Geriatric Patients

Introduction

According to the statistics from the Department of Statistics of Malaysia, the years that babies in Malaysia in 2020 are expected to live has increased further to 74.9 years or almost 75 years. Hence, our population is actually ageing. This could be due to

Decreased fertility
Lower infant mortality
Better healthcare & public health, e.g. vaccination, hygiene and nutrition

As we age, there is

Physiological changes, for example

Cognitive impairment, e.g. forgetful
Reduced muscle mass and total body water
Decreased GFR
Deteriorating sight and hearing
Inability to swallow solid dose form
Loss of manual dexterity; muscle weakness

Increased susceptibility to medical problems and complications
Functional ability, dependence and quality of life issues are of increasing concern

NOTE:

Some of the physiological changes listed above contribute to medication noncompliance.
Serum creatinine concentration is an unreliable indicator of renal function in elderly since it may remain in the "normal" range despite a reduction in renal function due to lower muscle mass.

Polypharmacy

Prescribing is an art, in which we should not over-treat patients or under-treat they when they need it.

However, as medications are the most common medical intervention, elderly patients are often expected to be on polypharmacy (i.e. regular use of >5 medications). This can lead to an increased incidence of ADRs including interactions between medications, which can then be overlooked in elderly patients and eventually lead to prescribing cascade.

In reality, polypharmacy may results from a number of factors, including

Patients with multiple medical conditions
Practical guidelines that recommend their use
Fragmental systems: multiple providers (cardiologist, internist, family physician, nephrologist, etc.)
Hospitalizations with inappropriate medication reconciliation

Despite the risks, polypharmacy is sometimes necessary as part of the optimal medical treatment. However, it is important to carefully evaluate the need for each medication and to implement only those that are truly necessary. In addition, it is important to

Evaluate the patient's level of drug adherence
Identify potentially inappropriate medications
Optimize and simplify medication regimen to enhance adherence and minimise adverse effects
Set an aim or target for the patients, such as symptom control or life prolongation

NOTE: You may find Drug-Induced Diseases, 2018 very useful in medication management review.

AGS Beers Criteria

The Beers Criteria were first developed in 1991 to decrease inappropriate prescribing and ADEs and, in particular, to identify medications or medication classes that should be avoided in older adults in nursing homes.

Since 2011, after Beer's death, the American Geriatrics Society (AGS) began to oversee the revisions and updates to the criteria.

AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2023 contains six tables:

Potentially inappropriate medication use in older adults
Drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome
Drugs to be used with caution in older adults
Potentially clinically important drug-drug interactions that should be avoided in older adults
Medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults
Drugs with strong anticholinergic properties

Please give this important guide a read!

Geriatric Giants

In 1965, Bernard Isaacs coined the term "Geriatric Giants". It is often used to refer to health impairments that appear in the elderly (do not fit into any specific organ-based disease categories) and often have multifactorial causes. These health conditions may have a major impact on quality of life and disability.

You may learn more of this in Geriatric Pharmacy Pocket Book, 2021.

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