Managing Geriatric Patients

Geriatric case management should always begin with a Comp - rehensive Geriatric As sessment, said Demetra Antimisiaris, PharmD, GCP, FASCP, assistant professor with the Department of Family Medicine & Geriatrics and director of Geriatric Pharmacotherapy at the University of Louisville School of Medicine in Kentucky. In a presentation at the 2011 annual meeting of the Hematology/ Oncology Pharmacy As sociation, Anti - misiaris said many criteria must be considered when assessing a patient’s functionality: nutritional status, activity levels, medical and psychological states, environment, and gait and balance. Obtaining this baseline measure is critical because commonly prescribed and over-the-counter medications often have unanticipated effects on an elder’s behavior or function.

Antimisiaris said medications—even run-of-the-mill drugs like ibuprofen— were never tested in this demographic prior to approval. “Older adults are underrepresented in clinical trials,” she said, adding that exclusions for comorbidities prevent many elderly patients from participating. “Data is especially sparse for individuals 75 and older.”

Antimisiaris cited an Alzheimer’s drug trial as an example of how drugs wind up being used in patients for whom they were never tested. This particular trial limited enrollment to individuals with Alzheimer’s and “no other neurodegenerative disease,” she said. Because an Alzheimer’s diagnosis is typically only confirmed at autopsy, Antimisiaris said the drug is likely going to be used in patients with other types of dementia, causing unexpected toxicities.

Even if more drug trials included the oldest patients, applying the results would be challenging. “We become more diverse as we age,” she said, explaining that “a pediatric kidney is a pediatric kidney, but a 65-year-old’s kidney might be different from another 65-year-old’s kidney depending on how they lived their life as they aged.”

Complicating the ability to recognize when an elderly patient is having a negative response to a drug or combination of drugs is the range of nonspecific signs and symptoms they exhibit. “Elderly people don’t present with the classic symptoms you might expect,” said Antimisiaris. One reason is that, as people age, protein levels diminish and the blood-brain barrier becomes increasingly porous. As a result, many patients will exhibit psychological changes, like “agitation, manic behavior, change in effect, confusion, not eating, or not sleeping.”

Guidelines in hand, a physician might respond to a complaint of insomnia with a prescription for zolpidem (Ambien), when replacing or discontinuing a drug in the patient’s current regimen could have resolved the problem. “Being strong in geriatric medication management requires knowing how unnecessary medication use happens and how to recognize when a medication is causing problems,” said Antimisiaris. “We’re so guidance driven [that] we’ve kind of lost the part about being able to see toxicities when they’re right in front of us.” She described a huge gap between “the bench science and the bedside” and said providers must exercise clinical judgment when caring for elders.

“Polypharmacy is prevalent among elderly patients,” Antimisiaris said, noting that guidelines often fail to address how drugs interact. Studies show total drug burden is important for this patient population, and she pointed to a 2007 study by Garfinkle and colleagues. They found that cutting the number of drugs given to a group of geriatric patients in palliative care by an average of 2.8 improved outcomes compared with a control group of patients whose drug regimens stayed the same. The 1-year mortality rate was 21% in the study group versus 45% in the control arm, and only 11.8% of patients in the study group needed referrals to acute care each year compared with 30% of patients in the control group. Drug burden affects quality of life, Antimisiaris said, with each additional unit negatively affecting physical function and cognitive task performance. “Keep what you need, lose what you want. … Keep the warfarin, lose the Ambien.”

Antimisiaris outlined important considerations when medicating elderly patients:

• Elders have decreased total body water, so use “baby doses” of watersoluble drugs to prevent excessive drug concentrations.
• Elders typically have more body fat and thus an increased risk of toxicity when using fat-soluble or lipophilic drugs (psychotropics, vitamins A and E, some statins), which are slow to activate and accumulate.
• Elders have decreased serum protein levels and consequently a higher rate of free drug, so treat to efficacy and not to levels.
• Almost 50% of elders are slow metabolizers, associated with an increased risk of adverse effects and toxicity; don’t just assume the drug is not working and then increase the dose.
• Watch for drug–drug interactions and toxicities in patients treated with 1 or more drugs metabolized along the CYP3A4 pathway.
• Elders, especially those aged >85 years, frequently have impaired kidney and renal function, so evaluate total drug burden.
• Try to elicit from the patient information about changes in behavior or mood by asking questions like “Are you sleeping?” or “Are you still doing [a favorite activity]?”; responses might indicate an adverse drug reaction.

Prescribing the right drugs is only one component of drug management for geriatric patients; adherence is another. With the typical physician’s office visit lasting only 7 minutes, Antimisiaris said, “nobody is testing [elderly patients’] literacy or cognitive function” to assess whether they are capable of managing their drug regimen. “Have the patient draw a clock,” she suggested. “That will tell you whether they can handle taking an aspirin a day,” she said.

Antimisiaris warned that the coming years are likely to bring an influx of elderly patients to oncology clinics. “The elders are coming…they’re sicker, more frail, and harder to manage,” she said. Before that happens, we must do more to learn about needs specific to elderly patients and to educate care teams on what we already know