Geriatric PharmacologyGeriatric Pharmacology& Polypharmacy Problems& Polypharmacy Problems

for Physical Therapistsfor Physical Therapists

Marilyn James-Kracke, Ph.D. Marilyn James-Kracke, Ph.D.

Associate Professor of PharmacologyAssociate Professor of Pharmacology

University of Missouri University of Missouri Medical SchoolMedical School

Lecture outline

1. Why physical therapists benefit from knowing some basic pharmacology.

2. Why elderly people experience more adverse drug reactions.

3. Which medications can cause problems that affect the work of physical therapists.

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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 therapistis trusted. Older patientswant your advice on everything including their medications. This could be good or bad.

This is probably truefor younger people also!

= authors of studies

Adverse Drug reactions more common in the elderly

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, askthem if they are taking any new medications.

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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

Polypharmacy How many prescription medications are too many? >4 or >6 Many elderly people receive 12 medications per day

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.

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 anestheticsbut may contribute to lower interest in physical activity - lower clearance of drugs

Note - drug absorption is normal in the elderly - slow GI tract gives plenty of time for absorption

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