24
Why the Elderly Need Individualized Pharmaceutical Care David B. Nash, MD, MBA Jennifer B. Koenig Mary Lou Chatterton, PharmD
Why the ElderlyNeed IndividualizedPharmaceutical Care
David B. Nash, MD, MBA
Jennifer B. Koenig
Mary Lou Chatterton, PharmD
■
Why the Elderly Need
Individualized
Pharmaceutical Care
byDavid B. Nash, MD, MBA
Jennifer B. KoenigMary Lou Chatterton, PharmD
Office of Health Policy and Clinical OutcomesThomas Jefferson University
April 2000
Supported by an educational grant from the National Pharmaceutical Council
© Copyright 2000 by Thomas Jefferson University.All rights reserved.
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
iii
About the Authors
David B. Nash, MD, MBA, FACP, is Founding Director,
Office of Health Policy and Clinical Outcomes at Thomas
Jefferson University Hospital and Associate Dean at Jefferson
Medical College in Philadelphia. A board-certified internist,
Dr. Nash is nationally recognized for his work in outcomes
management and quality-of-care improvement. His publica-
tions include more than 50 articles in major journals and
10 edited books.
Jennifer B. Koenig is a medical writer for the Office of
Health Policy and Clinical Outcomes at Thomas Jefferson
University Hospital. She has researched and written on a vari-
ety of topics, including pharmacoeconomics, behavioral
health, and numerous health policy issues.
Mary Lou Chatterton, PharmD, is Program Director for
Research in the Office of Health Policy and Clinical Outcomes
at Thomas Jefferson University Hospital. A registered
pharmacist, Dr. Chatterton has conducted and reported on
pharmacoeconomic and quality of life research in a variety of
clinical areas including central nervous system and infectious
diseases.
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
v
Table of Contents
Summary ........................................................................................................................... vii
Introduction ....................................................................................................................... 1
Multiple Diseases ............................................................................................................... 2
■ Optimal Therapy for Elderly Patients with Coexisting Conditions .............................. 6
Physiological Changes ...................................................................................................... 6
■ Changes in the Way the Body Processes Drugs ........................................................... 7
Absorption ................................................................................................................. 8
Distribution ............................................................................................................... 8
Metabolism ................................................................................................................ 8
Elimination ................................................................................................................ 9
■ Aging Organ Systems ................................................................................................... 9
Variation in Drug Action .................................................................................................. 9
■ Enhanced Effects .......................................................................................................... 9
■ Diminished Effects ..................................................................................................... 10
■ Side Effects ................................................................................................................. 11
Central Nervous System .......................................................................................... 11
Anticholinergic ........................................................................................................ 11
Cardiovascular ......................................................................................................... 11
Obstacles to Individualized Drug Therapy for the Elderly ...................................... 12
■ Switches ..................................................................................................................... 12
■ Limits ......................................................................................................................... 14
Conclusions: The Need for Coordinated Pharmaceutical Care ............................. 15
Appendix: Diseases of the Elderly .............................................................................. 16
References ........................................................................................................................ 18
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
vii
Advances in healthcare and pharmaceuticals havemade it possible to treat many common diseasesof the elderly.However, at a time when more inno-vative drug options are available, access to theseagents is often limited or denied by restrictiveaspects of drug benefit plans. For the elderly espe-cially, such limitations are counterproductive.More than any other group, older people needaccess to a wide range of prescription drugoptions to safely meet their specific healthcareneeds. A “one drug fits all” approach does notwork for elderlypatients because theyare exposed to uniquehealth variables thatare rare in youngerpatients. When thesefactors interact in anolder patient, individu-alized drug therapy isrequired, and restricted drug access could lead toineffective or negative health outcomes.
Selection of pharmaceutical therapy for elderlypatients can pose a significant challenge and isdetermined by three primary factors unique tothis group. First, the prevalence of multiple chron-ic diseases,or comorbidity, is much higher in olderindividuals. For example, nearly 40% of the elderlysuffer from arthritis plus another serious healthcondition, such as cardiovascular disease or dia-betes. Second, an older body reacts to pharmaceu-ticals quite differently than a youthful one due tothe physiological changes that accompany aging;metabolism rates change, organ function declines,and sensitivity to some drugs can be altered.Finally, compared with younger patients, there is
generally a wider variation in pharmacologicalaction of a drug across individuals.Taken together,these three factors create the need for flexibilityin prescribing for the elderly.
Although there are many high-quality pharmaceu-tical agents to treat diseases of the elderly, optimalselection of medications can only be achieved if awide range of drug options is available. If restric-tive drug policies or inadequate insurance planslimit the availability of pharmaceuticals, pre-
scribers may be unableto choose the best drugtherapy for theirpatients. Such restric-tions may compromisethe health of the elder-ly unnecessarily andresult in increased uti-lization of other med-
ical services, thereby increasing overall costs.Suchoutcomes are deleterious to everyone involved:patient, provider, plan, and payer.
Furthermore, several additional factors increasethe risk of sub-optimal pharmaceutical care forolder Americans.These patients often have a num-ber of physicians (specialists and sub-specialistsincluded) providing for their care without any col-laboration. Also, older patients, particularly thefrail elderly, migrate among separate treatmentsites, a practice that provides little continuity ofcare.What is greatly needed is the coordination ofall drug treatments for an individual patient—across sites,providers, and over time. Such a seam-less continuum may represent the next stage inthe evolution of geriatric pharmaceutical care.
■
A “one drug fits all” approach does not
work for elderly patients.
■
Summary
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
1
Introduction
Pharmaceutical therapy is the most commonmedical intervention used to treat the elder-ly, a group which currently comprises 13%
of total U.S. population and which accounts forapproximately one-third of all annual healthcarecosts, or $300 billion.1 Recent attention to pre-scription drug expenditures has stimulated dis-cussions about how to design drug benefit plans,public and commercial, that adequately addressboth medical and eco-nomic concerns of theelderly. An under-standing of the com-plexity of pharmaceu-tical therapy in theelderly is essential toachieving this goal.
Medications,especially recently developed agents,can often improve the health and quality of life ofolder individuals suffering from many conditions,including the most prevalent diseases of the elder-ly listed in Chart 1. However, the elderly, a diversepopulation with specialized healthcare needs,require pharmaceutical care that is individuallytailored to each patient based on his or her spe-cific health status. Due to considerable variationfrom patient to patient, there may be no one “best
practice” for treating every patient.The sources ofvariation include the presence of multiple chron-ic diseases, the physiological changes that accom-pany aging, and the wide variation in the proper-ties of drugs used to treat diseases of the elderly.These separate factors, which are further dis-cussed in this paper, interact to form a complexpicture.
The paper also presents“vignettes” illustratinghow these factors cancombine with uncoor-dinated pharmaceuticaltreatment to result incompromised care.Created by physiciansand pharmacists, each
vignette is a hypothetical account that under-scores the need for coordinated pharmaceuticalcare within the larger context of the entire health-care system.
The variations in response to medications amongthe elderly result in part from wide differences innumbers and patterns of coexisting conditions,organ function, frailty, cognitive ability, and capac-ity to perform activities of daily living. Since these
■
The elderly require individually tailored
pharmaceutical care.
