1. Geriatrics for
the family pharmacist:
part I
Sukanya Jongsiriyanyong
Department of Health, Bangkok Metropolitan Administration
09.Jun.2015
2. Geriatrics for the family pharmacist: part I
swallowing movements necessary for each bolus, coughing and if any
water was spilled out of the mouth. The swallowing movements were
epicondyl of the le
shaved when nece
sampled at 2500 H
Instruments, Maas
computer. During
signal at each vis
ject (by inspection
4th order, high-pa
(amplification and
tion software (Ide
Maastricht, The Ne
have been reported
of dysphagia (14).
Statistical analysi
Statistical analysis
15.0.1). Median v
number of particip
was scored on an
exact testing) wer
compared using th
were computed fo
vention (3 session
were analysed usin
level was set at 2-
Fig. 3. Gentle cervical spine mobilization. The participant was seated
comfortablywithhisheadsupportedagainstthechestofthetherapist,who
maintained the head in his hand and arm. The therapist gently mobilized
the head and cervical spine in order to correct the posture (i.e. centring the
headinaneutralpositionabovetheshoulders).Themobilizationconsisted
of free passive movements of the head without active participation of
the patients and without supplementary traction or other components.
Mobilization was performed within the available range of movement,
without eliciting muscular defence or complaints from the patients.
J Rehabil Med 2008; 40: 755–60.
Age and Ageing 2005; 34: 521–22.
N Engl J Med 2008; 358:e28
Dysphagia - kyphosis
4. Aging Society
www.thelancet.com. Published online February 8, 2013
Population ageing
accelerating rapidly
worldwide
9% 14% 20%
พ.ศ.2553 พ.ศ.2564 พ.ศ.2574
Epidemiology
Geriatrics for the family pharmacist: part I
5. ISSN 0858-5199
Labor force (15-59 years) 20,979 21,982 42,960
Elderly (60 years and over) 4,633 5,718 10,351
Elderly (65 years and over) 3,025 3,887 6,912
Pre-school ages (0-5 years) 2,282 2,180 4,462
School ages (6-21 years) 6,970 6,728 13,698
Women of reproductive age (15-49 years) 17,123
5. Life Expectancy at Birth (average number of years a person could expect to live after birth) 71.6 78.4
6. Life Expectancy at Sixty (average number of years a person could expect to live after age sixty) 20.1 23.3
7. Life Expectancy at Sixty-five (average number of years a person could expect to live after age sixty-five) 16.4 19.2
8. Vital Rates
Crude birth rate (per 1,000 population) 12.0
Crude death rate (per 1,000 population) 8.0
Natural growth rate (percent) 4.0
Infant mortality rate (per 1,000 live births) 10.6
Child (under 5) mortality ratio (per 1,000 live births) 17.5
9. Total Fertility Rate (average number of children a woman would have throughout her reproductive years) 1.6
10. Contraceptive Prevalence Rate (percent) 79.3
11. Estimated 3 Nationality Cross-border Population (x 1,000) 4,551
Myanmar 3,599
Cambodian 587
Lao 365
Mahidol
Population Gazette
Institute for Population and Social Research, Mahidol University Vol. 24 January 2015
Male Female Total
1. Total Population (x 1,000) 31,638 33,466 65,104
2. Population by Area of Residence (x 1,000)
Urban area (population living in all types of cities and municipal areas) 15,018 15,955 30,973
Rural area (population living outside urban areas) 16,620 17,511 34,131
3. Population by Region (x 1,000)
Bangkok Metropolis 3,867 4,175 8,042
Central (excluding Bangkok Metropolis) 8,898 9,450 18,348
Northern 5,490 5,785 11,275
Northeastern 9,069 9,545 18,614
Southern 4,314 4,511 8,825
4. Population by Age Group (x 1,000)
Children (under 15 years) 6,026 5,766 11,793
Population of Thailand, 2015
Estimated Population at Midyear 2015 (1st
July)
Geriatrics for the family pharmacist: part I
8. RAMPS
• Reduced body reserve
• Atypical presentation
• Multiple pathology
• Polypharmacy
• Social adversity
Geriatrics for the family pharmacist: part I
10. Age-related change in
lingual pressure
More pooling/pocketing
in the pharyngeal recesses
Increasing the risk of adverse
consequences due to ineffective
deglutition
Dysphagia
11. •Medication: digoxin, theophyllineM
•EmotionE
•AlcoholismA
•Late-life paranoid: social adversity, lonelinessL
•Swallowing disordersS
•Oral problemO
•No moneyN
•Wandering: due to dementiaW
•Hyperactivity/hypermetabolism: movement disorder, thyroidH
•Eating problemsE
•Enteral problem: chronic diarrhea, malabsorptionE
•Low nutrient dietL
•Shopping problemS
MEALS-ON-WHEELS
Geriatrics for the family pharmacist: part I
15. Comprehensive geriatric assessment
(CGA)
• Physical assessment
• Mental assessment
• Social assessment
• Functional assessment
Geriatrics for the family pharmacist: part I
16. Multiple pathology
Impression: 90-year-old-female; 14-year-education;
engineer; married
1. Abrasion wound both knees due to fall
2. Hypertension with drug-induced postural hypotension
3. Paroxysmal atrial fiﾞbrillation (on anticoagulant therapy)
4. Diabetes mellitus with diabetic retinopathy
5. Osteoarthritis of both knee joints with instability
6. Established osteoporosis with spinal stenosis with neurogenic claudication
7. Moderate dementia, probable Alzheimer’s disease with CVD
8. Vascular parkinsonism
9. Major depressive disorder; in remission
10. Malnutrition with oropharyngeal dysphagia
11. Urge urinary incontinence
RAMPS
Geriatrics for the family pharmacist: part I
18. Geriatrics for the family pharmacist: part I
Decreased in hepatic clearance:
alprazolam, amlodipine,
barbiturates,
chlordiazepoxide,
desmethyldiazepam,
diazepam, flurazepam,
imipramine, meperidine,
nortriptyline, propanolol,
quinidine, theophylline
“Pharmacokinetic process”
Absorption: little or no change
Distribution: increased body fat and decreased
body water
Elinimation:
Hepatic:
phase 1 enzyme activity reduction
phase 2 unchanged
Renal: decline in GFR (glomerular filtration rate)
Increased pharmacodynamic sensitivity:
benzodiazepines, anesthetics, opioids, dihydropyridines
Decreased pharmacodynamic sensitivity:
beta adrenergic receptor
23. ot replace
ult dose,
gimens
der people
ine
ules
ore
,
reat
ing
Medicines inappropriate
for prescribing in
older people and
recommended to
be avoided.*,2
Amitriptyline
Amiodarone
Antihistamines
Benzodiazepines
Dextropro-
poxyphene
Doxepin
Fluoxetine
Imipramine
Indomethacin
Methyldopa
NSAIDs
Nitrofurantoin
Oxybutynin
* Based on the Beers and McLeod criteria and revised
to be relevant for medicines available in Australia.
