Optimizing Pharmacotherapy in Older Patients: An Interdisciplinary Approach

Foreword
Contents
Part I: General Issues
1: The Impact of Ageing on Pharmacokinetics
1.1 Introduction
1.2 Age-Associated Changes in Organs and Systems
1.2.1 Body Composition
1.2.2 Cardiovascular System
1.2.3 Kidney
1.2.4 Gastrointestinal System
1.3 Age-Associated Changes in Pharmacokinetics
1.3.1 Absorption
1.3.2 Distribution
1.3.3 Metabolism
1.3.3.1 Hepatic Blood Flow
1.3.3.2 Phase I–II Metabolism
1.3.4 Drug Elimination
1.4 General Considerations
1.5 Pharmacokinetic Data for Personalised Prescribing
1.6 Conclusions
References
2: Polypharmacy: Definition, Epidemiology, Consequences and Solutions
2.1 Introduction
2.2 Epidemiology of Polypharmacy
2.3 Age-Related Changes in Pharmacokinetics and Pharmacodynamics
2.3.1 Pharmacokinetics
2.3.1.1 Absorption and Bioavailability
2.3.2 Distribution
2.3.2.1 Metabolism
2.3.2.2 Elimination
2.3.3 Pharmacodynamics
2.3.4 Consequences of Polypharmacy
2.3.4.1 Drug–Drug Interactions
2.3.4.2 Drug–Disease Interactions
2.3.4.3 Prescribing Cascades
2.3.4.4 Falls, Immobility and Fractures
2.3.4.5 Cognitive Impairment
2.3.4.6 Frailty, Physical Function, and Disability
2.3.4.7 Medication Errors
2.3.4.8 Economic Cost of Polypharmacy
2.3.5 Optimising Medications in Patients with Polypharmacy
2.3.5.1 Use of Nonpharmacological Options
2.3.5.2 Medication Reconciliation
2.3.5.3 Adherence
2.3.5.4 Medication Review
2.3.5.5 Medication Review Tools
2.3.6 Polypharmacy in the Frailest Adults
References
3: Drug–Drug and Drug–Nutrients Interactions: From Theory to Clinical Relevance
3.1 Introduction
3.2 Theory
3.2.1 Pharmacokinetic Interactions
3.2.1.1 Absorption
3.2.1.2 Distribution
3.2.1.3 Metabolism
3.2.1.4 Elimination
3.2.2 Pharmacodynamic Interactions
3.3 Age-Related Changes in Pharmacokinetics
3.4 Clinically Relevant PK Interactions
3.5 Age-Related Changes in Pharmacodynamics
3.6 Clinically Relevant PD Interactions
References
4: Inappropriate Prescription of Medicines
4.1 Introduction
4.2 Inappropriate Prescribing Criteria
4.3 Clinical Relevance of PIMs and PPOs
4.4 Clinical Trials of STOPP/START Criteria as an Intervention
4.5 Other Clinical Trials of PIM Criteria as an Intervention
4.6 Clinical Trials Using Pharmacist-Driven Interventions to Optimize Medication in Multimorbid Older People
4.7 Clinical Manifestations of IP in Older People
4.8 Medication Review Aimed at Minimizing IP and Its Consequences: A Practical Approach
4.9 Minimizing IP in Older People with Marked Frailty Approaching End-of-Life
4.10 Inappropriate Medication Avoidance: Summary and Practical Points
References
5: Prescribing Cascades
5.1 Introduction
5.2 Definition of Prescribing Cascades
5.3 Why Prescribing Cascades are Important for Older Adults
5.4 Original Investigations to Identify Prescribing Cascades
5.5 The Application of Prescribing Cascades to Inform Better Clinical Care and Deprescribing Initiatives
5.6 Conclusions
References
6: Adverse Drug Reactions in Older People: A Twenty-First Century View
6.1 Introduction
6.2 Definition of Adverse Drug Reactions
6.3 Prevalence and Cost of ADRs in Older Adults
6.4 Why Do ADRs Occur More Commonly in Older People?
6.5 Types of ADRs
6.6 Recognising ADRs in Older Adults
6.7 Preventing ADRs in Older People
6.8 Conclusion
References
7: Adherence: How to Measure and Improve It
7.1 State of the Art