■
Source: Centers for Disease Control and Prevention/National Center for Health Statistics. Current Estimates from the National
Health Interview Survey, 1995. Report 199, 1995.
CHART 1: Disease Prevalence in the Elderly
49Arthritis
Hypertension
Heart Disease
Diabetes
Depression
Stroke
0 5 10 15 20 25 30 35 40 45 50
Percentage of population 65 years and older
Alzheimer’s
40
31
13
10
10
7
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
2
factors differ by age, drug therapy requirementsand problems may differ across “younger-old”(ages 65-75), “older-old” (76-85), and “oldest-old”(86+) age cohorts.2 While the oldest-old group(especially those over 100 years of age) is growingfastest, their general physiological characteristics,their pharmacological needs, and their ability tohandle medications are poorly known.
In addition, the actions of medications for manyconditions, such as hypertension and depression,may differ for elderly individuals of various racialand ethnic backgrounds. Over the past 20 years,research has revealed clinically significant differ-ences in metabolism among some minorities.These individuals may be at greater risk of anundesirable outcome if prescribed the “standard”pharmaceutical remedy for many diseases. Forinstance, some studies have indicated that African-Americans are less responsive to some antihyper-tensive agents, specifically beta-blockers and ACE-
inhibitors. In many cases, treatment with a calci-um channel blocker or a diuretic may be moreeffective for this population. Chinese-Americansmay be more sensitive to the effects of certainantihypertensives, requiring a dosage adjustmentor selection of an alternate agent for optimal ther-apy.3 For these reasons, the availability of manytherapeutic options is necessary to adequatelymeet the needs of various ethnic and racialgroups. Although information on the differencesin therapeutic response among minorities hasbeen growing, much more research is required,particularly now as the elderly population increas-es in its diversity. By 2030, the rate of populationgrowth in older minority groups is projected to bealmost three times that of the total elderly popu-lation.4
Multiple DiseasesComorbidity, or the simultaneous presence of twoor more chronic diseases, is common in the elder-ly and is an important reason why treatment mustbe tailored to the needs of individual patients.Therate of comorbidity in the elderly population hasincreased steadily since the early 20th century.This increase may be attributed to a rise in thenumber of diagnoses and to increased longevity.5
As people age, the incidence and impact ofcomorbidity increase, resulting in a decline in wellbeing and functional abilities.6
Verbrugge and colleagues determined that a per-son over age 55 has an average of 2.68 chronic con-ditions,7 and Hobson cited an average of 5 coexist-ing conditions in patients 65 years and older.8 Thecommon thread through almost all comorbiditystudies is that the number of diseases per personincreases with age.5 Chart 2 depicts the prevalenceof chronic conditions and comorbidity in the elder-ly population. By the seventh decade of life, threeout of four people suffer from at least one chronicdisease and more than half have two or more dis-eases.5
Just as certain individual diseases are more com-mon in the elderly, there are also frequently occur-ring disease pairs. The simultaneous presence ofarthritis and high blood pressure is one such paircommon in older people; more than 24% of peo-ple older than 60 suffer the effects of both dis-eases (see Chart 3). Such comorbidity requirescareful selection of drug therapy to ensure safeand effective drug combinations. In Chart 3 theincidence of several common disease pairs isshown and potential drug interactions are high-lighted.
Patients with multiple diseases require multiplemedications. The NHANES III study found thatapproximately 30% of patients age 75 or olderwith two or more chronic conditions take at least5 prescription drugs regularly.9 Another studyreports that the average elderly person commonlytakes 4.5 prescription medications;8 among nurs-ing home residents this number may be as high as7 or more drugs.10
■
The actions of medications may differ in
elderly individuals of various racial and
ethnic backgrounds.
■
2 or more diseases
1 disease
0 diseases
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
3
Source: Guralnik, JM et al. “Aging in the Eighties:The prevalence of comorbidity and its association wih disability.”Advance Data
Report 170. 1989.
CHART 2: Comorbidity Increases with Age
60s 70s 80s
Age Ranges
Pop
ula
tio
n b
y Pe
rcen
tage
70
60
50
40
30
20
10
0
■
■■
◆◆
◆
▲
▲
▲
▲
◆
■
62
54
40
3428
24
1518
26
Prescribing multiple medications poses a chal-lenge to healthcare providers. Often, olderpatients visit multiple physicians for treatment ofvarious conditions. Coordinating medicationsamong multiple physicians in most current health-care systems is difficult,but without coordination,elderly patients are atincreased risk foradverse drug reactions(ADRs). As the numberof medications increas-es, so does the risk ofan ADR. An ADR canresult in mild to seri-ous injury to thepatient.10 Patients tak-ing 5 or fewer drugs have a 4% chance of an ADR.With 6 to 10 medications, the risk increases to10%, and at 11 to 15 medications, the risk of anADR skyrockets to 28%.11 These numbers indicatea need to take extra caution when determining thebest drug therapy for older patients.
For patients with comorbid conditions for whichthey receive multiple medications, two types ofADRs, drug-drug and drug-disease interactions, areof particular concern. Drug-drug interaction canoccur when the medications prescribed for twoconditions do not mix well. For example, an older
patient who has hyper-tension and depressionmay be taking guanethi-dine to reduce bloodpressure and a tricyclicantidepressant concur-rently. However, certainantidepressants inter-act with guanethidine,reducing its antihyper-
tensive effect.12 This could be potentially danger-ous for a patient with severe hypertension. Toavoid this drug-drug interaction, an alternate anti-depressant which does not reduce the effective-ness of guanethidine would be preferable.
■
Certain disease pairs may have much
greater effects on the patient.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
4
Managing Multiple Medications: Finding Combinations that Work
Mr. K is an 80-year-old widower who lives alone, but near his daughter who looks in on him. Hehas a history of heart disease and high blood pressure, conditions for which his cardiologist pre-scribes digoxin and an antihypertensive drug, respectively. One year after his wife’s death, Mr. Kstill does not seem to be his “old self.” He has lost touch with friends, appears lethargic during theday but cannot sleep at night, and seems increasingly sad. His daughter becomes concerned andbrings him to the family physician.A benzodiazepine for insomnia and a tricyclic antidepressantare prescribed.The drugs initially improve Mr. K’s mood, but he soon becomes confused and for-getful.Also, he complains of dizziness and even falls once.This close call results in another trip tothe physician, where his blood pressure is found to be extremely low.
Upon review of Mr. K’s medications, the family physician realizes the problem. In attempting tocontrol Mr. K’s rising blood pressure, his cardiologist had increased the dosage of the antihyper-tensive agent. The antidepressant, the insomnia medication, and the hypertension medicationtogether had produced the disorientation and dizziness. Further worsening the situation was thenon-prescription antihistamine that Mr. K takes frequently for his hay fever and other allergies.
The doctor contacts the cardiologist to discuss the dosage of the antihypertensive and to suggesta different blood pressure medication, possibly a diuretic. He also revises the antidepressant andinsomnia therapy by discontinuing the benzodiazepine and replacing the antidepressant with onealso having sedative effects, with instructions to take before bedtime. For the hay fever, the doctoradvises replacing the non-prescription antihistamine with a new intranasal steroid spray for hisallergies that would not add to his lethargy.The new drug regimen allows Mr. K to take fewer pillswhile getting better results.
