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Falls Risk

Pharmacodynamics

Goals of Prescribing

General risk factors for falling in the elderly:

  • Conditions that affect mobility or balance (such as arthritis, stroke, Parkinson's disease, arrhythmias, heart failure)

  • Visual impairment

  • Cognitive impairment

  • Urinary incontinence

  • Frailty (for example physical disability, general weakness).

Drug treatments:

  • Polypharmacy

  • Drugs that can cause postural hypotension, sedation, tachycardia or periods of asystole.

  • Psychoactive drugs (such as benzodiazepines, antidepressants).

Orthostatic responses and postural control

  • Blunting of reflex tachycardia - increased risk of hypotension arising from medication e.g antihypertensives, benzodiazepines, antiparkinsonian drugs

Cognitive function

  • Reduced cholinergic transmission - increased risk of confusion arising from medication e.g hypnotics, antichloinergics, b-blockers

Visceral muscle function

  • Reduced bowel motililty - increased risk of constipation arsing from opiates, antihistamines, anticholinergics
  • Bladder instability - urinary retention and incontinence

  • Avoid polypharmacy and unnecessary drug therapy

  • Treat the CAUSE rather than the symptom (may be an ADR from a current medicine)

  • Take into account all co-morbidities

  • Elderly patients may need reduced doses and smaller dose titrations.

  • ADRs occur more frequently

  • Ensure compliance - BP's, counselling

Pharmacokinetics

1. Absorption

  • Reduced gastric acid secretion and gastric motility

2. Distribution

  • Reduced total body water
  • Increased total body fat
  • Reduced serum albumin

3. Metabolism

  • Reduced hepatic mass and hepatic blood flow

4. Excretion

  • Generally GFR declines (as well as renal blood flow and renal tubular function)

Scenario

Contents

An 80 year-old woman presented to an outpatient clinic with a history of severe blackouts.

Past medical history: angina and HTN

DHx: bendroflumethiazide 2.5mg od

isosorbide mononitrate 60mg od

Her GP had recently commenced nifedipine SR 20mg bd for poorly controlled HTN. On examination her BP was 120/70mmHg while supine and 90/60mmHg on standing.

What are the underlying problems in this patient? what would you advise?

Introduction

  • Introduction
  • Pharmacokinetics
  • Pharmacodynamics
  • Falls risk
  • Goals of prescribing
  • Scenario
  • References

References

The proportion of older people in our society is growing.

People over 65 account for the highest activity and spend across primary, secondary and social care.

As a result of ageing, physiological changes can effect the pharmacokinetic and pharmacodynamic properties of drugs.

Walker, R, Whittlesea, C. Clinical pharmacy and therapeutics 4th edition 2007, Geriatrics 135

Falls - risk assessment, National Institute of Clinical Excellence http://cks.nice.org.uk/falls-risk-assessment#!scenariorecommendation

National service framework for older people - http://www.nhs.uk/nhsengland/NSF/pages/Olderpeople.aspx

Principles of Prescribing in the Elderly

Bijal Sona Tailor

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