Pharmaceutical Care In Elderly Patient

Pharmaceutical therapy is the most common medical intervention used to treat the elderly. Aged persons are described in different terminologies such as geriatrics, elderly, older people, senior citizens or seniors. They are usually 65 years and over in developed countries with high life expectancy or 60 years and over in developing economies. As one ages, the health declines and consequently the need for medication increases.

Elderly (geriatric) patient

Pharmaceutical care should be tailored to each patient based on his or her specific health status. Due to considerable variation from patient to patient, there may be no one “best practice” for treating every patient.The sources of variation include the presence of multiple chronic diseases, the physiological changes that accompany aging, and the wide variation in the properties of drugs used to treat diseases of the elderly.

Need For Individualized Pharmaceutical Care In The Elderly

Multiple Diseases

Comorbidity, or the simultaneous presence of two or more chronic diseases, is common in the elderly and is an important reason why treatment must be tailored to the needs of individual patients. Patients with multiple diseases require multiple medications. As the number of medications increases, so does the risk of adverse drug reactions (ADR). An ADR can result in mild to serious injury to the patient. For patients with comorbid conditions for which they receive multiple medications, there are two types of ADRs, drug-drug and drug-disease interactions, that are of particular concern.

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Drug-drug interaction can occur when the medications prescribed for two conditions do not mix well. Drug-disease interaction occurs in patients with comorbidity when a drug prescribed for one condition worsens another condition. Another additional concern for the older patient with multiple conditions is the possibility of synergism. Certain disease pairs may have much greater effects on the patient than the singular effects of the two component diseases. Such pairs may substantially reduce functional ability. For patients with multiple diseases, simply combining the standard treatments for each disease may not be effective.

Physiological Changes

Changes in the rate at which drugs are absorbed, distributed, metabolized, or eliminated by the body can affect the level of drugs in the bloodstream. Higher blood levels mean greater drug action and potentially greater toxicity, and vice versa. Each of these four “pharmacokinetic” processes may be greatly altered in elderly individuals, so all drug therapy regimens must reflect a consideration of these changes. In elderly, metabolism rates change, organ function declines and sensitivity to some drugs can be altered. It could have an enhanced or diminished effect.

Drug dose should be reduced in elderly patients because of a general decline in body function with age. Altered medication absorption in the elderly include: delayed gastric emptying, decreased splanchnic blood flow, elevated gastric pH and impaired intestinal motility. Although, the rate of drug absorption is rarely affected. The lean body mass decreases and body fat increases by almost 100% in elderly persons as compared to adults. Because of the smaller volume of body water, higher peak alcohol levels are observed in elderly than in young adults. Volume of distribution of a water soluble drug may decrease and that of a lipid soluble drug like diazepam increases with age. Drugs that are highly bound to albumin (e.g. warfarin, phenytoin) may have a greater free concentration because albumin is decreased in the elderly.

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Age related changes in hepatic and renal function greatly alter the clearance of drugs. Serum creatinine may not be a good predictor of renal functions, as creatinine production declines with age. Decline in cardiac output with age results in decrease of renal perfusion by 40% to 50%.

Due to progressive decrease in renal function, the dosage regimen of drugs that are predominantly excreted unchanged in urine should be reduced in elderly patients. A reduction in phase 1 reactions (oxidation, reduction and hydrolysis) can occur. This results in prolonged elimination of half lives of benzodiazepines and certain analgesics (dependent on phase-1 metabolism). This may result in drug accumulation and possible adverse effects. Discomfort, pain or difficulty swallowing medication is a problem faced by many elderly patients.

Non-adherence

Many elderly patients do not take their medication. Some even self medicate. There are many reasons for that. Some.may have conditions that affect their eyes hence cannot see the prescription. Poor hearing can also make a patient not hear every detail, the pharmacist said. Arthritis can affect the bones of the body, hence make.it difficult to grip and open medicine jars. Let us not forget memory loss can get in the way of adherence.

Furthermore, non-adherence in older persons may be due to polypharmacy, adverse drug reactions, and social conditions such as living alone and inability to afford medication.

Optimizing Drug Therapy of Elderly Patients

Pharmacist's coordinating and optimizing drug therapy to improve outcomes by reducing costs:

1. Designing patient specific strategies to improve adherence

2. Targeting patients taking unnecessary multiple prescriptions (often duplicate or triplicate therapies) that can cause serious harm and waste valuable resources

3. Reducing the number of serious at risk for side effects of drugs considered inappropriate for use in the elderly

4. Working with physicians to optimize drug therapies by increasing the use of medications considered to be best for individuals practices

5. Providing therapeutic interchange for certain drugs to provide equal or better clinical outcomes

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6. The elderly have a higher prevalence of multiple diseases, and thus receive more prescriptions and see more physicians who must then coordinate care

7. An older body can react very differently to medicines than a younger one due to physiological changes, such as changes in metabolism and organ function, and

8. There is wider variation in the pharmacological actions of a drug in elderly individuals

Role Of Pharmacist In Elderly Care

It is therefore necessary that a community pharmacist should be familiar with the tasks that have to be performed for the care of the elderly. But before he/she actually starts taking responsibility for the elderly, he/she has to learn some foundation skills in order to be ready to help the elderly.

1. Foundation or Basic skills

2. Relearn basic Pharmacy Practice skills