7.2 How to Assess Adherence
7.2.1 Let Us Look First at the Direct Methods
7.2.2 Indirect Measures
7.2.3 Subjective Measures
7.3 How to Improve Adherence
7.4 Conclusions
References
8: Medication Reconciliation and Review: Theory, Practice and Evidence
8.1 Introduction
8.2 Medication Reconciliation
8.2.1 Theory
8.2.2 Practice
8.2.2.1 Medication Discrepancies
8.2.3 Evidence
8.2.3.1 Optimising Limited Resources
8.2.3.2 Electronic Supports
8.2.3.3 The Role of Patients, Family and Informal Carers
8.2.3.4 Organisational Complexity and Management
8.3 Medication Review
8.3.1 Theory
8.3.2 Practice
8.3.3 Evidence
8.3.3.1 Effectiveness of Medication Review
8.3.3.2 Optimising Limited Resources
8.4 Summary
References
9: The Role of Pharmacists in Optimising Drug Therapy
9.1 Pharmaceutical Care at Patient Level
9.1.1 Medication Review
9.1.2 Continuity of Supply and Care
9.1.3 Patient Education and Shared Decision-Making
9.2 Pharmacists’ Role in the Education and Training of Other Healthcare Professionals
9.3 Models of Pharmacy Practice in Different Settings of Care and Countries
9.3.1 Ambulatory Care
9.3.2 Acute Care
9.3.3 Long-Term Care
9.3.4 Interprofessional Practice is Desirable But Challenging to Implement
9.3.5 The Prescribing Pharmacist
9.4 Conclusions and Perspectives
References
10: Deprescribing: Evidence Base and Implementation
10.1 Introduction
10.2 Definition of Deprescribing
10.2.1 Evidence Base for Deprescribing
10.3 Operationalizing Deprescribing for Older People Approaching End-of-Life
10.3.1 Prognostication of Survival
10.3.2 Identifying Medications to be Deprescribed
10.4 Shared Decision-Making
10.5 Conclusion
References
Part II: Geriatric Syndromes and Common Chronic Conditions
11: General Principles of Management of Patients with Multimorbidity and Frailty
11.1 Multimorbidity, Frailty and Their Interconnection
11.1.1 Multimorbidity
11.1.2 Polypharmacy
11.1.3 Frailty
11.2 Management of Multimorbidity
11.2.1 Target Population
11.2.2 Assessing of Interacting Conditions and Treatments
11.2.3 Incorporate Patient Preferences and Goal Setting
11.2.4 Individualized Management
11.2.5 Self-management
11.2.6 Monitoring and Follow-Up
11.3 Treatment of Chronic Diseases and Multimoridity in Frail Patients
11.3.1 Symptomatic Treatment of Diseases in Frailty
11.3.2 Preventive Treatment of Diseases in Frailty
11.4 Treatment of Multimorbidity and Frailty in the Precision Medicine Era
References
12: Frailty and Drug Therapy
12.1 The Concept of Frailty
12.2 Influence of Frailty on Pharmacokinetics
12.3 Frail Populations in Clinical Trials
12.4 Measuring Frailty in Healthcare Databases
12.5 The Complex Relationship of Frailty and Polypharmacy
12.6 Adverse Drug Reactions and the Development of Frailty
12.7 Frailty and Medication Management
12.7.1 Deprescribing
12.7.2 Medication Underuse
12.7.3 Medication Optimization
12.8 Knowledge Gaps
References
13: Falls and Impaired Mobility
13.1 Impact of Falls
13.2 Risk Factors for Falls
13.3 Mobility and Risk of Falling
13.4 Falls and Impaired Mobility, Common Adverse Drug Events
13.5 Prevention of (Medication-Related) Falls: Background and Evidence
13.6 Effect of Deprescribing of FRIDs on Impaired Mobility and Other Adverse Effects
13.7 How to Perform Medication Management of FRIDs
13.8 Conclusion
References
14: Optimizing Pharmacotherapy in Older Patients: Delirium
