Module 1 Basic Concepts in Geriatric Pharmacotherapy 2012

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Module 01: Basic Concepts in Geriatric Pharmacy

Current Content Expert Kevin W. Chamberlin, PharmD Assistant Clinical Professor University of Connecticut School of Pharmacy & UConn Center on Aging Legacy Content Expert William Simonson, PharmD, FASCP, CGP Independent Consultant Pharmacist Module Objectives: At the conclusion of this application- based activity, the participant will be able to: 1. Assess the major medical causes of elderly morbidity, mortality, and loss of independence. 2. Examine the major factors that contribute to and detract from wellness and ethical care in the geriatric population. 3. Compare the various types of living arrangements and reimbursement payer plans, including end-of-life planning, available to the elderly. 4. Apply strategies to overcome communication, economic, and social barriers common in geriatric patients. 5. Relate how physiologic changes in the older adult can influence pharmacokinetic and pharmacodynamic drug properties and guide therapeutic decisions.

01.01.01 Prevalence of Chronic Illness in the Older Adult Incidence of acute disease is greater in younger elderly than older elderly; opposite is true for chronic disease Risk of chronic illness increases rapidly with age 4 out of 5 people 65 and older have at least 1 chronic condition Multiple conditions common among very old Chronic conditions likely to o lead to disability o affect quality of life o decrease functionality

o increase the need for dependence on support services

With advancing age, the prevalence of chronic health conditions increases, compared to younger adults. Seventy-five percent of Medicare recipients age 65 to 69 have no chronic health conditions compared to approximately 90% of those over age 85. Multiple concurrent conditions are common in the elderly with many of these chronic conditions leading to disability, and a significant decline in the individuals quality of life. Among community-dwelling older adults, the risks of hospitalization increases with the number of chronic conditions (McNabney, Wolff). Furthermore, strict adherence to published Clinical Practice Guidelines within such patients can produce undesirable effects and even worsen conditions (Boyd, McNabney) 01.01.02 Disease States that Commonly Affect the Older Adult Common Medical Conditions Among Assisted Living Residents: Bladder incontinence (33%) Heart disease (28%) Bowel incontinence (18%) Osteoporosis (16%) Diabetes (13%) Stroke (11%) Parkinsons Disease (5%) Cancer (4%)

Mental Health Conditions Among Assisted Living Residents Dementia (mild) (25%) Depression (24%) Alzheimers disease (early stage) (11%) Mental retardation; developmental disabilities (10%) Alzheimers disease (mid-stage) (8%) Alzheimers disease (late stage) (4%)

Disorders That May Present in Unusual Ways in the Older Adult:

Depression Alcoholism Myocardial infarction Pulmonary embolism Pneumonia Cancer

The primary reason for moving into Assisted Living for 24% of residents in a 2007 report by Leroi and colleagues was reported to be increased medical needs. Older adults may be affected by a wide variety of health conditions including disorders that have their onset primarily in old age, such as Parkinsons disease or Alzheimers dementia. They may also be affected by conditions that initially occur at a younger age, but have more serious health consequences in the elderly, including hypertension and hyperlipidemia. Some conditions may present in unusual ways when they afflict the older adult where some signs and symptoms may be masked or be vague and non-specific. Some physical condition problems may present with psychiatric manifestations symptoms, while some psychiatric problems may present with physical manifestations. 01.01.03 Impact of Chronic Illness on Daily Living Prevalence of Disability: Increases with age

Types of Disability: Activity limitation Functional limitation

Morbidity: Multiple conditions produce greater disability Disability is the practical impact of a disease or disorder on daily living. It is manifested as limitations in activity, limitations in function, or both. Multiple conditions typically produce a greater degree of disability.

