Annals of Long Term Care

Orlando, FL; December 7-11, 2008

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Pharmacologic Treatment for the Elderly Requires Special Considerations

Orlando, Florida—Healthcare professionals face unique issues when dealing with geriatric pharmaceutical care, including the critical area of polypharmacy. These special considerations and the changing dynamic of the geriatric population were the subjects of a presentation at the ASHP meeting, “Polypharmacy and the Elderly: Case-Based Topics in Geriatric Care.”

The first presenter was Judith L. Beizer, PharmD, CGP, FASCP, Clinical Professor, St. John’s College of Pharmacy and Allied Health Professions, Jamaica, NY. Dr. Beizer began with an overview of pharmaceutical care in the elderly. She noted that by 2010, there would be an estimated 6.12 million Americans over the age of 85. By the year 2050, the U.S. Census Bureau estimates that the number of citizens over the age of 85 will be 20.86 million, creating what Dr. Beizer called a “silver tsunami.” She continued by saying that people over the age of 80 fill, on average, 22 prescriptions each year, as compared with those age 50 to 64 who fill, on average, 13 prescriptions per year.

Dr. Beizer outlined several considerations when prescribing for the elderly, including the physiologic changes that may have an impact on pharmacokinetics and pharmacodynamics, as well as changes in functionality that may affect the ability of patients to administer medications or to be adherent. She mentioned the need to consider the risks and benefits of treating with medications versus watchful waiting or nonpharmacologic treatment, the need for communication between healthcare providers, the possible socioeconomic barriers to access, and the ability of the elderly to afford their medications.

She continued her presentation with a discussion of the Beers Criteria 2003 update. The Beers Criteria provide a list of medications that are generally considered inappropriate when prescribed for the elderly because they tend to cause side effects related to the physiologic changes of aging. Dr. Beizer said the top three medications on the Beers list still being prescribed are propoxyphene, diphenhydramine, and promethazine. She continued by noting that high doses of short-acting benzodiazepines may be problematic in the elderly, and that high doses of iron are often prescribed for the elderly, creating problems with constipation.

Dr. Beizer then turned to polypharmacy, stating that use of multiple medications created potential for nonadherence and adverse effects, especially due to drug interactions, duplications of therapy, and increased costs. The causes of polypharmacy include multiple diseases, multiple prescribers, multiple sites of care, multiple pharmacies, self-medicating, using borrowed or leftover medications, not following directions carefully, and the use of medications to counteract side effects of other medications.

She also noted that clinical practice guidelines do not as a rule address treatment for older adults with multiple comorbid conditions. She cited the case of a hypothetical woman, 79 years of age, with chronic obstructive pulmonary disease, diabetes mellitus, osteoporosis, hypertension, and osteoarthritis. That patient would likely be taking 12 medications costing approximately $406 per month. To avoid polypharmacy, Dr. Beizer suggested regular review of every medication a patient is taking, including the indication for the medication and continued need, the dose being taken, adverse effects, and the use of other monitoring parameters. A good time to review medication use is when a patient is undergoing a transition in care, from hospital to nursing home, or rehabilitation center to home, for example.

Nonadherence is also a concern in treating the elderly. Dr.