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What are some contributing factors for drug complications in the elderly?
- Altered pharmacokinetics – Adverse drug reactions
- Multiple illness: More illness=more complication.
- Multiple drug therapy—Polypharmacy
- Poor compliance: Causes problems if not completed.
- Medication Errors
- Inappropriate prescribing
- Excessive drug costs
- Adverse drug rxn=any unintended effect of the drug.
- Polypharm: meds and vitamins are usually taken handfuls at a time.
- Medication errors: one of the top reasons people are admitted
- Inappropriate prescribing: Many Dr. don’t yet utilize electronic medical records, so drug mixups and contraindications can occur due to lack of information.
- Excessive drug costs (Plavix just went generic. Decreases “stickiness” of RBCs--> reduced blood clots. Will drop cost of drug.)
Altered pharmacodynamics in the elderly...
- Decreased percentage of sub q fat
- Increased percentage of body fat.
- Decreased percentage of body mass: Lost muscle tissue.
- Decreased total body water: Increases chance of toxicity.
- Reduced concentration of serum albumin: decreased absorption of Rx.
- Decreased hepatic metabolism: Decreased metabolism of Rx--> more active drug in system.
- Reduced renal excretion--> stays in system for longer
- Moral of the story: Decrease Dose, Decrease frequency.
How is checking for renal function different in the geriatric population?
In the elderly, the proper index of renal function is creatinine clearance
not serum creatinine.
- Timed test (12-24hr collection). How much creatinine is collected during that time?
- Dependent upon having ALL the urine samples.
- Serum levels and clearance levels should be roughly equal. Must then also have creatinine serum level.
- If not clearing, think toxicity.
Issues with Adverse Drug Reactions in the Elderly?
- Seven times more likely in elderly
- 16% of hospital admissions over 65 yrs.: Due to adverse drug rxn
- 50% of all medication-related deaths : Due to adverse drug rxn
- Elderly more likely to have:
- Confusion: More likely not to take, take wrong way, etc.
- Poor vision: Takes the wrong one(s) by mistake.
- Poor memory: Forgets to take. Need to take some kind of adaptive device to help remember when to take.
- Inappropriate dosing: Less Rx, longer interval.
- Drug-drug interactions: If taking lots of Rx, almost ensures interactions
- Polypharmacy: Multiple drugs taken together.
- Noncompliance: For all the reasons above, and also because sometimes they just don't want to.
St. John’s Wart: Increases bleeding time, interacts with lots of stuff. Something good to ask about specifically.
How do you monitor for adverse drug reactions?
- Take thorough drug history
- Lowest dosing
- Plasma level monitoring: Getting to therapeutic dose?
- Simplest regimen
- Review drug treatment schedule
How do you promote compliance with your elderly patients?
- Keep the drug regimen simple.
- Verbal and written instructions: Need to actually review what the medication is, how to take it, how to take it with the other medications they’re taking, etc... And write it down for them.
- Appropriate dosage form
- Clear labeling:Why, when, side effects, etc.
- Daily reminders: Need to be able to track what they have/have not taken. Work into their ADLs.
- Support system: Needs to be physically present with the pt.
- Frequent monitoring: Make sure they go for “well checkups.”