ELDERLY

• Elderly (>65) comprise 12% of the population

• consume 33% of all prescriptions
• occupy 50% acute-care hospital beds
• Elderly (>85) comprised the fastest growing segment of US population
during the 1990s.
• Drug use in elderly nursing home patients is high
• Average number of medications per patient = 8.1
• 65% are prescribed at least one psychoactive medication.
• Survey: 40% of 1106 nursing home residents received at least one, and 10% received
two inappropriate medications.*
Physiologic changes of aging
• Many body systems are affected by the aging process
• Visual impairment in 12%, hearing impairment in 28% of elderly.
• Respiratory: Vital capacity and FEV decline linearly with age
• GI: dysfunction in GI motility due to pathology vs. age. Constipation due to diet, physical
inactivity, drugs
• GU: up to 48% nursing home residents are incontinent, due to detrusor instability,
overflow incontinence, sphincter weakness
• also sexual dysfunction, BPH may occur
• Musculoskeletal: 30% loss of muscle tissue from age 30-80. Osteoarthritis secondary to
lifetime stresses of joint use.
• Peripheral Vascular System: Atherosclerosis and decreased elasticity of vessel walls,
major contributors to hypertension.
Physiologic changes of aging
• Psychiatric conditions
• Depression is the most frequent psychiatric disturbance.
• life stresses: family changes, loss of bodily functions, illnesses, change in living quarters
• increased central MAO activity and decreased NE activity
• sleep disorders
• dementia in 10% of elderly, up to 22% in elderly >80.
• structural and functional brain changes (Alzheimer’s disease)
• multiinfarct dementia secondary to hypertension/stroke
• secondary to other disease state (Parkinson’s disease)
• delerium is experienced by 25-30% hospitalized elderly
• secondary to aging processes, brain damage, disease, sensory impairment, drugs, infection
 Absorption
• Gastrointestinal tract most common absorption site.
• Decrease in number of gastric and parietal cells lining GI tract.
• Decrease secretions, e.g. saliva, gastric
• Results in increase gastric pH, achlorhydria or hypochlorhydria
• Decreased gastric motility and sphincter activity
• Delayed gastric emptying
• Mesenteric blood flow may decrease by up to 40-50%, atrophy of micro- and
macrovilli of mucosa
• Active transport system may be impaired
• Decreased hepatic blood flow, less first-pass removal
 Drug Distribution
• Volume of distribution of drugs in the elderly will be affected by
changes in
• blood flow
• plasma protein binding
• decrease in serum albumin
• increase in alpha-1-acid glycoprotein
• body composition
• decrease in total body water by 10-20%
• decrease in lean body mass by 25-30%
• increase in body fat
• males increase 84%, females increase 48%
 Clinical Significance?
• Water soluble drugs will have a smaller VD and thus greater serum
levels.
• aminoglycosides, ethanol, morphine

• Lipid soluble drugs will have a greater VD and thus lower serum levels.
• Diazepam, thiopental, most psychotropics except lithium, oxazepam, lorazepam

• Changes in VD will affect amount of drug needed for a loading dose, or

time needed to achieve steady state.
• Large VD = longer time to steady state and higher loading dose needed.
• Must be cautious with CNS drugs, e.g. benzodiazepines, and sensitivity in elderly
 Metabolism
• Rate of metabolism of drugs is influenced by nutrition, drugs,
diseases, smoking, serum albumin, hepatic function and age
• 1% annual reduction in hepatic blood flow after 25
• 1% annual decrease in liver mass
• Phase I metabolism (hydrolysis, oxidation, reduction), primarily
oxidation, declines with age.
• Thought due to decrease liver mass, not enzymatic activity
• Phase II metabolism (conjugation) is relative unaffected by age.
 Elimination
• Renal function may decline by 40-50% with age
• Kidney mass decreases by 10-20% by age 80.
• GFR decreases by 1ml/min/year from age 20-90.
• decreased cortical perfusion rate and filtration pressure, atrophy, vascular lesions of
small arteries, loss of glomeruli.
• Renal plasma flow decreases by 1-2% per year from age 20-90.
• Decrease in renal blood flow exceeds the decrease in cardiac output.
• compounded by various disease states, eg. CHF, hypotension.
• Tubular function decreases in proportion to GFR.
 Clinical Significance?
• SCr often remains stable, but CrCl measurements must consider
decrease in lean body mass.
• CrCl (ml/min) = (140-age)(IBW/72 x SCr) F=CrCl(.85)
• 24 hour urine collection will be more accurate
• Drugs which are excreted unchanged by the kidney may accumulate
even in “normal” dosing and should be carefully monitored.
• Aminoglycosides, digoxin, lithium (low TI), gabapentin
• Decreased tubular function is important for drugs which are
eliminated by tubular secretion
• penicillin, cimetidine, lithium
 Clinical Significance?
• Aminoglycoside dosing
• Use Ideal Body Weight to estimate lean mass
• IBW(male) = (height in inches-60) x 2.3 +50 kg
• IBW(female) =(height in inches-60) x 2.3 + 45 kg
• Adjust upward for increase extracellular fluid volume
• Adjust downward for decreased extracellular fluid volume
• Monitor for ototoxicity, nephrotoxicity
• Monitor drug levels with conventional and once-daily regimens
• Consult your clinical pharmacist for recommendations