Physical and Sensory Changes in the Older Adult: Considerations for Medication Management

Transcription

1 Physical and Sensory Changes in the Older Adult: Considerations for Medication Management Amber M. Hutchison, PharmD, BCPS Assistant Clinical Professor Auburn University Harrison School of Pharmacy

2 Disclosure/Conflict of Interest I, Amber M. Hutchison, have no actual or potential conflict of interest in relation to this program.

3 Objectives Review age related considerations for pharmacokinetic and pharmacodynamics changes in the older adult population. Describe how age related sensory changes affect an older adult s ability to self manage medications. Simulate age related sensory changes experienced by an older adult population.

4 What does aging look like to you?

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8 Older Adults: The Growing Population By 2030, 20.3% of the US population is expected to be >65 years of age Increase from 13.7% in 2010 and 9.8% in 1970 By 2030, all of the baby boomers will be considered to be older adults The population >85 years will double by 2036 and triple by 2049 Ortman JM. An Aging Nation: The Older Population in the United States.

9 Dependency Ratios in the US Adapted from: Ortman JM. An Aging Nation: The Older Population in the United States.

10 Pharmacotherapeutic Considerations Physical changes Pharmacokinetic changes Pharmacodynamic changes

11 Physical Changes Swallowing difficulties Poor nutrition Dependence on feeding tubes Visual disturbances Arthritis Sensory changes Decreased lung function Wooten JM. South Med J. 2012;105(8):

12 Pharmacokinetic Changes Absorption Distribution Metabolism Excretion

13 Absorption Reduced gastrointestinal (GI) motility Possible increased drug absorption Reduced gastric acid secretion increased gastric ph Reduced drug absorption Reduced gastric blood flow Reduced drug absorption Drugs with first pass metabolism may have increased absorption Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

14 Distribution Volume of distribution (Vd) affected Decreased albumin levels Highly protein bound drugs increased concentration of drug Increased proportion of body fat Fat soluble drugs increased Vd Drugs distributed to muscle decreased Vd Possible decrease in total body water Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

15 Metabolism Changes in the liver Decreased hepatic blood flow Decreased hepatic metabolism by decreased activity in oxidase system Decreased liver mass Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

16 Knowledge Check Your 73 year old patient is on drug A which requires an acidic environment for absorption. What may happen to the drug absorption in this elderly patient? A. Increase B. Decrease C. No effect

17 Knowledge Check Your 82 year old patient is on drug B which is highly protein bound. What may happen to the drug distribution in this elderly patient? A. Increase B. Decrease C. No effect

18 Knowledge Check Your 79 year old patient is on drug C which is fat soluble. What may happen to the drug distribution in this elderly patient? A. Increase B. Decrease C. No effect

19 Excretion Renal elimination Decreased GFR Decreased renal blood flow Estimates of CrCl Cockcroft Gault MDRD Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

20 Equations to Estimate CrCl Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

21 CrCl Estimations Weight to be used: If actual body weight (ABW) is less than ideal body weight (IBW), use ABW In patients with normal ABW, use IBW In obese patients, use a factor of 0.4 to calculate an adjusted body weight Winter, MA, et al. Pharmacotherapy. 2012; 32(7): Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

22 CrCl Estimations IBW calculation Men: IBW = kg (every in >5 ft) Women: IBW = kg (every in >5 ft) Adjusted body weight calculation AdjBW = IBW (TBW IBW) Winter, MA, et al. Pharmacotherapy. 2012; 32(7): Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

23 A Note about CrCl Estimations SCr depends on albumin Common practice is to round up SCr values for older adults This may not be the best estimate of CrCl in elderly patients Winter, MA, et al. Pharmacotherapy. 2012; 32(7): Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