Drug-disease interaction occurs in patients withcomorbidity when a drug prescribed for one con-dition worsens another condition. An example iswhen beta-blockers are used to treat heart diseasein a patient who also has respiratory problems.Although the use of beta-blockers after a heartattack has been associated with significantlyreduced mortality rates,these medications canexacerbate breathingproblems in patientswho also have asthmaor other respiratory dys-function.13 Potentialdrug-disease interac-tions should always beconsidered when pre-scribing for elderlypatients with comorbidity.
An additional concern for the older patient withmultiple conditions is the possibility of synergism.
Certain disease pairs may have much greatereffects on the patient than the singular effects ofthe two component diseases.7 Such pairs may sub-stantially reduce functional ability. Diabetes plusdepression or diabetes plus heart disease are twosynergistic pairs yielding exacerbated effects. Forpatients with multiple diseases, simply combining
the standard treatmentsfor each disease may notbe effective. Asexplained in a 1993 arti-cle in The Journal ofEpidemiology, “As thenatural course and thera-peutic interventions ofone disease will influ-ence the co-existing sec-ond (or even third) dis-
ease, comorbidity diminishes the practical value ofsingle-disease standards for treatment and manage-ment.”14 Many drugs on the market are tested insingle-disease trials and may include few elderly
■
. . . comorbidity diminishes the practical
value of single-disease standards for
treatment and management
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
5
CHART 3: Comorbidity and Drug Interactions*
Percentage Potential Population Over Drug
Comorbid Disease Pair Age 60 Interactions Adverse Effects
Arthritis and 24.1% NSAIDs + Digoxin Some NSAIDs mayHigh Blood Pressure increase digoxin levels
resulting in potential toxicity.
NSAIDs + ACE Inhibitors Some NSAIDs may bluntthe antihypertensiveeffects of some ACEinhibitors.
Depression and 15.0% Tricyclic Antidepressants + The concomitant use of Other Comorbid Disease Clonidine (for these agents may
hypertension) significantly increaseblood pressure and cause potential hypertensive crisis.
Arthritis and Heart Disease 8.0% NSAIDs + Coumadin With NSAID use, theanti-coagulant (blood-thinning) effect of coumadin may be enhanced. Also, there is increased risk of bleeding in the GI tract.
NSAIDs + Beta-blockers This combination couldresult in a reduced anti-hypertensive effect andincreased blood pressure,negatively impactingheart disease.
High Blood Pressure and 8.0% Digoxin + Calcium Digoxin and some Heart Disease channel blockers calcium channel
blockers show additive effects increasing the potential for digoxin toxicity.
Diuretics + Digoxin Arrhythmia can resultfrom the concomitantuse of digoxin withloop diuretics.
High Blood Pressure and 5.7% Thiazides + Insulin Thiazides reduce theDiabetes effectiveness of insulin.
Arthritis and Diabetes 5.5% Cortisone + Insulin Harmful increase in blood glucose levels in diabetics.
* This chart illustrates only a few examples of drug interactions and is not intended to represent the scope of all potential
interactions.
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
6
participants with comorbidities. This underscoresthe need for individually tailored and routinelymonitored drug therapy regimens.
■ Optimal Therapy for Elderly
Patients with Coexisting Conditions
The range of pharmacological actions now avail-able for the treatment of many diseases allowsphysicians to choose optimal medications forpatients with one or more comorbidity. Chart 4explains how antidepressant therapy can be opti-mized for patients with depression and a coexist-ing illness or condition.The chart lists the majorclasses of drugs used to treat depression, and outlines conditions that exist commonly withdepression. Because of the high prevalence ofcomorbidity and the plethora of possible diseasecombinations, there is no one preferred treatmentof depression in older individuals. Rather, as thechart indicates, the selection must be based on thepharmaceutical characteristics of the drug and theconditions of the patient; a medication that is agood choice for one patient may not be the bestchoice for another. This also holds true for thepharmaceutical treatment of diseases other thandepression. The wide availability of drug optionsfor the treatment of specific diseases helps toensure that optimal care can be obtained for older
patients with varying health status.
In addition, some illnesses may actually representa cluster of related diseases, with many commonsymptoms but differing in many aspects.Depression may be an example of such a cluster,since depressive symptoms vary among patients.For example, depression is associated with agita-tion in some patients,but not in others.These vari-ations in symptomatology may reflect differencesin the patterns of neurotransmitter imbalanceunderlying the disease. Although a decrease inserotonin appears to play a central role, norepi-nephrine and dopamine are implicated as well.The available antidepressant medications differ intheir relative effects on these neurotransmitters,and differences exist even among agents of thesame pharmacological class. Prescribers can takeadvantage of these differences in optimizing ther-apy for individual patients.
Physiological ChangesMany studies have demonstrated that age-relatedphysiological changes affect the outcomes of drugtherapy.15 As a group, the elderly span the contin-uum from near perfect health to extreme physio-logical decline. Dr. Robert M. Oskvig of theUniversity of Rochester Medical Center concurs:
Drug-Disease Interaction in a Patient with Arthritis and Heartburn
Mrs. R is a 63-year-old woman with a history of moderate heartburn for which she self-medicateswith an over-the-counter medication. She has recently noticed painful aching in her hands. Herdoctor diagnoses her with mild arthritis and orders a prescription for ibuprofen, an anti-inflam-matory pain reducer. However, Mrs. R does not mention her use of a non-prescription drug forheartburn.
After several weeks of regular ibuprofen use, Mrs. R experiences severe chest pain. She is rushedto the emergency room, but after a series of tests, the ER doctor rules out heart attack as the causeof the pain. Instead, he believes that Mrs. R has had a drug-disease interaction; the ibuprofen aggra-vated her heartburn severely, causing the intense chest pain.To alleviate the condition, the ER doc-tor contacts Mrs. R’s primary care physician to propose an alternate arthritis drug, which does notresult in gastrointestinal side effects such as heartburn. In addition, he suggests an evaluation todetermine the root causes of Mrs. R’s persistent heartburn.
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
7
“There is consensus that physical and medical het-erogeneity increases as the population gets older;that is, this population is unique for its non-homo-geneity.”16 Trends indicate that of the entire elder-ly population, the younger-old are the most homo-geneous in their health status; conversely, thephysiological integrity of the oldest-old varies con-siderably from individual to individual.16 With somuch variation, many drug options are necessaryto meet the health needs of specific elderly indi-viduals and groups safely and effectively.
■ Changes in the Way the Body
Processes Drugs
Changes in the rate at which drugs are absorbed,distributed, metabolized, or eliminated by the bodycan affect the level of drug in the blood stream.Higher blood levels mean greater drug action andpotentially greater toxicity, and vice versa. Each ofthese four “pharmacokinetic” processes may begreatly altered in elderly individuals, so all drugtherapy regimens must reflect a consideration ofthese changes.17
CHART 4: Optimal Therapy for Depression in Elderly Patients withCoexisting Conditions
Arrhythmia ∅ ∅ ∅ ●● ●● ● ●●
Constipation ∅ ∅ ● ●● ∅ ● ●●
Hypertension ∅ ●● ●● ●● ∅ ●● 1 ∅Insomnia ●2 ●● ● ∅ ●● ∅ ∅Hypotension ∅ 3 ∅ ∅ ● ∅ ● ●
Mobility Problems ∅ ∅ ∅ ● ∅ ● ●
Vision Problems ∅ ∅ ● ●● ∅ ● ●●
● Good choice ●● Adequate choice in most circumstances ∅ Use with caution
Sources: Drug Facts and Comparisons, 2000;Wells BG, Mandos LA. Depressive Disorders. In: Pharmacotherapy, Dipiro J editor.3rd ed. 1997:1395-1415.
