Geriatric Patients

Introduction

According to the statistics from the Department of Statistics of Malaysia, the years that babies in Malaysia in 2020 are expected to live has increased further to 74.9 years or almost 75 years. Hence, our population is actually ageing. This could be due to

Decreased fertility
Lower infant mortality
Better healthcare & public health, e.g. vaccination, hygiene and nutrition

As we age, there is

Physiological changes, for example

Cognitive impairment, e.g. forgetful
Reduced muscle mass and total body water
Decreased GFR
Deteriorating sight and hearing
Inability to swallow solid dose form
Loss of manual dexterity; muscle weakness

Increased susceptibility to medical problems and complications
Functional ability, dependence and quality of life issues are of increasing concern

NOTE:

Some of the physiological changes listed above contribute to medication noncompliance.
Serum creatinine concentration is an unreliable indicator of renal function in elderly since it may remain in the "normal" range despite a reduction in renal function due to lower muscle mass.

Polypharmacy

Prescribing is an art, in which we should not over-treat patients or under-treat they when they need it.

However, as medications are the most common medical intervention, elderly patients are often expected to be on polypharmacy (i.e. regular use of >5 medications). This can lead to an increased incidence of ADRs including interactions between medications, which can then be overlooked in elderly patients and eventually lead to prescribing cascade.

The danger of the prescribing cascade lies in the fact that new medications can unknowingly cause adverse effects, which are then misinterpreted as new medical diagnoses. This prompts further prescriptions to manage those side effects.

As the medication load increases, the patient’s health often worsens, leading to a sense of helplessness and the lifelong burden of taking unnecessary medications.

In reality, polypharmacy may results from a number of factors, including

Patients with multiple medical conditions
Practical guidelines that recommend their use
Fragmental systems: multiple providers (cardiologist, internist, family physician, nephrologist, etc.)
Hospitalizations with inappropriate medication reconciliation

Despite the risks, polypharmacy is sometimes necessary as part of the optimal medical treatment. However, it is important to carefully evaluate the need for each medication and to implement only those that are truly necessary. In addition, it is important to

Evaluate the patient's level of drug adherence
Identify potentially inappropriate medications
Optimize and simplify medication regimen to enhance adherence and minimise adverse effects
Set an aim or target for the patients, such as symptom control or life prolongation

NOTE: You may find Drug-Induced Diseases, 2018 and Perils of Polypharmacy, 2021 very useful in medication management review.

AGS Beers Criteria

The Beers Criteria were first developed in 1991 to decrease inappropriate prescribing and ADEs and, in particular, to identify medications or medication classes that should be avoided in older adults in nursing homes.

Since 2011, after Beer's death, the American Geriatrics Society (AGS) began to oversee the revisions and updates to the criteria.

AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2023 contains six tables:

Potentially inappropriate medication use in older adults
Drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome
Drugs to be used with caution in older adults
Potentially clinically important drug-drug interactions that should be avoided in older adults
Medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults
Drugs with strong anticholinergic properties

Please give this important guide a read!

NOTE: Another prominent potentially inappropriate medicines list is the European-based Screening Tool of Older People's Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START). The STOPP criteria aim to identify PIMs, while the START criteria identify medications commonly omitted where no contraindication exists.

Geriatric Giants

In 1965, Bernard Isaacs coined the term "Geriatric Giants". It is often used to refer to health impairments that appear in the elderly (do not fit into any specific organ-based disease categories) and often have multifactorial causes.

These health conditions may have a major impact on quality of life and disability.

You may learn more of this in Geriatric Pharmacy Pocket Book, 2021.

Summary

When reviewing polypharmacy in elderly patients, pharmacists should utilize the "10 Commandments of Polypharmacy" to identify opportunities to reduce medication burden. These principles, highlighted by Eric Christianson in The Perils of Polypharmacy, serve as a framework for safer prescribing:

You shall not start, request, dispense, or administer a medication without first reviewing an accurate, up-to-date medication list that includes all over-the-counter (OTC) products and supplements.
You shall consider non-pharmacological approaches and interventions to address patient concerns before initiating a new medication.
You shall assess the effectiveness of current therapy before adding a new medication for the same condition.
You shall consider any new symptom to be an adverse drug reaction until proven otherwise.
You shall not initiate a medication without a clear indication and a review of the relevant laboratory data.
You shall define duration limits for medications not intended for chronic use and avoid continuing medications indefinitely for short-term symptoms.
You shall not start a medication from the same or a similar class without providing a clear clinical rationale.
You shall not initiate a medication without first identifying other medications that may already be treating duplicate conditions.
You shall actively seek to eliminate or reduce medications during every comprehensive medication review.
You shall be as willing to accept the risks of discontinuing a medication as you were willing to accept the risks of initiating it.

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