14.1 Introduction
14.2 Mechanisms of Medications-Induced Delirium
14.3 Scales to Assess Patient’s Drug Burden of Delirium
14.4 The Recommendations of the Scientific Societies on the Medications with Potential Impact on Delirium
14.5 Medication Candidates for Delirium Prevention
14.6 Medications to Treat Delirium
14.7 Conclusions
References
15: Optimizing Pharmacotherapy in Older Adults: Urinary Incontinence
15.1 Introduction
15.2 Medications Review
15.3 Evaluation of Bowel Function
15.4 Pharmacological Treatment for Urinary Incontinence
15.5 Drug Management of Overactive Bladder/Urge Incontinence
15.5.1 Antimuscarinic Drugs
15.5.1.1 Mechanism of Action
15.5.1.2 Evidence
15.5.1.3 Clinical Use
15.5.2 β3 Receptor Agonists
15.5.2.1 Mechanism of Action
15.5.2.2 Evidence
15.5.2.3 Clinical Use
15.5.3 Botulinum Toxin
15.5.3.1 Mechanism of Action
15.5.3.2 Evidence
15.5.3.3 Clinical Use
15.6 Pharmacotherapeutic Management of Stress Urinary Incontinence
15.6.1 Duloxetine
15.6.1.1 Mechanism of Action
15.6.1.2 Evidence
15.6.1.3 Clinical Use
15.6.2 Desmopressin
15.6.2.1 Mechanism of Action
15.6.2.2 Evidence
15.6.2.3 Clinical Use
15.7 Topical Estrogen Therapy
15.7.1 Mechanism of Action
15.7.2 Evidence
15.7.3 Clinical Use
15.8 Drugs for Benign Prostatic Hypertrophy (BPH)
15.8.1 Mechanism of Action
15.8.2 Evidence
15.8.3 Clinical Use
15.9 Conclusions
References
16: Constipation
16.1 Lifestyle
16.2 Diet and Fiber
16.3 Pharmacologic Treatment
16.4 Bulk Forming Laxatives
16.5 Osmotic Laxatives
16.5.1 Poorly Absorbed Ions
16.5.2 Nonabsorbable Carbohydrates
16.5.3 Polyethylene Glycol
16.6 Stimulant Laxatives
16.6.1 Anthraquinone Derivatives
16.6.2 Diphenylmethane Derivatives
16.6.3 Castor Oil
16.7 Other Therapies for Chronic Constipation
16.8 Colonic Secretagogues
16.9 Opioid Antagonists
16.10 Serotonergic Laxatives
16.11 Enemas and Suppositories
16.11.1 Phosphate Enemas
16.11.2 Saline, Tap Water, and Soapsuds Enemas
16.11.3 Stimulant Suppositories and Enemas
16.11.4 Dioctyl Sulfosuccinate (Docusate)
16.12 Mineral Oils
16.13 Probiotics
16.14 Conclusion
References
17: Pain
17.1 Introduction
17.2 Practical Recommendations for the Use of Analgesics in Older Patients
17.2.1 Paracetamol
17.2.2 Nonsteroidal Anti-inflammatory Drugs
17.2.3 Opioids
17.2.3.1 Side Effects of Opioids
17.2.3.2 Examples of Opioids Frequently Used for Pain Management (See Table 17.1)
Tramadol
Tapentadol
Morphine
Fentanyl
Buprenorphine
Methadone
17.2.4 Adjuvant Drugs and Treatment of Neuropathic Pain
17.2.5 Cannabinoids
References
18: Hypertension
18.1 Hypertension Is Multifaceted in an Older Patient
18.2 Diagnostic Procedures
18.3 Treatment Modalities
18.3.1 Lifestyle
18.3.2 Drug Treatment
References
19: Heart Failure
19.1 Introduction
19.2 Definition of Heart Failure
19.3 Epidemiology and Natural History of Heart Failure
19.4 Pharmacological Management of HF
19.5 Pharmacological Treatment of Heart Failure in Older Persons (Fig. 19.3)
19.6 Risk Factors and Comorbidities
19.6.1 Risk Factors
19.6.2 Cardiovascular Comorbidities
19.6.2.1 Atrial Fibrillation and Conduction Abnormalities
Atrial Fibrillation
Symptomatic Conduction Abnormalities
Valve Disease
Aortic Valve Stenosis (AS)
Mitral Regurgitation
19.6.3 Non-cardiovascular Comorbidities
19.6.3.1 Cancer
19.6.3.2 Iron Deficiency and Anaemia
19.6.3.3 Infections
19.7 Considerations
References