Tri
cycl
icA
nti
dep
ress
ants
(T
CA
)
Tet
racy
clic
An
tid
epre
ssan
ts
Tri
azo
lop
yri
din
es
Am
ino
ket
on
es
Mo
no
anin
e O
xid
ase
Inh
ibit
ors
(M
AO
I)
Sele
ctiv
e Se
roto
nin
Reu
pta
ke
Inh
ibit
ors
(SS
RI)
Sero
ton
in/
No
rep
inep
hri
ne
Reu
pta
ke
Inh
ibit
ors
Note: This chart illustrates the range of antidepressant medications available for patients with varying conditions and characteristics, and is based on information from the sources cited and the opinions of several physicians. It is NOT, however, intended to be used as a tool to assist with prescribing.
1 Possible interaction between specific SSRIs and specific antihypertensives.2 Due to greater sedative effects, one sub-class of tricyclic antidepressants may be preferable to another sub-class for
patients with insomnia.3 One tricyclic antidepressant, nortryptiline, is not associated with exacerbated hypotension (Wells and Mandos, 1997).
Coexisting Conditions
Antidepressants by Class
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
8
AbsorptionAs people age,drug absorption rates fluctuate dueto changes in certain organs.18 For example, thechanges in an older gastrointestinal tract canaffect the absorption of drugs taken by mouth.19
Likewise, the absorption of drugs administeredtransdermally (across the skin) may be slowed bythe decreased vascularity in older patients.19 Ofthe four pharmacokinetic processes, absorptionhas the least significant impact on the choice ofpharmaceuticals for the elderly patient.
DistributionDepending on their chemical structure, drugs willdistribute to different places in the body. Somedrugs distribute to lean body tissue, while others
distribute to fatty tissue. As the body ages, it main-tains less lean body tissue and acquires greaterstores of fatty tissue.These changes will affect thedosage amount needed to produce the desiredtherapeutic outcome. If dosage is not appropriate-ly adjusted for the elderly, toxicity can occur.20
Toxicity refers to levels or conditions underwhich a drug causes an unanticipated, deleteriousreaction. This is an important consideration with adrug such as digoxin, which is used to treat heartdisease. Digoxin has a narrow therapeutic range,or “window” between the level at which the drugis effective and the level that results in toxicity.8
Also, digoxin distributes to the lean body mass, ofwhich there is less in most elderly. Combined,these two conditions require great care in pre-scribing this agent for older patients. For somepatients, an alternative treatment choice may berequired due to these age-related changes. Otherexamples of drugs that may be affected by age-related changes in distribution are gentamicin, apotentially toxic antibiotic; lithium carbonate, indi-cated for severe agitation;21 and some benzodi-azepines, used to treat anxiety and sleep disor-ders.22
In addition to changes in body composition, dietcan affect the body’s distribution of drugs.According to nutrition screening programs in awide variety of institutional and community set-tings, the risk rates for malnutrition in the elderlypopulation range from 25% to 85%.23 Malnutritionalters the therapeutic effect of some drugs thatutilize protein for distribution. Although improv-ing the diet is the best solution, sometimes this isnot possible, especially for community-dwellingelders who live alone. When malnutrition is sus-pected, the use of a non-protein-binding drug maybe the best choice.
MetabolismDrugs are broken down (metabolized) primarilyin the liver, and there is great variation in the rateof decline in liver function among elderly individ-uals. As people age, two important metabolicchanges occur. First, blood flow through the liveris reduced.24 Therefore, drugs that depend onblood flow to metabolize in the liver, such asisosorbide and lidocaine, should be started atlower doses and increased as necessary to achievethe desired therapeutic effect.8 Secondly, certainmetabolic pathways that metabolize drugs changeas people age. Some pathways are affected byaging, but some are not.25 If there is a decline infunction of a certain metabolic pathway, drugsthat use this pathway are less preferable than onesthat use other pathways. For example, metabolicreactions such as oxidation, reduction, and hydrol-ysis occur in the liver and are affected by aging.Therefore, drugs that use these processes couldhave altered effects in the elderly. Such drugsinclude the anti-anxiety agent diazepam, the car-diovascular agent quinidine, and the antidepres-sant nortriptyline.26
■
... this population is unique for its
non-homogeneity.
■
■
For some patients, an alternative
treatment choice may be required due to
these age-related changes.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
9
EliminationMany drugs are eliminated from the body throughthe kidneys. Unlike metabolism in the liver, therate of decline in elimination by the kidneys is fair-ly predictable. In elderly patients, kidney functionmay be reduced by as much as 50% by age 75.27
Of particular concern are renally eliminated drugswith a narrow therapeutic range. If kidney func-tion is reduced, toxicity may occur before thebody can rid itself of these drugs. Some examplesof drugs of this type include digoxin,8 aminogly-coside antibiotics, lithium, cimetidine28 andcoumadin.25
■ Aging Organ Systems
Although almost every organ system in the body isvulnerable to the effects of aging,there is great vari-ation in organ function among elderly individuals,especially the younger-old.27 Factors that effectorgan aging are heredity,disease, and lifestyle. Withdeclining organ function, the body responds differ-ently to pharmaceuticals. Chart 5 details the effectsof aging on various organ systems and the relatedimplications for prescribing.16
Variation in Drug ActionAs pharmaceutical innovation continues, the num-ber of drugs that exist to treat diseases of the
elderly will increase, offering the potential forincreased longevity and improved quality of life.As of October 1999, 600 new drugs were in devel-opment by American pharmaceutical companiesto treat diseases of the elderly.29 But, like existingagents, new medications for a given disease arelikely to vary greatly in effect. This is not to assertthat one drug is better than another necessarily;rather, that different drugs prescribed for an ill-ness can produce different responses, particularlyin elderly individuals.This section examines thesevariations and their impact on drug selection forolder patients.
■ Enhanced Effects
With age, organ systems can become more sensi-tive to the effects of certain drugs.When comparedto younger patients, the elderly are more likely toexperience atypical, enhanced drug effects at thetarget site — the organ or organ system where thedrug acts. For example, the elderly are generallymore sensitive to certain drugs that act in the cen-tral nervous system28 The phenothiazines, chlor-
Older Bodies Need Different Drugs
Mr.P,a 67-year-old ex-sports columnist and tennis enthusiast, fell during a match and broke his arm.In the emergency room, an intern prescribes the narcotic meperidine to relieve the pain.After sev-eral days Mr. P has an unexplained seizure.Apparently, although Mr. P appears to be in top physicalcondition for a man of his age, his kidney function is declining. His doctor explains that aging ofthe kidneys can result in poorer renal function,causing a build up of some drugs and drug by-prod-ucts that are renally eliminated.The drug Mr. P was given for pain produced a by-product that builtup in his system and caused the seizure.Although meperidine can work well for younger patients,his doctor says, older patients who may have compromised renal function have better luck withother painkillers. Because of Mr. P’s fit and youthful appearance, the intern had not considered thispossibility of age-related renal impairment.Mr.P is switched to morphine,which does not have theseizure-inducing by-product. Soon after, the dosage of morphine is reduced and then completelydiscontinued.
