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Geriatric and End of life Pharmacotherapy

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on 11 July 2013

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Transcript of Geriatric and End of life Pharmacotherapy

Includes hospice care
Ideally implemented early in disease progression to provide support
Defined as “treatment to reduce the violence of disease (Alldredge, et al., 2013).”
WHO defines palliative care as an approach that improves the quality of life of patients and their families who are facing life threatening illness, by preventing and relieving suffering

Palliative care

Most common mental illness among older adults, about 15% of the population over 65
Often under recognized and undertreated in the elderly
Often related to comorbid medical conditions
Majority of patients treated in primary care setting
SSRI’s are well tolerated by geriatric patients
Low dose SSRI considered first line for elderly patients i.e. citalopram 10mg daily with gradual dose titration
Response may take twice as long in geriatric population, re-evaluation should be scheduled in 8-12 weeks

Depression

Hypertension is present in 2/3 of patients over 65
Guidelines for treatment are the same JNC VII recommendations for adults
In patients over 80 proper blood pressure management can result in “30% reduction of stroke, 39% reduction in rate of death from stroke, 23% reduction in rate of death from cardiovascular causes, and 64% reduction in rate of heart failure (Alldredge, et al., 2013).”
Intensive treatment of BP in this population (target SBP <120) resulted in no change in outcomes, and increased adverse effects.


Hypertension

Consider functional status, comorbidities, and risk vs benefit of treatment
Medication management
Antiplatelet agents Aspirin or Plavix
Ace inhibitor (ramapril)
Angiotensin receptor blockers (losartan, valsartan)
Beta blockers (metoprolol, carvedilol)

Calcium channel blockers (i.e. diltiazem, verapamil, nifedipine, amlodipine) are helpful in CAD, but not indicated in heart failure

Coronary Artery Disease

Loop diuretics are more effective than thiazide diuretics.
Thiazide diuretics are less effective with renal insufficiency
Regular monitoring of creatinine, BUN, Na, and K are essential.
K supplement may be needed, especially for loop diuretics
Inform patients about frequency of urination on diuretics. Failure to do so may result in limited adherence and poor disease management

Diuretics

Affected by disease states, drug use, nutritional status, environment, genetic differences, liver mass, blood flow and sex
Liver mass declines and hepatic blood flow decreases by 45% (ages 18-65)
Drugs hepatic extraction ratios (i.e. nitrates, barbiturates, lidocaine, propranolol have reduced metabolism and doses should be reduced.

Metabolism

Gastric pH increases
Decrease in intestinal blood flow
Alterations of subcutaneous lipids and dermis can reduce absorption of transdermal medications
Rate of absorption of oral medications either unchanged or decreased.
Insufficient research for transdermal absorption so caution should be used

Absorption

Lance Ginsburg
Colorado State University- Pueblo
July 11, 2013

Geriatric & End of Life Pharmacotherapy

References

In some cases pain is so severe that patient requests that practitioner end life, which can be controversial and may have legal and ethical ramifications
In small number of cases palliative sedation may be appropriate to alleviate suffering and can be achieved by using benzodiazepines, barbiturates, and propofol.




Palliative sedation

Haloperidol (Haldol): in small doses (0.5-1mg) are useful for treatment of restlessness, delirium, or nausea and vomiting
Prochlorperazine(compazine), ondansetron (Zofran) metoclopramine (reglan): useful for Nausea and vomiting, suppositories are effective
Anticholinergic agents: help control oral secretions (i.e. atropine, scopolamine, hyoscyamine (Levsin), glycopyrrolate(Robinul)


Symptom management

Methadone is good first line, and is more affordable than long acting opioids
Second line extended release morphine sulfate when methadone is not appropriate
Transdermal fentanyl should be reserved for patients who are unable to swallow
Extended release oxycodone should be reserved for patients with renal impairment
Lidocaine (0.5-1mg/kg/hour IV or SQ can be decrease neuropathic pain






Pain management (cont)

Opioids
Family often feels that opiates cause addiction and hasten death
Long acting should be used chronic pain
Short acting opioids for breakthrough pain (i.e. morphine, dilaudid) in oral, IM, buccal, transdermal, rectal, sublingual or subcutaneous preparation. Some use small doses of methadone (2.5 or 5mg) every 3 hours
Can help with dyspnea is small doses due to vasodilation, reduced peripheral vascular resistance, reduced brains responsiveness to Co2.
Reduces anxiety
Federal statutes allow prescriptions for hospice patient to be faxed
Stool softeners should be used prophylactically
Benzodiazapines
Useful for treatment of anxiety
Can increase risk of falling
Alprazolam, Lorazepam, diazepam