20: Pharmacological Treatment of Cognitive and Behavioral Disorders in Dementia
20.1 Introduction
20.1.1 Alzheimer’s Disease (AD)
20.1.2 Vascular Dementia (VaD)
20.1.3 Dementia with Lewy Bodies (DLB)
20.1.4 Frontotemporal Dementia (FTD)
20.1.5 Other Neurocognitive Disorders
20.2 Pharmacologic Management of Cognitive Impairment
20.2.1 Acetylcholinesterase Inhibitors
20.2.1.1 Treatment Monitoring
20.2.2 Memantine
20.2.3 Aducanumab
20.2.4 Vascular Risk Modifications
20.2.5 Other Therapies
20.2.6 Other Considerations
20.3 Behavioral and Psychological Symptoms
20.3.1 Treatment of Hyperactivity-Impulsivity-Irritiability-Disinhibition-Aggression-Agitation (HIDA) Domain
20.3.1.1 Antipsychotic Drugs
Typical (or First-Generation) Antipsychotics
Atypical (or Second-Generation) Antipsychotics
Typical Vs Atypical Antipsychotics
Risperidone
Aripiprazole
Olanzapine
Quetiapine
References
21: Pharmacological Treatment of Osteoporosis in Older Patients
21.1 Epidemiology of Osteoporosis and Osteoporotic Fractures in Old Age
21.2 Older Persons with Osteoporotic Fractures Are Frail
21.3 Diagnosis of Osteoporosis and Intervention Thresholds in Old Age
21.4 Treatment of Osteoporosis in Older Persons
21.4.1 Calcium and Vitamin D Supplementation in Old Age
21.4.2 Pharmacological Osteoporosis Treatment in Old Age
21.4.2.1 Antiresorptive Treatment for Osteoporosis
Alendronate
Risedronate
Zoledronic Acid
Denosumab
Selective Estrogen Receptor Modulators (SERM)
21.4.2.2 Anabolic Treatment for Osteoporosis
Teriparatide
Abaloparatide
Romosozumab
21.4.2.3 Osteoporosis Treatment in Men
21.4.2.4 Effectiveness of Osteoporosis Treatment in Older Persons in the Clinical Setting
21.4.2.5 Lag Time to Benefit from Osteoporosis Treatment
21.5 Conclusion
References
22: Chronic Respiratory Disease: COPD, IPF
22.1 Introduction
22.2 Therapy of COPD: An Overview
22.3 Therapy of COPD: The Main Individual Components
22.3.1 Education
22.3.2 Rehabilitation
22.3.3 Devices Promoting Airways Mucus Clearance
22.3.4 Vaccinations
22.3.5 Sleep Hygiene
22.3.6 Nutrition
22.3.7 Pharmacological Therapy
22.3.8 Oxygen Therapy
22.3.9 Noninvasive Ventilation (NIV)
22.3.10 Remote Monitoring
22.3.11 Palliative Care
22.4 Therapy of Acute COPD Exacerbations
22.5 Idiopathic Pulmonary Fibrosis and Other Interstitial Lung Diseases in the Elderly
22.5.1 An Overview
22.5.2 Therapeutic Approach
22.5.2.1 Antifibrotic Therapy in IPF: Implications in Elderly Patients
22.5.2.2 Corticosteroids and Immunosuppressive Cytotoxic Therapy in Non-IPF ILDs
22.5.2.3 Antifibrotic Treatment in Progressive Fibrosing Non-IPF ILDs
22.5.2.4 Practical Considerations on the Therapeutic Management of IPF and Other ILDs in the Elderly
References
23: Diabetes Mellitus
23.1 Therapeutic Targets in the Elderly
23.2 Insulin Therapy in the Elderly
23.3 Non-insulin Therapy in Older Patients
23.3.1 Biguanides
23.3.2 Glucagon-Like Peptide 1 Receptor Agonists
23.3.3 Sodium-Glucose Transporter 2 Inhibitors
23.3.4 Dipeptidyl Peptidase 4-Inhibitors
23.3.5 Thiazolidinediones
23.3.6 Alpha-Glucosidase Inhibitors
23.3.7 Sulfonylureas and Glinides
23.4 Conclusion
References
24: Stroke Therapeutics in the Care of Older Persons
24.1 Background and Epidemiology
24.2 Ischaemic Stroke Classification
24.3 Pathophysiology
24.4 Risk Factors
24.5 Presentation
24.6 Assessment
24.7 Functional Assessment