■
With declining organ function, the body
responds differently to pharmaceuticals.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
10
CHART 5: Aging Organ Systems and Prescribing Implications
Organ System Effects of Aging Prescribing Implications
Respiratory system
Cardiac system
Central nervous system(CNS)
Gastrointestinal (GI) system
Renal system
Immune system
Increased sensitivity to certain pharmaceuticals
Increased rigidity of chest wall
Reduced lung muscle strength andendurance
Changes of heart (stiffening, reducedmuscle strength) and blood vessels
Increased sensitivity
Decline in receptors and pathways(fewer brain cells and connections)
Increase in gastric emptying time
Decrease in GI blood flow
Decreased blood flow in kidneys anddecrease in kidney mass
Decreased immunity to disease
Greater susceptibility to infection
Problems with sleep apnea and periodic breathing with narcotics
Exacerbation with opioids
Decreased strength and endurance oflungs with some medications
Weaker and slower heart beat and worsened circulation with diureticsand narcotics
Enhanced response to CNS agentsrequiring lower doses of drugs suchas barbiturates and opioids
Slower mobility and voluntary motoractivity; carefully monitor drugswhich affect motor function
Possible GI bleeding with someNSAIDs
Slower healing of drug-induced bleeding
Prolonged effects of drugs that areeliminated by the kidneys
Possible increase in antibiotic use
promazine and thioridazine, for instance, are usefulin treating agitated behavior because of their seda-tive effects. However, the administration of thesedrugs in the elderly may cause enhanced effectsincluding over-sedation and a drop in blood pres-sure. For patients with pre-existing hypotension(low blood pressure), this could cause weaknessand dizziness resulting in falls and fractures.17
Likewise, long-acting anti-anxiety drugs such asbenzodiazepines, which may be a good choice forelderly patients with occasional insomnia, are not
appropriate for long-term daily use because of theirtendency to build up and increase the risks of seda-tion, confusion, and falls.17 To induce sleep, alter-natives such as antihistamines or newer agentswithout these side effects could be considered.
■ Diminished Effects
The opposite of enhanced drug effects, dimin-ished effects are sometimes seen in the elderly.Just as some organ systems are more sensitive to
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
11
some agents, some systems are less sensitive toparticular drugs as well. For instance, the elderlytend to be less sensitive to some calcium channelblockers, which are used to treat heart disease.Older patients may require a higher dosage of acalcium channel blocker to achieve the same ther-apeutic effect as younger patients. This may bedue to the decrease in receptor sensitivity.Interestingly, older patients are more sensitive tothe secondary effects, or side effects, of some cal-cium channel blockers, which include decreasedblood pressure and heart rate. For these reasons,calcium channel blockers may be an appropriateand cost effective choice for treating patients withcomorbid heart disease and hypertension.17
■ Side Effects
As seen in the calcium channel blocker example,some drug side effects can be used to a patient’sadvantage depending on the individual and his orher particular health needs.Other side effects maynot be desirable but can be tolerated, againdepending on the patient’s condition.Three typesof drug side effects that are particularly significantfor elderly patients are central nervous system(CNS) effects, anticholinergic effects, and cardio-vascular effects.With younger patients, these sideeffects would not cause the same concern they dofor older patients; in fact, in some instancesyounger patients would not experience them atall. Because of the increased prevalence of comor-bidities and the tendency toward physiologicaldecline, the elderly may be more susceptible toside effects. Heightened sensitivity to side effectsis important in selecting drugs for individuals.
Central Nervous SystemThe central nervous system can be affected byparticular drugs used to treat other organ systems.For example, the H2 receptor antagonist cimeti-
dine, used to treat gastrointestinal disorders, hasbeen associated with reversible CNS side effects,such as confusion, psychosis, and hallucination inthe elderly and the severely ill.17 For patients whohave comorbid conditions or who are very old,selection of an alternative H2 receptor antagonistwith lesser side effects may be a safer choice. Inaddition, some NSAIDs that treat arthritis cancause confusion in elderly patients as well.
AnticholinergicAlso referred to as anticholinergic agents, drugsthat block the action of acetylcholine in the bodyhave many uses in elderly persons (e.g., glaucoma,Parkinson’s disease). However, anticholinergicproperties of agents used to treat other diseasescan result in negative side effects. Many of the tri-cyclic antidepressants,for example,which are oftenused to treat depression in older individuals, havesubstantial anticholinergic activity. Importantly,anticholinergic side effects often parallel problemsthat are already common in the elderly, including:8
■ Dry skin and mouth■ Tachycardia (rapid heart beat)■ Ataxia (inability to coordinate voluntary
muscular movements) ■ Dementia (disorientation, confusion)■ Constipation
If a patient shows signs of these conditions priorto drug selection, alternate agents that do notcause anticholinergic effects may be preferable.
Cardiovascular Several agents used to treat diseases of the elderlyhave effects on the cardiovascular system, theheart and blood vessels. Powerful diuretics oftenused for congestive heart failure may lower bloodpressure in the elderly. When blood pressuredrops significantly, orthostatic hypotension, adizziness that occurs when a person stands or sitsup quickly, can occur.A common problem in theelderly, orthostatic hypotension can result in life-threatening falls and fractures. The oppositeeffect, an increase in blood pressure, can becaused by some antibiotics and some NSAIDswith high sodium content.This is a cause for con-cern with hypertensive patients. Some psychoac-tive drugs, particularly tricyclic antidepressants,
■
The elderly may be more
susceptible to side effects.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
12
can cause arrhythmia, or an irregular heart beat.28
Finally, fluid and electrolyte disorders can at timesbe attributed to the use of some NSAIDs, antibi-otics, or diuretics—a consideration for patientswith congestive heart failure.
In addition to the CNS, anticholinergic, and car-diovascular side effects described, other sideeffects may materialize during the course of drugtherapy. All potential drug variances—be theyside effects, enhanced effects, or diminishedeffects—should be taken into account during
drug decision-making for elderly patients to avoidharm and optimize any properties that couldprove beneficial for an individual. An adequatechoice of medications should be available for thispurpose.
Obstacles toIndividualized DrugTherapy for the ElderlyConsidering the variation among elderly individu-als and the medications they use, individually cus-tomized drug therapy makes good sense.However, external obstacles often impede this ini-tiative. Major impediments include switching andlimiting drugs.Yet, these obstacles are not all with-in the control of the patient and physician. Asmedical and economic factors collide, patientwellness and quality of care can be compromised.
