ELDERLY CARE
practice, however the risks associated with this phenomenon remain substantial. Reports of the increased risk of prescribing errors, high risk prescribing, adverse drug incidences and problematic drug interactions suggest that pharmacy must continue in the provision of a high standard of pharmaceutical care. Providing pharmaceutical advice and support for the medical and prescribing teams in the community and hospital settings, remains key for Pharmacy as a profession.
In reading any literature on the pharmaceutical care and management of older people, it quickly becomes apparent that dementia is a significant factor associated with an aging population, with the prevalence expected to double in Scotland between 2011 and the year 2031. This anticipated increase in diagnosis will inevitably require investment from government, healthcare workers, and the general public to ensure successful management of this condition. Pharmacy can provide information on novel technologies for therapies, available treatments, drug delivery and the management of dementia, and as such pharmacy has been identified as having the potential to positively impact upon patients suffering dementia. This has been specifically highlighted in the Scottish Governments second Dementia Strategy 2013.6
It was recently highlighted at the Scotland Healthcare conference that although dementia is a well known factor, other mental health issues are prevalent in older people; anxiety, depression, and late onset schizophrenia coupled with alcohol abuse and often a reduction in patients ability to communicate, or make day-to-day decisions should make caring for mental health in older people a prime concern.7
As such,
patients should be provided with information so that they are equipped
to deal with any mental health developments. Such activities align with the Governments 2020 vision for Health and Care in Scotland.
In addition to the support patients require in their efforts to maintain mental wellbeing, physical wellbeing has been identified as important – and despite numerous facilities investing heavily in physical exercise classes for older people, the process of aging naturally results in changes in physiology. In many instances negative changes can be negated by regular and appropriate exercising, but nevertheless decline in factors such as kidney function, changes in body mass and alterations in total body fat ultimately have an impact on the bodies capacity to cope with medicines at doses that would have been tolerated when younger.
The term “Pharmacokinetics & Pharmacodynamics” tends to strike a rather inharmonious chord with many pharmacists, however as the experts in medicines, it is an area
IN READING ANY LITERATURE ON THE PHARMACEUTICAL CARE AND MANAGEMENT OF OLDER PEOPLE, IT QUICKLY BECOMES APPARENT THAT DEMENTIA IS A SIGNIFICANT FACTOR ASSOCIATED WITH AN AGING POPULATION, WITH THE PREVALENCE EXPECTED TO DOUBLE IN SCOTLAND BETWEEN 2011 AND THE YEAR 2031.
40 - SCOTTISH PHARMACIST
difficult to avoid. Below are some common alterations seen in the pharmacokinetics/dynamic profiles that are well documented in elderly patients.
Adsorption – despite significant age-related physiological changes in intestinal surface area, slowed gastric emptying and increase in gastric pH, alterations in drug absorption tend to be clinically inconsequential for most drugs.8
Controlled release
preparations activated by pH can often be less effective in older patients and enteric-coated dosage forms can also be prone to early dose release as a result of the increased gastric pH. One example where the variation of pH has an effect is with that of Calcium carbonate, which requires an acidic environment for optimal absorption. The age-related increase in gastric pH, Calcium absorption is decreased and consequently the patient is more likely to become constipated. It is suggested that elderly patients requiring calcium therapies should be prescribed a salt form that dissolves more easily in a less acidic environment, such as Calcium citrate.9
Distribution – As a person ages, although their body mass index may not alter significantly, total body fat can increase and total body water content often decreases.8
in physiological make up, may not always outwardly be apparent, however increased fat results in an increased volume of distribution for highly lipophilic compounds, as such potentially increasing their
elimination half-lives. This is evident in benzodiazepine medicines such as diazepam and chlordiazepoxide. Often medicine-dosing regimens need to be altered drastically, as the cumulative effect of aging significantly changes the pharmacokinetic profiles, particularly with benzodiazepine medicines.9
Metabolism – One of the main systems for medicines metabolism is that of the Cytochrome P-450 enzyme system, which is reduced as age progresses. Typically clearance of hepatically metabolised medicines decreases by 30-40 %.8 As metabolism varies significantly from patient to patient, a tailored or individual dose adjustment is required, as one cannot simply reduce doses by 30-40% across the board and expect patients to respond uniformly. Clearance of medicines that are metabolized by phase I reactions, such as oxidation, reduction or hydrolysis are more likely to be prolonged in elderly patients. Phase II conjugation reactions usually remain unaffected by the aging process.9
The effect This change
of first-pass metabolism reduces by approximately 1% per year of life after age 40 years, and although this does not seem like a significant change, with patient living longer, and populations being described as the oldest old (>85 years) – oral dosing of medicines in elderly patients requires a continued effort with regards to monitoring. Propranolol, nifedipine and the nitrates are each example of commonly used medicines at high risk of toxicity.8
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