24.8 Hyperacute Management of Acute Stroke
24.8.1 Ischaemic Stroke
24.8.2 Intracerebral Haemorrhage
24.8.3 Transient Ischaemic Attack
24.9 Secondary Prevention of Stroke and TIA
24.9.1 Antiplatelets
24.9.2 Antihypertensives
24.9.3 Lipid-Lowering Agents
24.9.4 Diabetes Treatment
24.9.4.1 Atrial Fibrillation
24.9.5 Carotid Endarterectomy
24.9.5.1 Post-Stroke Sequelae in the Older Person
24.10 Conclusion
References
25: Optimizing Pharmacotherapy in Older Patients with Depression or Anxiety
25.1 Depression
25.1.1 Pharmacological Treatment of Depression
25.1.1.1 Antidepressants Efficacy
25.1.1.2 Antidepressant Management
25.1.1.3 Duration of Treatment
25.1.1.4 Antidepressant Adherence
25.1.1.5 Antidepressant Resistance
25.1.1.6 Antidepressant, Depression and Neurocognitive Disorders
25.1.1.7 Mood Stabilizer
25.1.2 Non-pharmacological Treatment of Depression
25.1.2.1 Psychological Approach
25.1.2.2 Electroconvulsive Therapy
25.1.2.3 Repetitive Transcranial Magnetic Stimulation
25.2 Anxiety
25.2.1 Pharmacological Treatment of Anxiety
25.2.2 Non-pharmacological Treatment of Anxiety
References
26: Nutritional Deficiency and Malnutrition
26.1 Introduction
26.2 Causes of Malnutrition in Older People
26.3 Screening of Malnutrition
26.4 Assessment of Nutritional Status
26.4.1 Diagnosis of Malnutrition
26.4.2 Quantification of Energy and Nutrient Deficiency
26.4.3 Identification of Potential Causes of Malnutrition
26.5 Nutritional Therapy
26.6 Conclusions
References
27: Pharmacotherapy of Insomnia in Older Adults
27.1 Insomnia as the Most Common Sleep Disorder
27.2 Treatment
27.3 Pharmacological Treatment
27.4 Benzodiazepines and Non-benzodiazepine Receptor Agonists
27.5 Clinical Effects of BZDs
27.6 Susceptibility of Older Adults to BZDs
27.7 Side Effects of BZDs
27.8 Rationale for Prescribing BZDs
27.9 Guidance for Withdrawal
27.10 Alternatives to BZDs
27.11 Conclusions
References
28: Optimizing Pharmacotherapy in Older Patients: An Interdisciplinary Approach: Chronic Kidney Disease
28.1 Epidemiology and Staging Issues
28.2 Multimorbidity and Polypharmacy
28.3 Guideline-Based Recommendations and CKD Treatment Among Older Patients
28.3.1 Hypertension
28.3.2 Diabetes
28.3.3 Albuminuria
28.3.4 Hyperlipidemia
28.3.5 Bone Metabolism
28.3.6 Acidosis
28.3.7 Anemia
28.4 Nephrotoxicity
28.4.1 Suggestions to Prevent Nephrotoxic AKI
28.5 Conclusions
References
29: Palliation at End of Life
29.1 Introduction: Palliative Care for Older Patients
29.2 Approach to Prescribing Medications to Palliate Symptoms at End of Life in Older Patients
29.3 Route and Mode of Administration of Medications at End of Life
29.4 Managing Symptoms in Last Days of Life
29.4.1 The Use of Opioids for Pain Management at End of Life
29.4.2 Starting Opioids in a Patient Who Is Approaching End of Life
29.4.3 Morphine and Alternative Opioids for Dying Patients
29.4.4 Subcutaneous Opioids for Dying Patients Who Are No Longer Able to Take Oral Medications
29.4.5 The Use of Transdermal Opioid Patches in a Patient Who Is Imminently Dying
29.4.6 Opioid Adverse Effects
29.4.7 Medications for Nausea and Vomiting at End of Life
29.4.8 Management of Respiratory Secretions at End of Life
29.4.9 Management of Dyspnoea at End of Life
29.4.10 The Use of Medications to Relieve Agitation at End of Life
29.5 Using Medications for Palliation at End of Life: Summary
References
Index