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Um, so hello everyone. This is our, um, lecture on Medications in the Compre Comprehensive Geriatric Series. Um, this evening we have Eddie Rostan, one of our Geriatric registrars working in Yorkshire, presenting, going through medication and pharmacy in the elderly. Again, there'll be me and addie on the chat this evening. So if you have any questions just pop them in throughout. Um, but otherwise I'll hand over to Eddie. Thank you so much. No worries. Uh, thank you. So, yeah, hi, everyone. Uh, my name is Eddie Elderly Care Registrar working in, um, w Wakefield in West Yorkshire. Uh, thanks for letting me be part of this. Fantastic mind, the bleep, er elderly teaching series where at the end of it you'll be able to do a comprehensive Geriatric assessment. Er, so this talk specifically is on medication and pharmacy, er, in the elderly. So the aim is to give you a general sense of the bad side of medications, uh, and pharmacy in the elderly. Uh, and why it's actually this is more important in our older population than in our younger population. It's key to remember that every medicine we actually give is by definition, a poison. No medication is free, uh, 100% free from unwanted side effect either. Uh, so, and it's something that we can become quite, very safe there. We just sort of prescribing medications. So I'm gonna talk through some definitions, er, highlight some areas of concerns. Er, do a fairly big chunk on anticholinergics. Er, talk through some common adverse drug reactions in the elderly. Um, and then a little bit on, er, deprescribing and some deprescribing aids. So just some simple definitions, sir. Get us going. So, polypharmacy is, um, the, the definition does keep changing, but it's currently accepted as the concurrent use of five or more medications. It might seem really weird that you take five or more tablets in a day to us as a relatively young audience. Uh, but it's actually fairly common that a lot of older adults prescribe even up to three or four times that amount. So it's not uncommon that people are on sort of 15 to 20 medications every day. Ideally, polypharmacy should be listed as a comorbidity. So if you're cle in someone or seeing them in a clinic, if they do take five or more medications alongside all their other problem lists, you should put polypharmacy but we don't often do it because nearly every single one of our patients is on it. And so you just sort of become a bit blind to it because it'll be there on every patient and it might lose its impact, um, to give some statistics on kind of polypharmacy. Er, more than one in 10 people over the age of 65 are prescribed at least eight different medications per week and this rises to nearly 25% of people, uh, over the age of 85. So quite a lot. And all of these medicines have unwanted side effects. Uh, these are grouped as adverse drug reactions. So, Ad RS, uh, so if I refer to an AD R, it can be anything from as mild as a side effect to um like a really nasty Steven Johnson syndrome or toxic epidermal necrolysis. Uh We've got data that suggest about 25% of older adults will experience an adverse drug reaction. Uh with that number increasing as you're based on more drugs, sometimes this can lead to what's called a prescribing cascade where someone is prescribed a drug for a genuine indication. Uh They develop an AD R and then instead of that drug being changed or discontinued, you, you get prescribed a second drug to manage that AD R. So, uh a good example is someone with high BP that gets given a calcium channel blocker where a known uh AD R is ankle swelling. Um and then to manage this, they get given rather than changing the hypertensive medication. Um I am gonna talk a bit about the anticholinergic burden or a CD. So that's separate to the top three terms. Um But it's a collective uh term to describe the unwanted or in some cases wanted effects of many different drugs. Um where each drug can be given us specific score from 0 to 3. Um um with a combined score of three or more indicating a burden. So even one drug um can put someone on an anticholinergic burden. Uh So some particular areas of concern around um medicines in the elderly. So there's multimorbidity. So elderly patients are more likely to have one or more co coexisting medical conditions and a lot of comorbidities are often linked. You know, if you have a heart attack, you then go on to develop heart failure if you have heart failure. Yeah, you tend to have um hyper of the muscles in the heart which put you at a much higher risk of developing af um all of these conditions tend to be prescribed medication to manage them. So it's pretty obvious that our elder population have lots of comorbidities and have lots of medication to try and manage them. Some conditions like heart failure. You um may have heard of the five of heart failure, which are uh you know, an ace inhibitor, a beta blocker, an aldosterone antagonist, uh a diuretic and an SGLT two inhibitor. So someone might just be diagnosed with heart failure and they've got nothing else and immediately they're on five medications and, and they've got pharmacy. Um so Ad Rs, we spoke a bit about how up to 25% of elderly patients might get an AD R and there's evidence that between one and six and one and three hospital admissions are due to AD RS, which is really, really high, if you think about one in three people coming into hospital, er, due to the medications that they're on rather than the condition deteriorating. Um, there's lots of things that this can be due to, um, lots of things that this can be due to. Er, so elderly people have worse kidney function as they reduced clearance. So drugs can build up. They tend to have a slower metabolism. Generally they tend to have less fat stores. Um, one study has found that elderly people are seven times more likely to be admitted with an adverse drug reaction than a younger person. Um, and then another study found that 25% of adults came in with one issue then suffered an AD R, um, which prolonged their stay and increased their mortality. So, like a really common example of that would be someone who comes in with a pneumonia relatively simple, but they're on and furosemide and they've not eaten for a few days. And so the medicines put them into an AK I, um, and then this is, er, only a bit caused by their drugs, it's not caused by their pneumonia. Um, so drug interactions. So the more medications you're on, uh, the more chance that the drugs will interact And then in terms of pharmacokinetics. So uh older adults have less body water and less body mass. So water soluble drugs such as ethanol and lithium have a lower volumes of distribution. They do tend to have a little bit more uh fat stores around their organs. So, fat soluble drugs such as benzos do tend to have an increased volume of distribution which means they can feel their effects a bit more. Um I'd rather tend to have less albumin. So, uh which binds to active drugs and renders them useless. So, if you've got less albumin, it means you tend to have more, more active metabolite going around. Um and then we spoke about how it's reduced uh metabolism and reduced clearance. So all of these things combined or why you generally start at lower doses in an elderly person than you do in an adult. So, if you look in the BN, now for many, many different drugs, it will give you the adult dose and then it will say half this dose if you're starting it in an elderly person. So, anticholinergic burden, I hope it's a term you've heard of before, but if not, we're gonna go through it in quite some depth. Um So we'll just have a little uh neurophysiology, er, anatomy recap. So, acetylcholine is one of the is the main neurotransmitter used by your parasympathetic nervous system. So, when we use the term anticholinergic, it means that it antagonizes acetylcholine in your parasympathetic nervous system. And so your parasympathetic nervous system can't respond in the way that it generally wants to do. So, your P SM or parasympathetic nervous system controls your rest and digest functions. So it increases saliva production when you're hungry and you've got food in front of you. Um It controls your bowel motility. So when you're eating and it enhances your gastric motility, getting food through you, um it controls your bladder emptying. Um, so you can, and that's just a few of the things that it controls. But you can imagine that if you start to block the natural path of this, that's where you get your symptoms of a dry mouth, constipation and urinary retention. Some of the other things that the pa the er acetylcholine does is it helps your parasympathetic nervous system even. Um is it helps constrict your pupils and helps with your accommodation reflex. So, if this is blocked, then you tend to get um big, big eyes that let in too much light.