01.01.04 Disability and Activity Limitations Restricted Activity Days: Definition: staying in bed or decrease in usual activities Epidemiology: Incidence increases with age Severe Limitations: Definition: being unable to carry out basic activities Epidemiology: o Moderate limitations increase with age o Severe limitations decrease with age o 11% of the elderly have severe limitations Older adults with disabilities that limit their activities fall into one of two principal groups: those with restricted activity days and those with more severe limitations. A restricted activity day is one in which the older adult stays in bed or decreases his or her participation in usual activities. The number of restricted activity days tend to increase with age. Older adults with severe limitations may be unable to carry out many basic activities. While moderate limitations increase with age, severe limitations usually decline with age due to mortality or transfer to a long-term care facility. Severe limitations affect as many as 11% of the elderly. Activities of Daily Living (ADLs) Personal hygiene / grooming Dressing / undressing Self-feeding Functional transfers Toileting Ambulation ( Instrumental Activities of Daily Living (IADLs)


Managing finances Grocery and clothes shopping Transportation Finance management Basic Activities of Daily Living (ADLs) consist of self-care tasks necessary for fundamental functioning. Functional transfer examples include getting from the bed to the wheelchair, or getting on or off the toilet. Ambulation is measured by walking without the use of any assistive device including a walker, cane, or crutches, and without the use of a wheelchair. Instrumental Activities of Daily Living (IADLs) are not necessary for fundamental functioning; however, they do let an individual live independently in a community. 01.01.05 Disability and Functional Limitations Types of Functional Activities: ADLs dressing eating transferring toileting bathing shopping house cleaning accounting (banking) food preparation (cooking) transportation IADLs

Epidemiology of Functional Limitations: 30% of community dwelling elderly report ADL or IADL performance problems Greatest problems with ambulation and hygiene (ADLs) and with shopping and transportation (IADLs) Nursing Facilities and Assisted Living Facilities report the most common ADL problems are with bathing and dressing

Risk of functional limitations increases with age, which can lead to an increased risk of institutionalization and death May compromise the quality of life or indicate need for long term care

For more information: Lawton Instrumental Activities of Daily Living Scale: Like activity limitations, the risk of functional limitations also increases with age. Functional activities include personal management tasks, known as activities of daily living (ADLs), and home management tasks, referred to as instrumental activities of daily living (IADLs). Of the ADLs listed, the most common problems experienced by the older adult are bathing and walking. In nursing facilities and assisted living facilities the most common ADL problems are with bathing and dressing. Of the IADLs, the most common problems are shopping and transportation. While only 30% of community dwelling older adults report problems with performing such activities, functional limitations may compromise the quality of life of an older adult and indicate a need for a higher level of care or institutionalization. They are also associated with increased mortality. 01.01.06 Loss of Independence in the Elderly Contributing Factors: Physical disability Cognitive disability Limitations of activity and function Loss of spouse Financial limitations

Options: In-home caregivers Moving to live with another family member Retirement communities Assisted living Nursing homes

Loss of independence can be a traumatic experience for the older adult. Many factors can cause the loss of this independence, including physical or cognitive disabilities, the loss of a spouse, or financial limitations. Any of these problems may limit the activities and functions the person can perform, forcing them to depend on someone else for their care. This dependency may be harder for women who have been in a care giving role for much of their lives. For many older adults, the loss of independence is synonymous with placement in a nursing home. This fear prompts many elderly to try to compensate for the loss until additional service and assistance is absolutely necessary. Unfortunately, this behavior puts many older adults in the position of doing harm to themselves or others. Continuing care retirement communities (CCRCs) may provide an attractive alternative for such people because they provide various levels of care ranging from independent living to nursing facility in a campus-like environment. This can help the aging adult transition gradually to a more dependent lifestyle by providing additional services when the resident needs them. 01.01.07 Patterns of Drug Use in the Elderly Older adults take an average of 4-6 prescription medications 20 medications or more may be taken for multiple chronic illnesses Polypharmacy leads to increased risk of:o o o o o

Toxicity and adverse reactions Improper drug administration Non-compliance with regimen, including missed doses Drug-drug interactions, both pharmacokinetic and pharmacodynamic Drug-disease interactions

The elderly consume a disproportionate amount of both prescription and nonprescription drugs. While making up approxi