20.9 15.4 3.1 0.1 0.2 0.2 0.3 0.4 0.6 0.9 1.5 2.2 9.6 6.1 7.3 4.2 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

All Ages Age 65+ Age 85+ Female 50.9% Male 49.1% Female 58.8% Male 41.2% Female 71.1% Male 28.9% $72,791 Under 65 65+ $49,161 $45,101 $41,644 $29,465 $27,241 $55,946 $26,751 $34,211 $38,067 $17,043 $19,615 White Black Hispanic White Black Hispanic Mean Median 60 50 40 30 20 10 Males Females 54.7% 55% 48.1% 42.9% 37.2% 27.7% 23.8% 19.5% 18.1% 15.1% 10.1% 8.5% 0 Heart Disease Hypertension Stroke Cancer Diabetes Arthritis

$25,000 $20,000 $15,000 $10,000 $5,000 $0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Prevalence of Cardiovascular Disease Percent of Population 90 80 70 60 50 40 30 20 10 0 84.7 73.6 73.1 78.8 39.6 39.6 14.9 8.7 20-39 40-59 60-79 80+ Men Women Source: NCHS and NHLBI. These data include coronary heart disease, heart failure, stroke and hypertension. Prevalence of Stroke Percent of Population 18 16 14 12 10 8 6 4 2 0 15.4 12.6 7.4 7.5 2.7 0.3 0.6 1.0 20-39 40-59 60-79 80+ Men Women Source: NCHS and NHLBI.

Prevalence of Heart Failure Percent of Population 16 14 12 10 8 6 4 2 0 14.7 12.8 9.1 4.9 1.9 1.4 0.3 0.2 20-39 40-59 60-79 80+ Men Women Source: NCHS and NHLBI.

Aging Effect Vd Effect Examples body water lean body mass fat stores plasma protein (albumin) plasma protein ( 1 -acid glycoprotein) Vd for hydrophilic drugs Vd for for drugs that bind to muscle Vd for lipophilic drugs % of unbound or free drug (active) % of unbound or free drug (active) ethanol, lithium digoxin diazepam, trazodone diazepam, valproic acid, phenytoin, warfarin quinidine, propranolol, erythromycin, amitriptyline

Large reduction in CV reserve

Source: Am J Cardiol 1992:70:748-51

High Potential for Severe ADE amitriptyline chlorpropamide digoxin >0.125mg/d disopyramide GI antispasmodics meperidine methyldopa pentazocine ticlopidine High Potential for Less Severe ADE antihistamines diphenhydramine dipyridamole ergot mesyloids indomethacin muscle relaxants

Combination ACE inhibitor + potassium ACE inhibitor + K sparing diuretic Digoxin + antiarrhythmic Digoxin + diuretic Antiarrhythmic + diuretic Diuretic + diuretic Benzodiazepine + antidepressant Benzodiazepine + antipsychotic CCB/nitrate/vasodilator/diuretic Risk Hyperkalemia Hyperkalemia, hypotension Bradycardia, arrhythmia Electrolyte imbalance; arrhythmia Electrolyte imbalance; dehydration Sedation; confusion; falls Hypotension

Combination NSAIDs + CHF Thiazolidinediones + CHF BPH + anticholinergics CCB + constipation Narcotics + constipation Anticholinergics + constipation Metformin + CHF NSAIDs + gastropathy NSAIDs + HTN Risk Fluid retention; CHF exacerbation Urinary retention Exacerbation of constipation Hypoxia; increased risk of lactic acidosis Increased ulcer and bleeding risk Fluid retention; decreased effectiveness of diuretics Drug Atropine Codeine Colchicine Digoxin Ephedrine Reserpine Salicylic acid Scopolamine Taxol Vincristine Herb common name (Latin name) Belladona (Atropa belladonna) Poppy (Papaver somniferum) Autumn crocus (Colchicum autumnale) Foxglove (Digitalis purpurea) Ephedra (Ephedra sinica) Rauwolfia (Rauvolfia serpentine) Willow bark (Salix purpurea) Jimson weed (Datura stramonium) Pacific yew (Taxus brevifolia) Madagascar periwinkle (Catharanthus roseus)

Suggested mechanism of antidepressant effect: inhibit reuptake of serotonin, dopamine, and norepinephrine, inhibition of monoamine oxidase, etc

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued requirements regarding medication listed in hospital medical record (2005 National Patient Safety Goals FAQs) Requires that herbs/supplements/nutraceuticals-includes "alternative and complementary interventions that may be used individually, in combinations of alternative or complementary interventions, or in combination with medications. be documented in the medical record