Clinical pharmacology of old age

ABSTRACT

Introduction: With the majority of elderly persons consuming multiple drugs, inappropriate drug use is a major issue in geriatric medicine.

Areas covered: We reviewed PubMed, Embase, and Cochrane from inception to 1 May 2019 for potentially inappropriate use of medications, polypharmacy, and age-dependent changes in pharmacokinetics and pharmacodynamics. We selected to highlight new aspects that have emerged in recent years: appropriate monitoring of drug adherence and the introduction of Big Data analysis in advancing geriatric pharmacology.

Expert opinion: There are major gaps in the pharmacological treatment of the elderly. Most drugs were designed and tested in adults, with no pharmacokinetic and pharmacodynamic data on changes in old age. This void must be corrected through systematic and well-designed research programs. Potentially inappropriate use of medications (PIM) in the elderly is a serious issue in advanced age. Analysis of PIM shows relatively low predictive value in real life medicine. Most physicians continue to prescribe to the elderly medicines which should not be given at all, or not combined. Polypharmacy is a complex issue in old age, and in many cases treating physicians are not conducting critical assessment of the need for numerous medications.

KEYWORDS:

• Old age
• drugs
• potentially inappropriate medications
• polypharmacy
• adherence
• pharmacokinetics
• pharmacodynamics
• machine learning
• artificial intelligence
• big data analysis

Article Highlights

• Potentially inappropriate medications (PIM) are common among elderly patients where more than one-third of prescription drugs used in many countries are taken by elderly patients.

• Polypharmacy is a very serious pattern of practice among the elderly. Not surprising, it is associated with increased risk of adverse drug reactions, including hospital admission. Polypharmacy is the result of poor quality of drug prescribing by physicians.

• Adherence, defined as the ability of patients to adhere to medication schedule prescribed to them by their health-care providers, is probably the big white elephant in the room when it comes to understanding and predicting a favorable response of the elderly to drug therapy.

• We present the use of Proportion of Days Covered (PDC), available in the electronic medical chart, as a powerful tool in establishing and monitoring drug adherence in the elderly.

• Advanced age is associated with a plethora of pharmacokinetic changes, most of which translate into drug accumulation in the body, as compared to non-geriatric adults.

• We introduce the use of Big Data analytics as an effective tool to establish drug effects and adverse effects in studying geriatric clinical pharmacology. This field is being emerged during the last few years and will undoubtedly become mainstream in the next decade.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.