Geriatrics as Patients general overview. There are several considerations when working with geriatric patients. Along with physical changes, there are also pharmacokinetic and pharmacodynamic changes as well. These changes impact the approach to pharmacotherapeutics. Geriatric patients sometimes have unique demographics and experience transitions of care and care settings that can also impact their treatments. Lastly, there are some general principles of prescribing to be followed when treating older adults.
The geriatric population is the fastest growing segment in the U.S. population. By 2030, approximately one-fifth of the population will be over 65 years of age. Despite the elderly only making up 13% of the population, they account for 30% of prescription drug use. Polypharmacy is common in this population. Emergency visits for adverse drug reactions (ADRs) more common in older adults than younger adults. Functional status changes often make medication management difficult.
Physical Changes Associated with Aging
- Mental changes
- Increased susceptibility to delirium and cognitive side effects of drugs
- Sensory changes
- Sight: One-third of older adults have visual impairment.
- Hearing: One-third of older adults have hearing impairment.
- Smell and taste: Diminished smell and taste may impair nutrition; compounded by medications.
- Peripheral sensation: contributes to fall risk; compounded by medication
- Musculoskeletal changes
- Impaired manual dexterity
- not dramatically different in older adult compared to younger adult
- increased fat stores, decreased total body water and serum albumin
- decreased hepatic blood flow, decreased CYP 450 system function
- decreased renal mass and glomerular filtration rate and tubular secretion; serum creatinine is an unreliable marker of renal function
- Reduced homeostatic mechanisms
- Altered receptor sensitivity
- Increased sensitivity to drugs
As previously mentioned, geriatric patients are at high risk for ADRs. There are multiple reasons for this concern. There is a high incidence of non-adherence with treatments although it may be either intentional or unintentional. Unsafe medication practices such as taking all medications at one time may also play a role. There is a high prevalence of use of over-the-counter (OTC) and herbal therapies. With the existence of polypharmacy there is a greater risk of drug-drug interactions and the need to use one drug to treat side effects of another. One reason this population experiences polypharmacy is the prevalence of comorbidities. However, as a provider, remain vigilant of other medications in use when prescribing additional drugs to any patient.
General Principles for Prescribing for Older Adults
- Before prescribing collect a “complete” drug history; revisit at least every 6 months.
- Avoid a drug if benefit is only marginal.
- Evaluate drug list for duplications.
- Review drug list for ADRs and query patient.
- Prescribe nonpharmacological treatments whenever possible.
- Ensure patient symptom not part of normal aging.
- Make risk predictions.
- Start low, go slow.
Beer’s criteria is a guiding foundation that should be used when prescribing medications to geriatric patients. The American Geriatrics Society updated this list in 2019. This information can be found in print online through a web search. There is an app that can be downloaded for free but access to the Beer’s list requires a paid subscription to the American Geriatric Society. In addition to Beer’s criteria, there is also STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) that can be utilized for safe prescribing of older adults. These tools are explicit criteria that facilitate medication review in multi-morbid older people in most clinical settings. General rules of drugs to avoid include those that:
- Have narrow therapeutic ranges
- Have slow elimination rates
- Totally depend on kidney excretion
- Have high drug-drug interactions
- Have high ADR profiles
Guidance that can be provided to geriatric patients and their families can make a meaningful impact for some. Any patient who takes multiple medications should carry a medication list that include allergies and ADRs. Even more helpful is for patients to create the habit to bring their medications in a bag to each visit. A brown bag or non-transparent bag should be encouraged to protect privacy. Pill boxes can be very helpful is assuring patients take the right medication at the right time. If the patient is having trouble remembering when to take medications, there are pill boxes with alarms and various features to help aid in assuring dosing at the right time. Each time a patient moves to a different level of care such as moving from hospital to long term care or hospital to home health, there should medications should be reconciled. Additionally, if a patient is seen for post-hospital follow up, medications should be reviewed and reconciled as new or different medications are often prescribed.
When assessing geriatric patients, it is important to complete a functional assessment. Medicare includes functional assessments in their required annual wellness assessment. A patient’s ability to manage activities of daily living (ADLs) and cognitive status are strong indicators of their ability to manage their medications. When assessing ADLs, there are some standardized tools that can be used such as the Katz ADLS or the Lawton instrumental activities of daily living. Assessment of vision and hearing are also important key elements to self-care as well. The availability of a social support system is also important to assess. Cognitive status assessments can be performed with tools such as the Geriatric Depression Scale for depression, Mini-Mental State Examination, or Mini-Cog. Medication management assessment tools include: Medication Management Ability Assessment, Medication-Assisted Treatment.
When suspicion occurs that medication regimens are not followed, there are some important assessments to be done. Assess potential causes on unintentional non-adherence. Perhaps the patient is not able to afford their medication or perhaps they do not have transportation to pick up medications from the pharmacy when they need refills. Additionally, a functional assessment as discussed above may reveal reasons a patient is physically or cognitively having difficulty adhering to a treatment plan. A home assessment for frail older adults may also be warranted. Mobile applications used for clinical decision making as well as many electronic health records will flag prescribers when there is a concern for drug-drug or drug-food interactions or duplications. However, collaboration with pharmacists whenever there is a question is always a good idea. Pharmacists are an important part of the healthcare team.
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