24 CrCl Estimations n=12 CrCl Mean +SD (ml/min) 24 hour CrCL CrCl Estimations in Patients >65 years with SCr <0.8 mg/dl Mean Difference (95% CI) (ml/min) Pearson s Correlation (r) Actual SCr CrCl ( ) P value Rounded SCr CrCl ( 31.6 to 0.8) Adapted from: Winter, MA, et al. Pharmacotherapy. 2012; 32(7):

25 CrCl Estimations n=12 CrCl Mean +SD (ml/min) 24 hour CrCL CrCl Estimations in Patients >65 years with SCr <1 mg/dl Mean Difference (95% CI) (ml/min) Pearson s Correlation (r) P value Actual SCr CrCl ( ) Rounded SCr CrCl ( 35.1 to 9.9) <0.001 Adapted from: Winter, MA, et al. Pharmacotherapy. 2012; 32(7):

26 Calculate the CrCl for a 79 year old male pt with SCr=1.1. Pt is 5 11 tall and weighs 180 pounds.

27 Calculate the CrCl for a 79 year old female pt with SCr=1.1. Pt is 5 11 tall and weighs 180 pounds.

28 A Note about CrCl Estimations Consider: Reviewing the literature of the drug manufacturer and determine how CrCl was calculated in trials Consider calculating CrCl rounded and not rounded and evaluate the patient Winter, MA, et al. Pharmacotherapy. 2012; 32(7): Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

29 Pharmacodynamic Changes Altered Number of receptors Receptor affinity Second messenger function Cellular response Cellular nuclear response Wooten JM. South Med J. 2012;105(8): Miller SW. Therapeutic Drug Monitoring in the Geriatric Patient

30 SECURE Project Activity

31 SECURE Project Developed by Lee Memorial Health System in Fort Meyers, Florida Designed to be used for a wide range of experiences Medical personnel Non medical personnel Including workers in sales, etc. Simulates sensory changes in the older adult

32 First Activity Eye Troubles Take out glasses 1, 2, and 3 Try reading the newspaper article Take out your phone and try to read the phone screen Take out glasses 4 Again, try reading the package insert and your phone screen Look at your neighbors Use the printed Number Card Game trace from 1 through 10

33 First Activity Eye Troubles Take out glasses 5 and put them on Open the pill bottle, sort out these tablets : One white Two green Two blue Two yellow Try reading the package insert Take out your phone and try to read the phone screen

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37 First Activity Eye Troubles Glasses simulation Glasses #1: Glaucoma Glasses #2: Macular degeneration Glasses #3: Hemianopsia Glasses #4: Cataracts Glasses #5: Age related yellowing of the lens

38 Other Eye Issues Age related vision changes: Decreased ability to see objects clearly Decreased ability to focus on objects at varying distances The need for more lighting in order to function Decreased ability to perceive depth Slow accommodation to changes in light sensitivity Decreased ability to discriminate colors in the blue green violet range

39 Eye Issues: How can we help? Have a system for identifying medications besides just color Avoid glare areas use blinds More light on signs Use large print for handouts and signs Bold print for publications Avoid printed materials in bluegreen violet range Use yellow background with red print

40 Eye Issues: How can we help? Place mats or tablecloth in contrasting color from tableware Have curbs, edges of steps, handrails, door knobs, etc. marked in contrasting colors Stand close to the older person and use touch Utilize high intensity light for reading areas

41 Hearing Loss Issues Video inglosssimulator hlsimulation/

42 Hearing Loss Issues How can we help? May try to lower pitch of your voice Face the person who you are speaking to Speak at a distance of 3 6 feet Use touch to get the person s attention Enunciate your words slowly and clearly Keep sentences short and simple Eliminate background noises

43 Impaired Manual Dexterity Take out the gloves Sort out the pills Open a safety pin Button a button on your shirt or blouse Take off a earring or watch Remove a card from your wallet or purse Use your phone For more fun: put on the gloves and glasses TOGETHER Try to do all of the activities above

44 Useful Tools for Managing Therapy in Older Adults Explicit criteria Beers Criteria START STOPP ASCP Drug Regimen Review Checklist Elliott DP. PSAP. 2011;

