Drug Therapy in Older Adults

• By 2033, persons over the 65 years of age will outnumber those under 18 years of
age in the United States.
• Typically, persons with two or more chronic conditions take five or more prescription
drugs.
• Administration of drugs in the older adult population requires special attention to
age-related factors that influence drug absorption, distribution, metabolism, and
excretion.
• Drug dosages are often adjusted according to the older adult’s weight, laboratory
results, and comorbid health problems.
• Drug toxicity may develop in the older adult for drug doses within the therapeutic
range for the younger adult.
• Drugs for older adults should initially be prescribed at low dosages with a gradual
increase in dosage based on therapeutic response.
Physiologic Changes
Physiologic changes associated with aging can influence absorption,
distribution, metabolism, and excretion of drugs as well as pharmacodynamic
responses at receptors and target organs. These physiologic changes include
the following:
 A reduction in total body water and lean body mass, resulting in increased
body fat, which alters the volume of distribution of drugs.
 A reduction in kidney mass and lower kidney blood flow, leading to a
reduced GFR and reduced clearance of drugs excreted by the kidneys.
 A reduction in liver size and blood flow, resulting in reduced hepatic
clearance of drugs.
A decline in the physiologic processes that maintain equilibrium in the older
adult may mean a higher incidence of adverse effects. Examples of this
include:
 Postural hypotension in response to drugs that reduce blood pressure
 Volume depletion and electrolyte imbalance in response to diuretics
 Excessive bleeding with anticoagulant and antiplatelet drugs
 Altered glycemic response to antidiabetic drugs
 Gastrointestinal irritation with nonsteroidal antiinflammatory drugs
(NSAIDs)
Physiologic changes with aging affect the determination of risk versus benefit
underlying drug choice, dose, and frequency.
Pharmacokinetics
Absorption
• Adults experience several GI changes with aging that may
influence absorption. These include a decrease in small-bowel
surface area, slowed gastric emptying, reduced gastric blood
flow, and a 5% to 10% decrease in gastric acid production.
• Other common problems that occur in older adults that can
significantly influence drug absorption include swallowing
difficulties, poor nutrition, and dependence on feeding tubes.
Distribution
• With aging, adults experience a decline in muscle mass and a 20% to 40%
increase in fat.
• The increase in body fat means lipid-soluble drugs have a greater volume
of distribution, increased drug storage, reduced elimination, and a
prolonged period of action.
• Older adults have a 10% to 15% reduction in total body water, which
affects water-soluble drugs, and a 10% reduction in albumin.
• Reduced albumin levels can result in decreased protein binding of drugs
and increased free drug available to exert therapeutic effects, but it also
increases the risk for drug toxicity.
Metabolism
• Hepatic blood flow in the older adult may be decreased by 40%; aging also results
in a 15% to 30% decrease in liver size and a reduction in cytochrome P450 enzyme
activity, which is responsible for the breakdown of drugs.
• A reduction in hepatic metabolism can decrease first-pass metabolism and can
prolong drug half-life, resulting in increased drug levels and potential drug toxicity.
• To assess liver function, liver enzymes must be checked. Elevated levels of alanine
aminotransferase (ALT or SGPT) and aspartate aminotransferase (AST or SGOT) may
indicate possible liver dysfunction.
• However, an older adult can have normal liver function test (LFT) results and still
have impaired hepatic enzyme activity.
Excretion
• Excretion is altered by age-related changes in kidney function, such as
decreased renal size and volume, which differ for each individual.
• It is generally accepted that the GFR declines by 1mL/min after 40 years of
age (normal GFR is 100-125mL/min).
• Changes in kidney function affect many drugs, leading to a prolonged half-
life and elevated drug levels.
• Changes in kidney function require dosage adjustment, especially if the
drug has a narrow therapeutic range.
Pharmacodynamics
• Pharmacodynamic responses to drugs are altered with aging as a result of
changes in the number of receptor sites, which affects the affinity of
certain drugs. These changes are seen most clearly in the cardiovascular
system and central nervous system.
• Older adults experience a loss of sensitivity in adrenergic receptors,
affecting both agonists and antagonists; this results in a reduced response
to beta blockers and beta2 agonists.
• There is a reduced blood flow to the brain, and the BBB also becomes
more permeable. This puts the older adult at risk for CNS drug side effects
which include dizziness, seizures, confusion, sedation, and extrapyramidal
effects.
Nursing Implications: Older Adult Drug Dosing
and Monitoring
Polypharmacy
• Polypharmacy refers to the use of more medications than is
medically necessary.
• Risk factors associated with polypharmacy include advanced
age, female sex, multiple health care providers, use of herbal
therapies and OTC drugs, multiple chronic diseases, and the
number of hospitalizations and care transitions.
• To reduce the risk for and incidence of polypharmacy, nurses
must be involved in the coordination of care for older adults.
Adverse Drug Events
• No drug is safe. Every year, more than 775,000 emergency department (ED)
visits occur due to adverse drug events (ADEs), and more than 125,000 people
are hospitalized due to ADEs.
• Most visits and hospitalizations occur due to reactions to blood thinners, drugs
used to treat diabetes and seizures, cardiac drugs, and drugs used for pain
control.
• There are five types of ADEs: (1) adverse drug reactions, (2) medication errors,
(3) therapeutic failures, (4) adverse drug withdrawal events, and (5) overdoses.
• Older adults have multiple risk factors for ADEs, including frailty, multiple
comorbidities, polypharmacy, and cognitive issues.
Adherence
• Adherence to a drug regimen is a problem for all patient age groups, but it is
especially troublesome in older adult patients. Older adults may fail to ask
questions during interactions with HCP, which leads to the drug regimen not being
fully understood or precisely followed.
• Failure to adhere to a drug regimen can lead to ADEs, resulting in hospital
admission, readmission to health care institutions, and even death.
• Education is the cornerstone of adherence, and this includes education of the
patient, family, and formal and informal caregivers.
• The Medicare Modernization Act of 2003 made it possible for older adults to
obtain prescription drug coverage through Medicare. However, not all older adults
have insurance that includes prescription drug coverage, nor are they able to
afford their drugs even with insurance.
Health Teaching with the Older Adult
Specific factors that enhance educational readiness and promote adherence in the
older adult include the following:
 Ensure that the patient is wearing eyeglasses and has working hearing aids in place
if needed.
 Speak in a tone of voice that the patient can hear; sit facing the patient, and limit
distractions.
 Treat the patient with respect; never infantilize; expect that the patient can learn.
 Use large print and dark type against a light background; use a font with serifs, or
“feet and tails”, which makes letters close together easier to read.
 Review all drugs at each patient visit; ask the patient to bring all drugs to each
appointment, and advise use of only one pharmacy.
 Advise the patient to complete the vial of life (medical information for emergency
personnel to use in the provision of care) and keep it on the refrigerator door
where safety personnel will know to look for it.
 Instruct the patient to keep a list of all drugs taken, bring it to all health
appointments , and carry it when out of the house.
 Encourage a simple dosing schedule when possible.
 Suspect recently prescribed drug(s) if new confusion or disorientation occurs.
 Encourage the patient to report if a drug is not improving the condition for which it
was prescribed.
 Consider use of memory aids such as pill organizers or planners, alarms, blinking
lights, or prerecorded messages.
End