Transcript Geriatric Pharmacology &Polypharmacy

Geriatric Pharmacology
& Polypharmacy Problems
for Physical Therapists
Marilyn James-Kracke, Ph.D.
Associate Professor of Pharmacology
University of Missouri
Medical School
1. Why physical therapists benefit from
knowing some basic pharmacology.
PT
2. Why elderly people experience more
adverse drug reactions.
3. Which medications can cause problems that
affect the work of physical therapists.
Pharmacology
Lecture
outline
•
Attitude of the elderly towards
PT
and
medications
Older people are more likely to prefer physical
means than medications to feel better.
• Why
•
•
•
•
•
•
•
•
•
•
Elderly distrust medications they don’t understand.
too many medications prescribed for them - confusing
afraid of choking on medications.
Physicians are always changing and rushing them.
for the elderly, PT provides social interaction as well as
health care - they enjoy being with healthy fun therapist.
Elderly trust personal contact - like hands on approach
nuturing approach - encouragement - humor
side effects of the medications often make them feel
worse - disoriented, sleepy, weak, stomach ulcers,
hearing impairment, etc
For the elderly, medication risk is greater and benefit is
less than in younger people.
In contrast, physical therapy has little risk and definite
benefits in both the old and the young.
The physical therapist
is trusted. Older patients
want your advice on
everything including their
medications.
This could be good or bad.
This is probably true
for younger people
also!
Adverse Drug reactions more common in the elderly
= authors of studies
Bounce back time - If an elderly person is started on a new medication and 2 to 3
days later they are taken to the emergency room, suspect a drug reaction.
If a older patient seems very different than at your last PT session, ask
them if they are taking any new medications.
Magnitude of the Medication problems in the elderly
• Patients >65 years old were 13% of the population
by 2000.
• Patients greater than >85 years old are the fastest
growing segment of the population.
• This 13% of the population consumes 30% of all
medications
• Elderly population is expected to triple from 1985
to 2060.
• Elderly are the most physiologically
heterogeneous category - state of health varies
extensively - physical strength, - cardiac condition, renal
and liver function for clearance of drugs.
• Compliance - misuse and errors - side effects
Factors contributing to adverse drug reactions
in elderly patients
Heart, kidney,
liver, thyroid
Orthostatic hypotension, when
they standup, blood goes to their
feet - weak sympathetic nervous
system response to constrict
veins and increase heart rate.
Low thyroid function causes
lower body temperature,
metabolic rate, & heart rate.
Polypharmacy
How many prescription medications are too many? >4 or >6
Many elderly people receive 12 medications per day
Kidney clearance is
reduced
Blood flow to all
organs like kidney
and liver is reduced therefore clearance is
reduced - exercise
may help them clear
more drug by
increasing circulation
Breathing affects
clearance of inhaled
Note - drug absorption is normal in
the elderly - slow GI tract gives plenty anesthetics
but may contribute to
of time for absorption
lower interest in
physical activity lower clearance of
drugs
Biggest errors made in
prescribing for elderly people
• Polypharmacy - a drug for every complaint and elderly
people have lots of aches and pains, circulation and
breathing difficulties etc
• Side effects are missed because they are misinterpreted as
part of getting old - particularly senility - hearing loss etc
• Elderly people often see a different doctor every time and
the next doctor does not realize that the patient was clever
and active a week ago.
• Physicians often assume that the patient is ill because they
are not taking their medications when in fact they are
taking them and the amount prescribed for them too much.
Reasons why elderly have compliance
problems for taking medications
•
•
•
•
•
•
•
•
opening pill containers(weak/arthritis pain/tremors/spills)
fear of choking while swallowing large pills
reading the labels and information
depression - sleepy - poor concept of time for doses
cognitive impairment - can’t recall a few moments ago
cost of medications are prohibitive -- food vs. medications
adverse drug reactions limit benefit of medications
Bottom line - you’re never sure whether they are taking too
much or too little.
Elderly are more likely to tell their PT than their doctor whether they are taking their
medications or not because they are too polite to tell a doctor that his pills make them
feel sicker. You are in a position to make a difference!!
Dizziness, Fainting and Weakness
• Inner ear disturbances, nauseants, low blood pressure, anemia and
hypoxia, electrolyte imbalances like hypokalemia, dehydration.
• Antihypertensive medications - beta blockers, Ca channel blockers,
diuretics, ACE inhibitors, nitrates, clonidine, alpha blockers orthostatic hypotension - side effect is an extension of the desired
blood pressure lowering.
• Antianginal therapy - nitrates, beta blockers, Ca channel blockers
• Certain antiarrythmic drugs - bretylium, amiodarone
• Drugs that cause anemia - NSAIDs can cause bleeding of the GI tract
which can lead to severe anemia
• Cytotoxic agents used to treat cancers or arthritis or autoimmune
diseases like lupus erythematosis, and to prevent transplant rejection
also inhibit the bone marrow from making red blood cells
– methotrexate
– cyclophosphamide
– azathioprine
– cyclosporine
Analgesics - nonsteroidal
antiinflammatory drugs = NSAIDs
• Old arthritic people take more of these but they are also
prone to stomach/intestinal ulceration due to cycloxygenase
inhibition of the synthesis of protective prostaglandins in the
gastric mucosa.
• chronic slow blood loss causes anemia
– look for very pale weak patient
• can be sudden onset - severe hemorrhage
• platelet activity is slowed by NSAIDS
• patients taking these meds should be asked if they have
abdominal discomfort before starting activity
• activity increases blood pressure - may precipitate a bleed
• longer term use of high dose NSAIDs can cause kidney
damage and loss of erythropoeitin made by the kidney which
is a hormone that stimulates red cell production and without it
there is anemia.
Bruising - hematomas
• Vit K is important for making clotting factors - malnutrition causes
bruising -lack of green leafy vegetables in diet containing Vit K
• Anticoagulant dose too high (warfarin-coumadin competes with Vit K)
• NSAIDs - inhibit platelets - causes longer bleeding times
• antibiotics killed bacteria in the gut that make Vit K
• Steroid use - Cushing syndrome - weakens blood vessels
• drugs causing dizziness - orthostatic hypotension cause falls
–
–
diuretics (dehydration)
blood pressure lowering medications
• Ineffective Parkinson’s treatment - excessive falling
• cancer chemotherapy - reduces platelets for clotting and makes a person
weak enough to fall more frequently.
• Intramuscular injections - for people on anticoagulants
• Elder abuse