Pain and Anxiety

All medications should be reviewed upon admission to hospice (change in level of care)
Treatment based on symptom management
Pain
Depression
Hypoxia
Pain control and comfort should be at the forefront of treatment


Medication Management

In 2009 41.6% of all deaths occurred under hospice care
83% of hospice patients are over 65
Qualify for hospice if two physicians believe that the natural course of the disease will result in death within six months
nurse practitioners aren't permitted to certify the patient's terminal illness, but after a doctor certifies the illness, the nurse practitioner can serve in place of an attending doctor (Hospice and Respite Care)
Patients can be re-certified
Palliative vs curative approach
Pain and symptom management
Assistance with ADL’s


Hospice

Designed to optimize quality of life for patients and families in last weeks and months of life
Palliative care
Hospice


End of Life Care

Most common cause of disability in geriatric population, up to 30%
Non-pharmacologic and alternative therapy helpful in reducing amount of medication needed
Acetaminophen is the first line drug of choice
Maximum dose should be decreased by 50% to 75% in patients with history of alcohol abuse or reduced hepatic function
Nsaids can be useful but can cause renal impairment and GI complications and should be used cautiously in the elderly
Salicylates (ASA) have less renal and GI toxicity
COX2 inhibitors i.e. celecoxib (Celebrex) have less GI complications but have equivalent renal complications
Topical analgesic (capsaicin) but can take 4-6 weeks of regular use to achieve optimal benefit
Glucosamine 1500mg combined with chondrointin (can increase insulin resistance) 1200 mg daily
Opioids can be helpful, but stool softeners should be prescribed prophylactically

Osteoarthritis Pain

Most common problems in elderly, and most common reason for hospitalization
Often present with atypical signs
More likely to have polymicrobial infections
Longer duration of treatment
Common infections in the elderly:
Pneumonia
5-10X increased risk
Most commonly Strep pneumonia
Can require hospitalization and broad spectrum antibiotics
Recommended first line are beta lactams and macrolides (ceftriaxone and azithromycin) with fluoroquinolones monotherapy (levofloxacin or moxifloxacin)
Urinary tract infections
Most common bacterial infection in elderly and present atypically
Ranges from mild cystitis to life threatening urosepsis
Can be difficult to treat due to resistant organisms, most commonly E-coli and Klebsiella
Oral sulfonamides or fluoroquinolones (Bactrim , levaquin),
Nitrofurantoin should be avoided in patients with impaired renal function
Medications should be adjusted based renal function


Infections in the elderly

Educate about diet and lifestyle changes, self monitoring, alcohol abstinence
Elderly are more susceptible to hypoglycemia
Initial treatment is with metformin, unless renal impairment is present
Glyburide is long acting sulfonylurea and should be used cautiously in the elderly because of risk of hypoglycemia
Meglitinides such as repaglinide and nateglinide are preferred because they do not require adjustment for renal function.
Insulin may be used if adequate control is not achieved
Early use of Insulin may prevent micro and macrovascular complications
All new diabetic medications should be started at a low dose and titrated up to prevent hypoglycemic episodes
Goal should be to keep hgb A1C <7%


Diabetes

10.9% of men age 65-74 and 24.2% of women have total cholesterol over 240mg/dL
81% of deaths from CAD are over 65years old
Higher rate of hypercholesteremia in women correlates with higher risk of CAD, therefore aggressive treatment of dyslipidemia is essential in the geriatric population
Statins are the drug of choice to lower cholesterol
Hepatic function should be monitored
Rarely rhabdomyolysis and myopathy(CK >10X upper normal limit) can occur, which warrants discontinuation
Hydrophilic statins such as pravastatin(Pravachol), rosuvastatin (Crestor) and pitavastatin (Livalo) can reduce potential side effects and drug interactions
If combination therapy is indicated ezetimibe (Zetia) may be used
Niacin may also be used in combination with statins, but is not recommended as first line treatment because of increased risk of myopathy and hyperglycemia
Alcohol can increase triglycerides by as much as 50%

(Alldredge, et al., 2013)


