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May Not be Suitable for all Ages

May Not be Suitable for all Ages. Overview of drug effects in the geriatric population Alicia Ridgewell Northern Health Pharmacy Resident August 2011. Outline. Learning Objectives Definitions/Background Patient case Goals of therapy Recommendations Monitoring Summary.

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May Not be Suitable for all Ages

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  1. May Not be Suitable for all Ages Overview of drug effects in the geriatric population Alicia Ridgewell Northern Health Pharmacy Resident August 2011

  2. Outline • Learning Objectives • Definitions/Background • Patient case • Goals of therapy • Recommendations • Monitoring • Summary

  3. Learning Objectives • Understand what is meant by the terms: poly-pharmacy, pharmacokinetics, pharmacodynamics and geriatric population • Outline the issues around the aging body and the effects of medications • Identify medications to be wary of in the geriatric population, including adverse effects to watch for

  4. Definitions • Geriatric population • ‘Older adult’ = ≥ 65 yrs • ‘ Elderly adult’ = ≥ 70 yrs • ‘Frail elderly’= ≥ 85 yrs • Polypharmacy • Pharmacokinetics • Pharmacodynamics

  5. Problems with Polypharmacy • Geriatric population tend to have more medical conditions • More medications = risk for adverse reactions • Drug- drug interactions • ‘Prescribing cascades’ • Adherence issues

  6. Pharmacokinetic/dynamic Changes • Physiological changes of organ systems that alter drug metabolism, excretion and response • i.e. changes in receptor sensitivity, renal and hepatic function • Decreased ability to maintain homeostasis • Increased susceptibility to disease symptoms and medication adverse events

  7. Medication Adverse Effects • Movement disorders / Balance concerns • Incontinence • Cognitive impairment • Insomnia • Delirium • Agitation • Hallucinations • Depression

  8. Common Offending Medications • Antihistamines i.e. diphenhydramine • Antiparkinson agents i.e. Benztropine • GI antispasmodics i.e. Dicyclomine • Antidepressants i.e. Amitriptyline • Benzodiazepines i.e. Diazepam (long-acting) • Short-acting benzos should be used sparingly at conservative doses • Antipsychotics i.e. Haloperidol, Loxapine

  9. Common Issues in Dementia • Agitation • Aggression • Psychosis (delusions/hallucinations) • Wandering • Depression • Sleep disorders

  10. Patient Case: HH

  11. Course in Hospital

  12. Course in Hospital

  13. Delirium • Risk Factors • i.e. Age, medications, history, comorbidities • Common Causes • i.e. drugs, infection, pain, acute disease, exacerbation of chronic disease, substance abuse • Protocol at GR Baker

  14. Antipsychotics in Dementia • Typical vs. Atypical • i.e. haloperidol, chlorpromazine, loxapine vs. risperidone, olanzapine, quetiapine • Side effects • EPS, TD, weight gain, diabetes, hyperlipidemia • Efficacy • Lack of well done, long term studies • Mortality/Stroke risk • Place in practice

  15. Goals of Therapy • Prevent mortality • Decrease agitation and aggression (behavioural issues) • Minimize risk to self and others • Minimize adverse effects from medications • Decrease medication load

  16. Recommendations • Aug 18: Reviewed by Elderly Care team • Recommendations: • Discontinue Benztropine • Discontinue prn metoclopramide and haloperidol • Begin taper of haloperidol • Dr. Fine in agreement

  17. Monitoring

  18. Patient Case - Update • Since medication changes made: • One episode of calling out and trying to pull gown off • Writer states patient easily re-directed • Sleeping well • No concerns/issues with agitation or aggression documented • Next step: further taper of haloperidol

  19. Summary • Always suspect a medication • Be wary of ‘beers criteria’ medications and use with caution • Reserve prn orders for behavioural issues as last resort • Re-evaluate need for antipsychotic medications

  20. Questions?

  21. References • Koda-Kimble MA et al. Handbook of Applied Therapeutics. 8th ed. Lippincott Williams & Wilkins. Philadelphia USA. 2007.p.97.1-97.8 • http://www.update.com/contents/drug-prescribing-for-older-adults?view=print • http://www.update.com/contents/treatment-of-behavioral-symptoms-related-to-dementia?view=print • http://www.update.com/contents/first-generation-antipsychotic-medications-pharmacolgy-administration- and-comparative-side-effects?view=print • http://www.update.com/contents/second-generationantipsychotic -medications-pharmacolgy-administration- and-comparative-side-effects?view=print • Network of Excellence for Geriatric Services. Best Practices for Nursing Care of the Older Adult. Northern Health CPG. Delirium. 2005

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