■ Switches
A variety of circumstances can lead to a switch inan elderly patient’s drug therapy regimen. Manytimes these switches are not based on a physi-cian’s advice, but instead are the result of factorsbeyond patient and physician control such as achange in insurer, formulary, or care setting.Pharmaceutical switches can occur when apatient retires from employment, which oftenmeans a change in health insurance benefits.Because drug formularies vary by insurer, patientscould be forced to switch drugs when theychange insurers,even if their current drug therapyregimen is working perfectly. Similarly, whenpatients migrate across various care settings, asthe elderly are likely to do, formularies maychange and drug switches may occur. Fromhome, to hospital, to nursing facility, to hospice,the availability of specific medications to olderpatients will fluctuate.
Similarly, switches can occur when drugs in thesame class are prescribed interchangeably as acost-saving measure.Therapeutic interchange mayresult in unexpected, and unwanted, responses
Taking Advantage of Side Effects
Mrs.W,a 70-year-old married smoker and dia-betic, cares for her husband, whose healthhas been in decline since his stroke a yearago. The worry about her husband’s healthplus the physical burden of caring for himhas placed considerable stress on Mrs. W.Her doctor has warned her about long-termsmoking, but she continues with the habit.Her blood pressure has recently been ele-vated at 140/100 mmHg, and traces of pro-tein have been found in her urine, whichindicates that Mrs. W might be developingdiabetic kidney disease. Her doctor suggestsa medication that could manage both thehypertension and kidney disease: an ACE-inhibitor (for high blood pressure) that hasthe side effect of reducing the protein inMrs.W’s urine.This medication could lowerher blood pressure and could possibly fore-stall kidney disease, thereby “killing twobirds with one stone,” as Mrs.W puts it.
■
Drug variances should be taken into
account to optimize any properties that
could prove beneficial.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
13
due to variation amongdrugs of the same class, asalluded to earlier. Expertmedical groups, notably theAmerican Association forGeriatric Psychiatry (AAGP)31
and the American MedicalAssociation (AMA)32 havevoiced concerns regarding the appropriateness ofdrug interchange in the elderly. The AAGP sup-ports the notion that biological and physiologicalcharacteristics of the elderly, like comorbiditiesand changes in pharmacokinetics, may causeunexpected changes in the effects of certain med-ications. The AAGP also asserts that restrictedchoice of medications may be detrimental to theelderly individual and to the community in manyways.31
Therapeutic interchange—or switching—may be
used by organizations orhospital pharmacies as acost-saving measure, andindeed cost savings are doc-umented in some cases.33
But often the cost savingsare minimal, are offset byhigher utilization costs forother services,34 or are a
trade-off with reduced quality of care.35 Severalstudies have reported negative health outcomesresulting from switches as well. Even substitutingdosage forms—chewable tablets for capsules orliquid for solid medication—can present prob-lems for older patients who may have difficultywith chewing,measuring,or pouring.36 This couldresult in hazardous under- or over-medication. Inone study, when patients who were stabilized onone of three medications for hypertension wereswitched to a fourth agent, there were increases in
The Aging Body, Multiple Diseases, and Medication Restriction: A Cascade of Events
Mrs. C, a small, thin woman of seventy-five, lives alone in a low-rent apartment and is often lonelyand anxious. She kept her health benefits after retiring from her secretarial job ten years ago, buther plan does not cover all of her medical expenses. She suffers from atrial fibrillation, an abnor-mal heart rhythm that could result in dangerous blood clots. To reduce the risk of clotting, herphysician has prescribed the anticoagulant drug warfarin, which she has now been taking for overa year.
When Mrs. C reports that she is depressed and anxious, her physician prescribes an antidepressantmedication. But she is told at the pharmacy that the prescribed drug is not covered by her healthinsurance and is given an alternate antidepressant with the same mechanism of action.After twomonths on this medication her depression and anxiety have improved. But her clothes feel biggerand she is eating less, and the slightest pressure seems to result in a black and blue bruise on herbody.
The next time Mrs. C visits her doctor, her weight has dropped ten pounds and she shows signs ofmalnutrition. She shows him the bruising.When the doctor asks how she is doing on the medica-tion he prescribed for depression, she tells him about the replacement.The doctor then is able tounderstand the unfortunate cascade of events that have occurred. He explains that a side effect ofthe replacement drug is appetite suppression, and this has reduced Mrs. C’s already small appetiteto almost nothing.Without a healthy diet, the anticoagulant effects of the warfarin she takes for herheart condition have become exaggerated.The excess anticoagulant in her blood has caused thebruising.The doctor says he is glad she brought these symptoms to his attention because with timea more serious problem such as stroke could have developed.
■
... restricted choice of medications
may be detrimental to the elderly
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
14
clinic visits, laboratory services, and side-effectsmanagement, even though all four drugs were ofthe same class.37 Although the scope of this paperprecludes a detailed account of all the negativeoutcomes of pharmaceutical switches, numerousstudies show similar findings.38
■ Limits
As with drug switching, some policy-makers anddrug benefit managers have sought to managecosts by limiting the number or range of drugsavailable for reimbursement.Limits have also beensuggested as a way to promote appropriate pre-scribing in nursing homes.39 Studies have demon-strated, however, that limits can result in negativeoutcomes for elderly patients:“Under use of bene-ficial drug therapy by seniors has been associatedwith increased morbidity, mortality, and reducedquality of life.”40
For example, a Medicaid study revealed that thenumber of gastrointestinal surgeries increasedafter an important drug for peptic ulcers wasremoved from the formulary.41 In another study,when caps were placed on the drug benefit ofMedicaid beneficiaries, nursing home admissionsincreased.42 In the latest nursing home guidelines,however, the Health Care FinancingAdministration (HCFA) suggested that patientstaking nine or more drugs might be receiving
inappropriate care. The American Society forConsultant Pharmacists opposes this claim,responding,“The number of medications orderedper resident per month is not a meaningful mea-sure of quality.The correct number of medicationsmust be determined individually for eachpatient.”39 Yet, individualization of pharmaceuticalregimens for the elderly is challenging if switchesand limits occur without regard to the specifichealth status of the patient, as with routine thera-peutic interchange and some restrictive drug poli-cies.
In addition to the potential for counterproductiveeffects on treatment outcomes, limiting drug bene-fits is not always a cost-saving measure because ofthe possible negative economic outcomes associat-ed with under-utilization and other inappropriateprescribing practices.43 Numerous studies havedocumented a cost shift rather than cost savingswhen drug limits are used as a cost containmentstrategy; drug costs may be reduced, but utilizationof services increases.38 Focus should be onappropriate prescribing practices rather than sav-ings strategies that could compromise care. Toensure a stable balance between quality therapyand cost-minimization, simply limiting drugs willnot work.A coordinated approach to pharmaceuti-cal care in which elderly patients have access tomuch-needed pharmaceutical options may reducemoney spent on complications while enhancingquality of care.44
■
The number of medications is not a
meaningful measure of quality
for each patient.
■
■
Under use of beneficial drug therapy
by seniors has been associated with
increased morbidity, mortality, and
reduced quality of life.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
15
Conclusions: The Need for CoordinatedPharmaceutical Care The elderly can benefit most from custom-designed, coordinated pharmaceutical therapy,but they are also the population at greatest risk forreceiving sub-optimal drug therapy if their uniqueneeds are overlooked.The special risks that olderAmericans face—due to comorbidities, age-relatedphysiological changes, and variation of drugeffects—call for individually tailored drug therapyprograms and a coordinated approach.As the paceof innovation in pharmaceuticals, diagnostics, andmedical practice quickens, the “practice gap”between the availability of important innovationsand their most effective use is widening. Theadvent of “disease management,” which hasbrought many important advances beyond episod-ic and uncoordinated care, has resulted inincreased cooperation and information-sharingamong providers.
