres
sympatholytics Methyldopa Aldomet
a-Blockers Hypertension Phenoxybenzamin Dibenzyline
e Minipress
Prazosin
Digitalis CHF Digoxin Lanoxin
glycosides
Sodium channel Arrhythmias Quinidine Cardioquin, others
blockers Lidocaine Xylocaine, others
Infection Drug Groups
Antibacterial Drugs
Aminoglycosides Gentamicin Garamycin; others
Streptomycin
Cephalosporins Cefaclor Ceclor
Cephalexin Keflex; others
Erythromycins Erythromycin Many trade names
Penicillins Penicillin G Bicillin, many others
Penicillin V V-Cillin K, many
Amoxicillin others
Ampicillin Amoxil, many
others
Polycillin, many
others
Sulfonamides Sulfadiazine Silvadene
Sulfisoxazole Gantrisin
Tetracyclines Doxycycline Vibramycin, others
Tetracycline Achromycin V,
Antiviral Drugs
Principal Indication
Herpesviruses Acyclovir Zovirax
Vidarabine Vira-A
Cytomegalovirus Foscarnet Foscavir
Ganciclovir Cytovene
Influenza A Amantadine Symadine,
Symmetrel
Human Delavirdine Rescriptor
immunodeficiency Didanosine Videx
virus (HIV) Efavirenz Sustiva
Nelfinavir Viracept
Ritonavir Norvir
Cancer Drug Groups
Major Groups Generic Name Trade Name
Alkylating agents Busulfan Myleran
Carmustine BCNU, BiCNU
Cyclophosphamide Cytoxan, Neosar
Mechlorethamine Mustargen
Antimetabolites Cytarabine Cytosar-U, others
Floxuridine FUDR
Fluorouracil Adrucil
Methotrexate
Plant alkaloids Paclitaxel Taxol
Vinblastine Velban, Velsar
Vincristine Oncovin, Vincasar
Antineoplastic Daunorubicin Cerubidine, others
antibiotics Doxorubicin Adriamycin, others
Idarubicin Idamycin
Hormone therapy for cancer
Estrogens Conjugated Premarin, others
estrogens
Estradiol
Antiestrogens Tamoxifen Nolvadex
Androgens Testosterone Many trade names
Antiandrogens Flutamide Eulexin
Biologic response Interferon a-2a Roferon-A
modifiers Interferon a-2b Intron A
Interleukin-2 Proleukin
Monoclonal Bevacizumab Avastin
antibodies Rituximab Rituxan
Tyrosine kinase Imatinib Gleevec
inhibitors Gefitinib Iressa
 1. EFFECTS OF AGE ON
PHARMACOKINETICS

12
 PHARMACOKINETICS
• “What the Body Does to the Drug”
– Absorption
– Distribution
– Metabolism
– Excretion

13
 Absorption
“Movement of drug from the site of administration into
the blood stream”
How does absorption occur ?
1. Passive diffusion:
• Absorption method for most drugs
• Energy independent
• Following concentration gradient
2. Active transport
• Energy dependent
• May opposite concentration gradient
3. Facilitated diffusion

14
 Influence of Age on Absorption
• Reduced gastric acid production
– May alter solubility of certain drugs  alter rate of
absorption
• Reduced bowel movement
– Delay or reduce absorption of basic drugs
– Increase absorption of acidic drugs
• Decreased blood flow
– Delay absorption

15
Drug Distribution
After a drug is absorbed into the body, it undergoes
distribution to various tissues and body fluid compartments
(e.g., vascular system, intracellular, and so forth.
Drug distribution may be altered
in older adults because of several physiological
changes such as decreased total body water, decreased
lean body mass, increased percentage body fat, and decreased
plasma protein concentrations
 DISTRIBUTION
 Distribution of drugs is much depends on body composition
 Change of body composition  change in Volume Distribution (Vd)

Young Adults Geriatrics

Body water 61% 53%

Lean body mass 19% 12%

Body fat 26-33 (women); 38-45 (women);

