PHARMACOTHERAPY IN

ELDERLY PATIENTS

Suharti K Suherman
Dept. Pharmacology & Therapeutic
Medical Faculty, University of Indonesia
 Epidemiology
80 90 % elderly patient (EP) take at
least 4 5 drugs per day
EP > 65 yrs of age 18% of the
population consume > 40% of
health service expenditure on
drugs
 ADRs are 2 3 x > common in EP than
in young & middle-aged adult

ambulatory EP aged > 75 yrs are

prescribed 70% more
medications than younger
patients (25 44 yrs)
 Patients aged 70 & over admitted to general
medical wards 24% cause by
severe ADR
12% risk indicators for a severe adverse
drug reaction were : a fall before
admission , GI bleeding or
haematuria & the use of 3 / > or
drugs
Conclusion : ADRs are an important cause of
hospital admissions in older
people. A fall before admission
may indicate a severe adverse
drug reaction.
 EP tend to have multiple diseases
polypharmacy is common
drugs interactions
poor compliance with dosing regimen ;
error rate in taking drugs is about
60% in patients > 60 yrs of age , &
it markedly if > 3 drugs are
prescribed
 these errors are potentially
serious in EP than in young &
middle-aged people
Changes of organ function require
dosage modification
 Elderly patients (EP)

are a subset of frail older people with

multiple comorbidities

have impaired homeostasis

have wide inter-individual variability

 the freality syndrome includes :
an excessive of lean body mass
a in walking performance &
mobility
poor endurance associated with a
perception of exhaustion & fatigue
 Drugs for EP
disease states & older age may
cause changes in phar kinetic &
dynamic of drugs

how best to use drugs to treat them in

order to maximize efficacy &
minimize adverse rxs
 Clinical pharmacology for EP

pharmaceutical factors mode of

administration, drugs form
phar kinetic factors absorption,
distribution, metabolism, &
excretion
phar dynamic factors different
pharmacological sensitivity to
drug effects
 pharmaceutical factor

many EP dont like to swollow large tablet

(ie. potassium tab) the more ill,
the more dehydrated become
the more difficult
to avoid the adherence to the
oesophagus it should taken with at
least 60 mL of water
sometimes the taste of the tab a
problem
 phar kinetic factors

absorption
there are no well-documented
examples to show that this is
a specific problem
distribution
to adjust dosages for body
weight in EP, especially for
drugs with low therapeutic
index
 Some changes related to aging that affect kinetics of
drugs
2030 yrs 60 80 yrs
body water (% of BW)61..53
lean body mass (% of BW)19..12
body fat (% of BW)..2633 ().3845
1820 ().3638
serum albumin (g/dL)..4.7.3.8
kidney weight (% of young adult) 100..80
hepatic blood flow.100....5560
(
 in plasma protein binding of
some drugs (phenytoin),
caused by fall in plasma
albumin level
distribution of body water & fat
is altered & lipid soluble drugs
accumulate to a > extent
than in younger pat caused
by proportion of fat in elderly
 metabolism
liver capacity to metabolize
drugs doesnt seems
consistenly with age for all
drugs
Fig 1 level of nifedipine after IV in 6
old & 11 young healthy men
Fig 1.Level of Nifedipine after IV
 Effects of age on hepatic clrearance of some drugs

age-related no age-related difference

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barbiturate ethanol
diazepam lidocain
chlordizepoxide lorazpam
flurazepam nitrazepam
tolbutamide salicylate
theophyllin warfarin
quinidine propanolol
 renal excretion
- GRF with age , & by 80 yrs old
to 6070 mL/min
- tubular function with age
drugs or its active metabolites
excreted mainly in the urine
require dose ( digoxine,
aminoglycosides, lithium,
procainamide, furosemide)
Fig 2. Level of urinary furosemide after IV inj
 Phar dynamic factors
drugs sensitivity can be changed in EP ,
independent of the kinetic
its may cause / sensitivity
cause by the changes in the response
of their receptor
i.e. a. EPs are > sensitive to the effects of
digoxin probably cause by
sensitivity of their Na/K-ATP-ase
b. sensitivity to -adrenoceptors
may pharmacological effects of
-adrenoceptors agonist &
antagonis (Fig 1 & 2)

c. sensitivity to anticoagulant effects

(warfarin) & responsiveness of
the CNS to centrally acting drus :
hypnotics, sedatives, transquilizer,
antidepressant
 Some drugs take > attention

Sedative-hypnotics
pharkinetic t1/2 many benzodiazepn
& barbiturates by 50
150% between 3070 yrs
especially at 60 70 yrs.
& the present of hepatic / renal function
contribute of elimination ; &
in volume of distribution
phardynamic:>sensitive to sedative-hypntic
drugs (ataxia & other signs of
motor impairment
 Analgesics opioid analgesics the
elderly are often markedly >
sensitive to the respiratory
effects
Cardiovascular drugs
antihypertensive
 A

Fig 3. Changes in heart

rate & K level after
terbutaline (2 agonist) IV
inj, old & young women

B
Fig 4. Changes in sys &
pulse rate after
nifedipine IV inj.
 General principles of prescribing drugs for
all diseases

remember the goals of the treatment

decide what the best th/ is use
nonpharmacological management
options first
if they need pharmacotherapy select
medicines wisely based on the
suitability of the patient
 use medicines based on the best
evidence the right dose &
duration & route of administration
remember the risk benefit ratio for
each drug
evaluate / monitor the result of all
treatments!

special attention for elderly patients

with chronic diseases
 Take a careful drug history. The disease
to be treated may be drug-induced,
or drugs being taken may lead to
interaction with drugs to be
prescribed
Prescribe only for a specific disease a
specific drug /s