Still, additional coordination of pharmaceuticalcare is often required because disease-by-diseaseapproaches may neglect interactions among dis-eases and their treatments.45 The rise of medicalspecialists and sub-specialists coupled with the
increase in fragile elderly with chronic, comorbiddiseases demands greater coordination of care.Older patients often see several prescribing physi-cians, who may not be aware of all the medica-tions patients are taking. Such disconnected carecan result in poor outcomes including medicationerrors and adverse events, as illustrated in thevignettes included in this article. Similarly, theincreasing number of health system mergers hasresulted in increased shifting of patients amongtreatment sites, a practice that can disrupt thecontinuum of care so necessary for the propertreatment of the frail elderly.
To address these issues, the next step in the evo-lution of geriatric pharmaceutical care will be toimprove the coordination of pharmaceutical treat-ments, including the identification of patientswith undiagnosed, untreated, or under-treated dis-ease.While the ability to select drug therapy for agiven disease from a full bank of pharmaceuticaloptions is important, every provider involved in apatient’s care—including primary care physicians,specialists, pharmacists, nurses, and others—alsoneeds a complete picture of the therapy plan.
Recent strategies to coordinate pharmaceuticalcare include the use of technologies such as pre-scription tracking software and computer algo-rithms to spot patients at risk for sub-optimal useof medications.Moreover, the use of highly trainedclinical pharmacists is increasing, as is the stream-lining of standard processes for getting the rightdrugs to patients. While these strategies haveimproved the coordination of care in some set-tings, most elderly patients have yet to benefitfrom these innovations because implementationhas not been system-wide.44 The vision for thefuture is a more complete and cohesive coordina-tion of all aspects of care—including pharmaceu-tical care—in all healthcare settings.
■
The next step in the evolution of geriatric
pharmaceutical care will be to improve
the coordination of treatments.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
16
Appendix: Diseases of theElderlyOnly a handful of diseases account for most of thehealthcare utilization and costs incurred by theelderly population. In order to provide a morecomplete illustration of the healthcare needs ofseniors, descriptions of some of their most preva-lent diseases are provided below.
Arthritis affects over 49% of older Americans,according to a 1995 National Center for HealthStatistics report.1 A disease with more than 100forms, arthritis is a debilitating and painful inflam-mation of the joints. Although arthritis affects peo-ple of all ages, the elderly are particularly at risk forits most common form,osteoarthritis.The total costof arthritis care to the U.S. is more than $65 millionannually. Although many older people believe thatarthritis and its accompanying pain is just a simplefact of aging, Dr. Steven Abramson of the ArthritisFoundation contends that early diagnosis and treat-ment of arthritis can forestall serious joint damage.He encourages patients to seek treatment fromtheir physician when early signs strike rather thanrelying only on over-the-counter products that pro-vide minor pain relief.2
Heart Disease, the leading cause of death amongolder Americans,manifests in many forms, includingcoronary artery disease and congestive heart failure(CHF).3 Coronary artery disease, or atheroscle-rosis, occurs when the inner walls of arteriesbecome narrow due to an accumulation of cells, fat,and cholesterol. This makes it difficult for blood topass through the heart,and can cause a heart attack.A second major disease of the heart, congestive
heart failure, occurs when the heart is not pump-ing fast or strongly enough to deliver the requiredamount of blood and oxygen to the body.The caus-es of CHF can include high blood pressure, coro-nary artery disease, past heart attack, or disease ofthe heart muscle itself. Two other diseases of theelderly, hypertension and stroke, are very closelytied to heart disease, but are significant enough intheir singular impact as to warrant a separatedescription.
Hypertension, more commonly known as highblood pressure, means that the pressure in theheart’s arteries is above the normal level, approxi-mately 120/80 mmHg.3 The top number (systolicpressure) describes the pressure while the heart isbeating; the bottom number (diastolic pressure)indicates the pressure when the heart is at rest.Hypertension can be an early warning sign forother life-threatening heart diseases. While ahealthy diet and regular exercise can help, medica-tion is often necessary to reduce high blood pres-sure, especially in older patients.
Diabetes, a chronic disease for which there is nocure, affects approximately 13% of the age 65+population.1 It is possible that this estimate islower than the actual number of diabetes casesbecause many people remain unaware of their ill-ness until it reaches advanced stages. Diabetes isthe result of the body’s inability to properly pro-duce or use insulin, a hormone necessary for con-verting food into energy. Type II diabetes, themost common form of the disease, affects olderAmericans most often because of increasedlongevity, obesity, and lack of exercise.
When a blood vessel to the brain gets clogged orbursts, a stroke occurs. As a result, the portion of
■
As medical and economic factors collide,
patient wellness and quality of care
can be compromised.
■
■
As pharmaceutical innovation contin-
ues, the number of drugs that exist to
treat diseases of the elderly will increase.
■
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
17
the brain supplied by that vessel shuts down, asdoes any part of the body it controls. Affecting 7%of the seniors over age 65,stroke can be caused bysmoking, uncontrolled hypertension, or heart dis-ease.3
Depression is characterized by four main groupsof symptoms: anxiety, a depressed mood, slowermental and physical functioning, and various physi-cal complaints. In the elderly compared to youngerpatients, however, different symptoms are empha-sized. Anxiety, for instance, is more common inolder patients. In addition, older patients tend toreport symptoms of depression less often, viewingthem as just the effects of old age.5 This underre-porting suggests that there may be even greaternumbers of depressed seniors than the 10% cited inChart 1.
Alzheimer’s Disease, the most widespread typeof dementia, is a progressive, degenerative braindisease that causes confusion, memory loss, and
diminished cognitive abilities. Almost all of the 4million Americans who currently suffer fromAlzheimer’s disease are older people. As the elder-ly population grows, 14 million Americans willhave Alzheimer’s by 2050 unless a cure is found. 6
Sources:1. Centers for Disease Control and Prevention/National Center
for Health Statistics. 1995; Series 10, Report 199.
2. Reuters Health Information. 1999;http://www.arthritis.ca/pages/introduction/
3.American Heart Association.What is Heart Disease? 1999;http://www.americanheart.org/Patient_Information/hhrt-dis.html
4.American Diabetes Association. Diabetes Facts and Figures.1999; www.diabetes.org.
5. Gottfries C. Is there a difference between elderly andyounger patients with regard to the symptomatology and aeti-ology of depression? Clinical Psychopharmacology 1998;13:S13-S18.
6.Alzheimer’s Association. Statistics and Prevalence. 1999;www.alz.org.
■W
HY
TH
EE
LD
ER
LY
NE
ED
IN
DI
VI
DU
AL
IZ
ED
PH
AR
MA
CE
UT
IC
AL
CA
RE
18
References1.White E, Danish A. The elderly as the new consumer of
healthcare. In: Nash D, Manfredi M, Bozarth B, Howell S, edi-tors. Connecting with the New Healthcare Consumer:Defining Your Strategy. McGraw-Hill, 2000:413-437.
