Full Answer Section

• • Decreased Renal Function: The kidneys are the primary route of drug elimination. Renal function declines with age, leading to reduced drug clearance and a higher risk of drug accumulation and toxicity. This is often measured by estimated Glomerular Filtration Rate (eGFR).  

  • Changes in Body Composition: Older adults typically have a higher proportion of body fat and a lower proportion of lean muscle mass. Lipid-soluble drugs may have a larger volume of distribution, leading to prolonged effects. Water-soluble drugs may have a smaller volume of distribution, leading to higher initial concentrations.  

  • Reduced Albumin Levels: Albumin, a protein that binds to many drugs, decreases with age. This can lead to a higher proportion of unbound (active) drug in the bloodstream, increasing the risk of adverse effects.

• Pathophysiological Changes:

  • Multiple Comorbidities: Older adults often have multiple chronic conditions (e.g., diabetes, heart failure, kidney disease), which can affect organ function and drug metabolism. These diseases can also require multiple medications, increasing the risk of drug interactions.  

  • Heart Failure: Reduced cardiac output can decrease blood flow to the liver and kidneys, further impairing drug metabolism and excretion.  

  • Kidney Disease: Chronic kidney disease significantly impacts drug elimination, requiring careful dose adjustments.  

2. Polypharmacy in the Elderly:

Polypharmacy, commonly defined as the concurrent use of five or more medications, is a significant problem in the elderly population. It increases the risk of several adverse outcomes:  

• Adverse Drug Reactions (ADRs): The more medications a person takes, the greater the chance of drug interactions and adverse reactions. These reactions can range from mild side effects to serious complications requiring hospitalization or even leading to death. Evidence supports this; a study by Fulton et al. (2005) found that the risk of ADRs increased significantly with the number of medications taken.  

• Drug Interactions: Multiple medications can interact with each other, either increasing or decreasing the effects of one or both drugs. These interactions can be difficult to predict and can lead to serious consequences. For instance, combining certain medications that both prolong the QT interval (a measure of the heart’s electrical activity) can increase the risk of a potentially fatal heart rhythm disorder.  

• Reduced Medication Adherence: A complex medication regimen can be difficult for older adults to manage, especially if they have cognitive impairment or physical limitations. This can lead to missed doses, incorrect dosages, and ultimately, treatment failure. A study by Marcum et al. (2018) found that polypharmacy was associated with lower adherence rates in older adults.  

• Increased Healthcare Costs: Polypharmacy leads to increased healthcare utilization due to ADRs, hospitalizations, and the need for additional medications to treat side effects.  

3. Clinical Practice Guidelines to Prevent Unnecessary Medications:

Several clinical practice guidelines and tools can help prevent the use of unnecessary medications in elderly patients:

• Beers Criteria: The Beers Criteria, published by the American Geriatrics Society, is a widely used list of medications that are potentially inappropriate for older adults due to their higher risk of adverse effects. It provides guidance on drug selection and helps clinicians avoid potentially harmful medications in this population. https://americangeriatrics.org/ (Search “Beers Criteria”)  

• STOPP/START Criteria: The Screening Tool of Older Persons’ Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START) criteria provide explicit, evidence-based recommendations for medication appropriateness in older adults. STOPP identifies potentially inappropriate medications, while START identifies medications that should be considered when specific conditions are present. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4060293/  

• Deprescribing Guidelines: Deprescribing is the process of carefully reducing or stopping medications that are no longer needed or are causing harm. Several guidelines and resources are available to assist clinicians in deprescribing safely and effectively. For example, the “Canadian Deprescribing Network” offers resources and tools. https://www.deprescribing.org/  

It is important to use these resources in conjunction with a thorough patient assessment, considering individual patient factors, comorbidities, and preferences. A multidisciplinary approach involving physicians, pharmacists, and other healthcare professionals is crucial for optimizing medication management in older adults.