Hyperlipidemia

Proven to reduce mortality and morbidity, except in stage IV heart failure
Atenolol is not indicated in heart failure
Carvedilol and metoprolol have similar reductions in mortality
Renally cleared so doses may need to be adjusted based on renal function


Beta Blockers

Essential in treatment of HF
Consider dosing frequency for convenience (i.e captopril TID vs. ramapril daily)
Evaluate for intolerable cough with ACEI
Combination of two has proven to lower mortality and hospitalization higher risk of hyperkalemia and worsening renal function

ACEI and ARB

Common cause of morbidity and mortality in geriatric population
Standard treatment consists of three or more medications
Diuretics
Beta blockers
Ace inhibitors
Angiotenson receptor blockers
Digoxin
spironolactone

Heart Failure

Polypharmacy

Hypotension
Decreased ability to maintain homeostasis can cause hypotension in older adults, i.e. higher rate of orthostatic hypotension in elderly (20% in patient over 65) and is aggravated by drugs with sympatholytic activity (TCA, phenothiazine's, alpha adrenergic blockers), vasodilators (i.e. nitrates, alcohol) and volume depleting agents (diuretics).
Receptor sensitivity
Some brain atrophy is common in older adults, along with increase cerebrovascular resistance and reduced oxygen consumption
Drugs with anticholinergic properties can cause memory loss, confusion and cognitive impairment
Decline in CNS dopamine synthesis can cause increased sensitivity to dopamine blocking agents (i.e antipsychotics)

Pharmacodynamic changes

Reduction in renal function is the most common cause for adverse drug events in the geriatric population
These changes are compounded by atherosclerotic changes, decrease in cardiac output, and alterations in profusion, which can decreases renal blood flow by as much as 50%
Decrease in GFR and urine concentrating ability and sodium conservation
Creatanine clearance and tubular secretory capacity reduced
Decrease in number of functional Nephrons


Excretion

Decrease in cardiac output
Increase in peripheral vascular resistance
Proportional decrease in hepatic and renal blood flow
Decrease in total body water and lean body mass requiring decreased dosing, especially for medications that are distributed in body water (i.e. Lithium, digoxin)
Lipid soluble drugs may take longer to reach desired response and accumulation with continued use
Decreased serum albumin can impair protein binding medications (i.e. Dilantin)

Distribution

Decreased metabolism slows down healing and recovery time
Homeostatic mechanisms of cardiovascular and nervous systems are less effective and slower to respond to change
Decrease metabolism and excretion
Tissue composition changes
Changes in receptor sensitivity
Changes related to ageing are progressive and occur over the course of their lifetime

Pharmacologic Considerations

Geriatric Population
In 2008 13% of the US population is over age 65, by 2030 this percentage is expected to increase to 20%
58% of population over 65 are women, 67% of population over 85 are women
In 2011 average life expectancy was 78.7 years
5 Leading causes of death is all persons over age 65:
Heart Disease
Cancer
Stroke
Chronic lower respiratory disease
Diabetes



(Alldredge, et al., 2013)

Alldredge, B., Corelli, R., Ernst, M., Guglielmo, J., Jacobson, P., Kradjan, W., et al. (2013). Applied Therapeutics: The Clinical Use of Drugs. Philadelphia: Lippincott Willimas & Wilkins.
Barkley, T., & Myers, C. (2008). Practice Guideline for Acute Care Nurse Practitioners. St. Louis: Elsevier.
Hospice and Respite Care. (n.d.). Retrieved july 4, 2013, from Medicare.gov: http://www.medicare.gov/coverage/hospice-and-respite-care.html
Hoyert, D., & Xu, J. (2011). National Vital Statistics Report. Hyattsville: Center for Disease Control.
Standards of Medical Care in Diabetes. (2012). Diabetes Care, s28-38.
What is palliative care? (n.d.). Retrieved July 4, 2013, from get palliative care.com: http://www.getpalliativecare.org/whatis/

“multiple medication use is the primary cause of drug-related adverse events in the older population according to the center for disease control and prevention (Alldredge, et al., 2013).”
Needed for treatment of multiple disease processes
Can be caused by lack of communication between providers
Duplicate prescribing of drugs in similar classes
Unrecognized medication side effects
Careful medication regimen review is essential to identify potential interactions
28% of hospitalizations of geriatric patients are the result of adverse drug events or poor medication adherence.


Were Overmedicating the Elderly
http://www.youtube.com/watch?v=PnZItiKbCUw
Full transcript