2.The Silent Epidemic.America’s Senior Care Pharmacists.1999. http://www.ascp.com/medhelp/silentepic.html
3. Levy R. Ethnic and racial differences in response to medi-cines: Preserving individualized therapy in managed pharma-ceutical programmes. Pharmaceutical Medicine 1999;7:139-165.
4. Profile of Older Americans. U.S.Administration on Aging.1999; 1-15.
5. Guralnik JM, LaCroix A, Everett D, Kovar M. Aging in theeighties:The prevalence of comorbidity and its associationwith disability. National Center for Health Statistics. 1989;170:1-8.
6. Stewart AL, Greenfield S, Hays RD,Wells K, Rogers WH, BerrySD, et al. Functional status and well-being of patients withchronic conditions. JAMA 1989; 262:(7)907-913.
7.Verbrugge L, Lepkowski J, Imanaka Y. Comorbidity and itsimpact on disability.The Milbank Quarterly 1989; 67(3-4)450-484.
8. Hobson M. Medications in older patients.Western Journal ofMedicine 1992; 157:(5)539-543.
9. Pfizer Inc. Pfizer Facts:The health status of older adults.Pfizer U.S. Pharmaceuticals 1999;1st ed.:1-28.
10. Daly MP, Lamy PP, Richardson JP. Avoiding polypharmacyand iatrogenesis in the nursing home. Maryland MedicalJournal 1994; 43:(2)139-144.
11. May F, Steward R. Drug interaction and multiple drugadministration. Clinical Pharmacology 1977; 22:322-328.
12. May JR. Adverse drug reaction and drug interactions. In:Dipiro, editor. Pharmacotherapy 1997;3rd ed.:101-116.
13. Lamy PP. Institutionalisation and drug use in older adults inthe US. Drugs & Aging 1993; 3:(3)232-237.
14. Schellevis FG, van der Velden J, van de Lisdonk E, van Eijk JT,van Weel C. Comorbidity of chronic diseases in generalpractice. Journal of Clinical Epidemiology 1993; 46:(5)469-473.
15. Beyth RJ, Shorr RI. Epidemiology of adverse drug reactionsin the elderly by drug class. Drugs & Aging 1999; 14(3):231-239.
16. Oskvig RM. Special problems in the elderly. Chest 1999;115(Suppl):158S-164S.
17. Chutka DS, Evans JM, Fleming KC, Mikkelson KG.Symposium on geriatrics—Part I: Drug prescribing for elder-ly patients. Mayo Clinic Proceedings 1995; 70(7):685-693.
18. Evans M,Triggs E, Cheung M, Broe G, Creasey H. Gastricemptying rate in the elderly: Implications for drug therapy.Journal of the American Geriatric Society 1981; 29(5):201-205.
19. Parker BM, Cusack BJ,Vestal RE. Pharmacokinetic optimisa-tion of drug therapy in elderly patients. Drugs & Aging 1995;7(1):10-18.
20. Shepherd M.The risks of polypharmacy. Nursing Times1998; 94(32):60-62.
21. Carr M, Carr M. Dangerous brew.The Canadian Nurse 1999;34-36.
22.Vestal RE. Aging and pharmacology. Cancer 1997;80(7):1302-1310.
23.American Dietetic Association. Elder insecurities: Poverty,hunger and malnutrition. Hungerline 1996; Spring(6):1-3.
24. Nagle BA, Erwin,WG. Geriatrics. In Dipiro, editor.Pharmacotherapy 1997; 3rd ed.: 87-100.
25. Loughran S. Medication use in the elderly:A population atrisk. MEDSURG Nursing 1994; (2):121-124.
26. Stein BE.Avoiding drug reactions: Seven steps to writing safeprescriptions. Geriatrics 1994; 49(9):28-36.
27. Potempa K, Folta A. Drug use and effects in older adults inthe United States. International Journal of Nursing Studies1992; 29(1):17-26.
28. Montamat SC, Cusack BJ,Vestal RE. Management of drugtherapy in the elderly. New England Journal of Medicine1989; 321(5):303-309.
29. PhRMA. Pharmaceuticals: Rx for the Graying of America.1999; 1-13.
30. Furberg C, Herrington D, Psaty B.Are drugs within a classinterchangeable? The Lancet 1999; 354:1202-1204.
31.American Association for Geriatric Psychiatry. Position paperon formulary choices and restrictions. 1997; Bethesda MD.
32.American Medical Association. Survey on physicians and pre-scribing issues in hospitals and HMOs. Prepared by theGallup Organization. 1989; Chicago IL.
33. Pettita A,Ward R, Anandan J, Beis S, Johnson A.The cost-effectiveness impact of a preferred agent HMG-CoA reduc-tase inhibitor policy in a managed care population. Journalof Managed Care Pharmacy 1997; 3(5):548-553.
34. Horn SD, Sharkey PD, Phillips-Harris C. Formulary limitationsand the elderly: results from the managed care outcomesproject. American Journal of Managed Care 1999; 4(8):1105-1113.
35. Stock A, Kofoed L.Therapeutic interchange of floxetine andsertraline: Experience in the clinical setting.AmericanJournal of Hospital Pharmacy 1999; 51:2279-2281.
36. Lamy PP. Over-the-counter medication:The drug interactionswe overlook.American Geriatric Society 1982; 30:569-575.
37. Hilleman D, Mohiuddin S,Wurdeman R,Wadibia E. Outcomesand cost savings of an ACE inhibitor therapeutic inter-change. Journal of Managed Care Pharmacy 1997; 3(2):219-223.
38. Levy R, Cocks D. Component Management Fails to SaveHealth Care System Costs:The Case of RestrictiveFormularies. 1999; 2nd ed. Reston,VA. NationalPharmaceutical Council.
39. Clark T. Quality Indicators and the Nursing Facility Survey:Implications for Consultant Pharmacists. 1999;http://www.ascp.com/public/news/hcfaqualindrev.html
40. Rochon PA, Gurwitz JH. Prescribing for seniors: Neither toomuch nor too little. JAMA 1999; 282(2):113-115.
41. Bloom B, Jacobs J. Cost effects of restricting cost-effectivetherapy. Medical Care 1985; 23:872-880.
42. Soumerai SB, Ross-Degnan D,Avorn J, McLaughlin T,Choodnovsky I. Effects of Medicaid drug-payment limits onadmission to hospitals and nursing homes. New EnglandJournal of Medicine 1991; 325(15):1072-1077.
43. Covington,T. Drug benefit: Design and management. In:Nash D, Manfredi M, Bozarth B, Howell S, editors.Connecting with the New Healthcare Consumer: DefiningYour Strategy. McGraw-Hill, 2000:207-236.
44. Paone D, Levy R, and Bringewatt R. Integrating pharmaceuti-cal care:A vision and framework. 1999; 1st ed. Bloomington,MN: National Chronic Care Consortium and NationalPharmaceutical Council.
45. Bodenheimer T. Disease management—Promises and pitfalls.New England Journal of Medicine 1999; 340(15):1202-1205.
The Office of Health Policy and Clinical OutcomesThomas Jefferson University1015 Walnut Street, Suite 115Philadelphia, PA 19107-5099Phone (215) 955-6969Fax (215) 923-7583