45 Beers Criteria Most recently updated in 2015 Applicable for all older adults except those in palliative and hospice care List of potentially inappropriate medications (PIM) Medications are included if there is a poor risk to benefit ratio 2015 AGS Updated Beers Criteria. J Am Geriatr Soc. 63(11):

46 Beers Criteria Five tables summarizing recommendations: Medications to avoid in older adults Medications to avoid in older adults with certain disease states Medications to be used with caution in older adults Important drug drug interactions in older adults Medications requiring adjustments based on kidney function 2015 AGS Updated Beers Criteria. J Am Geriatr Soc. 63(11):

47 Beers Criteria Provides rationale against use Helpful for report of irregularities to physician Gives recommendation May recommend complete avoidance or avoiding drug in certain circumstances Classifies quality of evidence Rates strength of recommendation 2015 AGS Updated Beers Criteria. J Am Geriatr Soc. 63(11):

48 START Tool Screening Tool to Alert doctors to Right Treatment Designed to address errors of omission Factors contraindications into recommendation Arranged by organ system Article reports 57.8% of patients had one or more medications omitted Barry PJ, et al. Age Ageing. 2007;36:

49 Selected START Criteria Organ System CV System Respiratory System Recommendation Warfarin in the presence of chronic atrial fibrillation, where there is no contraindication to warfarin Inhaled steroid in mod severe asthma or COPD, where reversibility of airflow obstruction has been shown. Locomotor system Bisphosphonate in patients taking glucocorticoids for >1 month (i.e. chronic corticosteroid therapy). Endocrine System Aspirin therapy in diabetes mellitus with well controlled blood pressure Barry PJ, et al. Age Ageing. 2007;36:

50 STOPP Tool Similar in intent to Beers criteria Screening Tool of Older Persons Prescriptions Designed to address potentially inappropriate medications 65 criteria included in the tool Arranged by organ system Includes a recommendation and italicized rationale Hamilton HJ, et al. BMC Geriatr. 2009;9:5.

51 Selected STOPP Criteria Organ System Recommendation Rationale CV System Calcium channel blockers with chronic constipation May exacerbate constipation CV System Aspirin at dose >150 mg/day bleeding risk, no increased efficacy CNS and Psychotropics GI System TCA s with cardiac conductive abnormalities Diphenoxylate, loperamide or codeine phosphate for treatment of diarrhea of unknown cause Pro arrhythmic effects May delay recovery in unrecognized gastroenteritis Adapted from: Hamilton HJ, et al. BMC Geriatr. 2009;9:5.

52 ASCP Drug Regimen Review Checklist Available from: /upload/drr%20checklist.pdf Elliott DP. PSAP. 2011;

53 ASCP Drug Regimen Review Checklist Drug Indications Does each prescribed medication have a current and valid indication? Does the resident have conditions or indications for which medications may be appropriate or are not being used? Medication effectiveness Is the medication appropriate for the indication being treated? Is the dose of medication adequate? Elliott DP. PSAP. 2011;

54 ASCP Drug Regimen Review Checklist Medication Safety Is the dose of medication excessive? Is the resident experiencing signs or symptoms of adverse medication effects? Is the resident experiencing a problem resulting from a drug drug, drug food, or drug laboratory test interaction? Medication Monitoring Are monitoring parameters in place to evaluate medication effectiveness and safety? Do results of medication monitoring indicate a need for intervention? Elliott DP. PSAP. 2011;

55 ASCP Drug Regimen Review Checklist Medication Errors Is there evidence of a medication error? Medication Cost Do any issues related to medication cost need to be addressed? Elliott DP. PSAP. 2011;

56 Physical and Sensory Changes in the Older Adult: Considerations for Medication Management Amber M. Hutchison, PharmD, BCPS Assistant Clinical Professor Auburn University Harrison School of Pharmacy