Pharmaceutical Care for Geriatrics

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1 Continuing Professional Pharmacy Development Program Pharmaceutical Care for Geriatrics Presented by: Alla El-Awaisi; MPharm, MRPharmS, MSc Event Organizer: Dr. Nadir Kheir; PhD Disclaimer: PRESENTING AUTHORS HAS NO RELATIONSHIPS TO DISCLOSE Introduction Outline Dr Nadir Kheir, Assistant Professor & Coordinator of Continuing Professional Pharmacy Development Pharmaceutical Care for Geriatrics Alla El-Awaisi, Clinical Pharmacist, Qatar University. Home Healthcare pharmacists Sabah Khalifa, Clinical Pharmacist, HMC Small group discussions Cases presentation Concluding remarks Learning Outcomes By the end of this Workshop, you will be able to: 1. Discuss the ageing process and its impact on drug therapy. 2. Describe the general guidelines for prescribing for geriatric patients. 3. Implement strategies to resolve medication related problems in geriatric patients. 4. Undertake a medication review for a geriatric patients. 5. Provide practical steps to improve medication compliance in geriatric patients.

2 Geriatric Definition: Age 65 years or older How other look at an older person? Chronological Age Biological Age Psychological Age Life Expectancy Rise Qatar- Life Expectancy

3 Specific Therapeutic Challenge of Prescribing in Geriatrics Why is Polypharamcy so common in Geriatrics? Altered responses to therapy Multiple pathology Polypharmacy Adverse drug reactions Compliance Increasing age More diagnoses Polypharmacy Prescribing for Older patients 1 Inappropriate prescribing Excessive amount Inadequate clinical indication Excessive duration of treatment Prescribing for Older patients 2 Medication- related problems Non-compliance Adverse drug reactions (ADRs) Drug interactions

4 Non-compliance associated with dose form & packaging Lose faith in health service Worsening of disease signs and symptoms Prolonged patient suffering Factor Packaging Examples Some containers may be too small or large for the older patient to handle Child- resistant caps may be difficult to remove especially by arthritic patients. Unable to manage blister packaging Implications of noncompliance Liquids May be easier to manage if a tablet is hard to swallow Measuring of 5ml spoonsful may be difficult for some older people (e.g. those with Parkinson disease) Glass bottles may be heavy for frail older patients to lift Palatability If not palatable, the patient may not take medicine Patient preserve therapy as ineffective Additional physician visits Unnecessary hospitalization Tablet size Non-oral dosage forms Change in appearance If size is too small, the patient may have difficulty in picking it up If the size is too big, they may find it hard to swallow May not be easy to administer, e.g. inhalers, eye drops, suppositories May not be as acceptable to administer, e.g. suppositories Potential cause of non-compliance if not warned or counselled about change, e.g. different generic tablet Factors that significantly increase risk of a geriatric suffering from ADR Examples of common ADR in Geriatrics Polypharmacy Female gender Small body size Hepatic or renal insufficiency Previous adverse drug reactions. Type of drug Hypnotics Diuretics NSAIDs Opioid analgesics Anticholinergic Long acting oral hypoglycemics Antidepressants Common side effect Excessive sedation, hangover effect, falls, confusion Dehydration, incontinence, electrolyte disturbances Upper GI upset, GI bleeding, oedema and heart failure Constipation Confusion, dry mouth, constipation, urinary problems Hypoglycemia Hyponatremia 11/02/2013 CPH-CPPD 5 (AE)

5 Examples of different types of drug interactions and their consequences Type of interaction Pharmacokinetic drug-drug Pharmacodynamic drug-drug Drug- nutritional status Drug- herbal product Drug- alcohol Drug- disease Example Mechanism of action Outcome Ciprofloxacin and olanzapine Anticholinergic and donepezil Low albumin and phenytoin Gingko and aspirin Alcohol and chronic use of benzodiazepines Metoclopramide in parkinson disease Cipro inhibits CYP1A2 leading to an increase in plasma concentration of olanzapine Antagonism Increase in free phenytoin concentration Decrease in platelet function and adhesion Synergy Increase in dopamine receptors blockade Rigidity, falls Decreased effect of donepezil confusion, somnolence, ataxia Increased risk of bleeding Increased sedation increased sedation and risk of falls Worsening of Parkinson s disease 17 Falls cause fractures!!!! Falls Statistics Consequences of falls 1/3 to ½ of >65 year olds in community fall each year (many more than once) Risk of falling increases with age Falls can cause fractures 1 in 20 Osteoporosis > 50 years -1 in 3 women An osteoporotic fracture every 2-3 minutes 50% of hip fracture pts. lose their independence Mortality Injury and Disability Health Care Costs

6 Principles of medication review Indication Appropriateness Dosage Directions Concomitant medical illness Compliance Adverse drug reaction Side effect treated with another Drug interactions Unnecessary duplication Duration Other Effective interventions Role of carers Education and training Nursing/ residential homes Primary/ secondary care interface Medication review strategies Medication review strategies Various strategies have recently been developed to identify older patients at risk from adverse effects and to reduce the risk of initiating drugs likely to cause adverse events Beers criteria for potentially inappropriate medication use in older adults: 1991, 1997, 2003 updated 03/2012 STOPP and START Criteria STOPP (Screening Tool of Older Peoples Potentially In-appropriate Prescriptions) Comprises 65 clinically significant criteria for potentially inappropriate prescribing in older people. Each criterion is accompanied by a concise explanation as to why the prescribing practice is potentially inappropriate. Examples: NSAIDS, especially heart failure and renal disease Sedatives, in particular benzodiazepines Opiate analgesia Warfarin and anti-platelet combinations Age and Ageing 2008, Gallagher P, O Mahoney D

7 Medication review strategies Strategies to improve compliance START (Screening Tool to Alert doctors to Right Treatment) Simplification Consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. Understanding patient s perspective information Examples: Warfarin in Atrial fibrillation Bisphosphonate for those on glucocorticoids > 1month Calcium and Vitamin D with known osteoporosis Clopidogrel post stroke (stop aspirin and dipyridamole) Compliance aids Containers Labeling Various Duties of Pharmacists Session activity: Divide into groups of 4-5 and go over the following cases The Merck Manual of Geriatrics: 2009

8 Concluding Remarks By the end of this Workshop, you will be able to: 1. Discuss the ageing process and its impact on drug therapy. 2. Describe the general guidelines for prescribing for geriatric patients. 3. Implement strategies to resolve medication related problems in geriatric patients. 4. Undertake a medication review for a geriatric patients. 5. Provide practical steps to improve medication compliance in geriatric patients. References and further reading Centre for Pharmacy Learning and Development. Managing Medicines in Older People. CPD. Queens University Belfast, Belfast Milton JC, Hill-Smith L, Jackson LH. Prescribing for older people. BMJ 2008; 336: BPAC. Managing medicines in older people. Best Practice Journal. Issue 47, October Livingston S. Effective interventions to support medicines use in older people. The Pharmaceutical Journal 2003; 270: /02/2013 CPH-CPPD 5 (AE) 11/02/2013 CPH-CPPD 5 (AE) Acknowledgment Questions? Dr. Nadir Kheir Mrs Sabah Khalifa Sara Hayder Ahmed Reem Hasan EL-Ajez 11/02/2013 CPH-CPPD 5 (AE)

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