18-20 (men) 36-38 (men)
Serum albumin 4.7 g/dL 3.8 g/dL

17
Depending on the specific drug, these changes can affect how
the drug is distributed in the body, thus potentially
changing
the response to the drug.
For instance, drugs that bind to
plasma proteins (e.g., aspirin, warfarin) may produce a
greater response because there will be less drug bound to
plasma proteins and more of the drug will be free to
reach the target tissue.
Drugs that are soluble in water(e.g., alcohol, morphine)
will be relatively more concentrated in the body
because there is less body water in which to dissolve
the drug
Drug excretion
The kidneys are the primary routes for drug excretion from
the body
There is a linear reduction in renal functions with aging
in most patients, although not all.
Aging and common geriatric disorders can impair kidney
function
Leads to drug accumulation and toxicity if not
monitored,
especially for drugs that are excreted in active form
such as digoxin, lithium, aminoglycosides,
vancomycin etc.
 Effects of Aging on Drug Excretion
Reduction in number of functioning
nephrons/decreased glomerular filtration rate
Longer half-life of medications
Increased side effects
Increased potential for toxicity

21
 Pharmacodynamics

• “What the Drug Does to the Body”

• Generally, lower drug doses are required to
achieve the same effect with advancing age.
– Receptor numbers, affinity, or post-receptor
cellular effects may change.
– Changes in homeostatic mechanisms can
increase or decrease drug sensitivity.

22
 Pharmacodynamics (PD)
• Age-related changes:
  sensitivity to sedation and psychomotor impairment with
benzodiazepines
  level and duration of pain relief with narcotic agents
  drowsiness and lateral sway with alcohol
  HR response to beta-blockers
  sensitivity to anti-cholinergic agents
  cardiac sensitivity to digoxin
Summary of the physiological effects of aging that
may alter pharmacokinetics in older adults
Drug Administration

Absorption
Altered gastrointestinal function due to:
Decreased gastric acid decreased absorbing area

Decreased stomach emptying decreased motility

Distribution
altered due to
Decreased body water Decreased lean body mass
Increased body fat Decreased plasma proteins
 Hepatic Metabolism
Altered due to:
Decreased Liver mass
Decreased Liver blood flow
Decreased Enzyme activity
Renal Excretion
Altered due to
Decreased Kidney mass
Decreased Kidney blood flow
Decreased Tubular function in nephron
 PHARMACODYNAMICS
The Impact of Aging on pharmacodynamics
Higher sensitivity of receptors to CNS drugs
Decreased homestasis  risk of orthostatic hypotension in
response to antihypertensives
Multipathology  polypharmacy  drug interaction

Benzodiazepines may cause more sedation and poorer

psychomotor performance in older adults.
morphine produces longer pain relief but danger is increased
for respiratory depression

26
 Polypharmacy leads to:
More adverse drug reactions
Drug-drug interaction
Decreased adherence to drug regimens
Poor quality of life
High rate of symptomatology
(Unnecessary) drug expense

27
 Risk rises exponentially as the number of
drugs increases

100
percent of patients with ADR

10

1
0 2 4 6 8 10 12 14 16 18 20
number of drugs taken

28
 • Drug reactions in the elderly often produce effects
that simulate the conventional image of growing
old:

unsteadiness drowsiness
dizziness falls
confusion depression
nervousness incontinence
fatigue malaise
insomnia

29
 • Drugs most frequently associated with adverse
reactions in the elderly:
– psychotropic drugs-benzodiazepines
– anti-hypertensive agents
– diuretics
– digoxin
– NSAIDS
– corticosteroids
– warfarin
– theophylline

30
 Principles of Prescribing for Elderly

• Balance between overprescribing and

underprescribing
– Correct drug
– Correct dose
– Targets appropriate condition
– Is appropriate for the patient

Avoid “a pill for every ill”

Always consider non-pharmacologic therapy

31
 Principles of Prescribing for Elderly
• Uses the correct drug
– Be as specific as possible and be cognoscente of drug-drug
and drug-disease interactions.
• Prescribes the correct dosage
• Start low and advance dosage slowly.
• Use proper interval between dosing
• Avoid drugs that affect multiple organ systems if
possible, be specific
• Use drug that is appropriate for your patient
• Failure in any one of these can result in adverse drug
events (ADEs)
32
 Principles of Prescribing for Elderly
• If possible, avoid prescribing an additional drug to
treat an adverse drug event.
• Adverse effects are frequently dose related so adjust
dose!!
– Discontinue or lower the dosage of the compounds that the
patient is taking first before adding more compounds.
• Have a high index of suspicion that this new
condition may be iatrogenic induced!
• Any new symptom or condition in an elderly patient
should be considered a drug side effect until proven
differently!!!

33