Geriatrics for the family pharmacist: part I
24. MAKE MEDICINES COUNT Download a QR reader to your mobile device and scan this
QR code to view our resources on medicines in older people
Also available at www.nps.org.au/older-people
and medicines burden, when in doubt DON’T
Medicines that accumulate or are nephrotoxic in impaired kidney function3,4
ANALGESICS BLOOD CARDIOVASCULAR ENDOCRINE
codeine
hydromorphone
NSAIDs and
COX-2 inhibitors
morphine
oxycodone
tramadol
apixaban
dabigatran
enoxaparin
rivaroxaban
atenolol
bisoprolol
digoxin
fenofibrate
atorvastatin†
simvastatin†
glibenclamide
glimepiride
gliptins (saxagliptin, sitagliptin, vildagliptin)
metformin‡
GASTROINTESTINAL GENITOURINARY MUSCULOSKELETAL NEUROLOGICAL PSYCHOTROPIC
H2-antagonists solifenacin§
sildenafil
tadalafil
tolterodine§
vardenafil§
allopurinol
bisphosphonates
colchicine
strontium ranelate
teriparatide
baclofen
gabapentin
galantamine
levetiracetam
memantine
methysergide
paliperidone
pramipexole
pregabalin
topiramate
varenicline
acamprosate
amisulpride
benzodiazepines
bupropion
desvenlafaxine
duloxetine
lithium
reboxetine
venlafaxine
† Risk of adverse effects increases in patients with kidney disease co-administered medicines that inhibit cytochrome P450 3A4. A recent study reported increased
adverse effects and a low (but avoidable) absolute risk of kidney injury when atorvastatin or simvastatin were taken in combination with clarithromycin or erythromycin.5
‡ Maximum daily dose of 2 g for patients with a glomerular filtration rate (GFR) of 60–90 mL/min, and 1 g for patients with a GFR of 30–60 mL/min.6
Metformin is not recommended for patients with a GFR less than 30 mL/min.
§ Not available on the PBS/RPBS.
Prescribing criteria do not substitute for good clinical decision-making but can alert an increase in risk7
Geriatrics for the family pharmacist: part I
25. Right
patient
10 points about using medicines in older people1
Use non-pharmacological treatments first – medicines should not replace
effective psychosocial care
Use a low dose and increase slowly – start with half the usual adult dose,
adjust based on tolerability and response
Use the lowest number of medicines – with the simplest dose regimens
Use a limited range of medicines – understand their effects in older people
Provide simple verbal and written instructions – for every medicine
and repeat prescription
Anticipate adherence issues – use alternatives to tablets or capsules
where needed and avoid child-proof containers
Consider current medicines as the cause of new symptoms before
looking elsewhere – do not assume symptoms relate to old age
Regularly review treatment – stop medicines no longer indicated,
adjust dose with declining kidney function
People are central to quality use of medicines – seek input and treat
the person, not the disease
Make medicines count – consider the appropriateness of prescribing
and medicines burden, when in doubt DON’T
Medicines
for prescri
older peop
recommen
be avoided
Amitriptyline
Amiodarone
Antihistamines
Benzodiazepine
Dextropro-
poxyphene
Doxepin
* Based on the Beers and M
to be relevant for medici
Geriatrics for the family pharmacist: part I
Right
drug
Right
dose
Right
technique
Right
route
Right
time
28. Frailty prevention
Healthy diet
Resistance exercise
Aerobic exercise
Tai-chi
Optimized management of medical conditions
Promising intervention
Geriatrics for the family pharmacist: part I
Frailty assessment
37. Geriatrics for the family pharmacist: part I
Primary prevention for frailty
38. Secondary prevention for frailty
“ใน1ปีที่ผ่านมา เคยหกล้มไหมคะ” “รับประทานได้ไหมคะ”
RAMPS
Frailty assessment
Promising intervention
Geriatrics for the family pharmacist: part I
40. Swallowing technique for stroke patient with dysphagia
• Eat slowly, not rushed
• Small amounts of food/liquid
• Concentrate on swallowing
• Avoid mixing food & liquid in the same mouthful
• Use stronger side of the mouth (unilateral weakness)
HAZZARD’S GERIATRIC MEDICINE AND GERONTOLOGY 6th Ed
41. Geriatrics for the family pharmacist: part I
Nutrition: protein 1.2-1.5 g/kg/day
Age: thin skin & decrease capillary blood flow
Moisture
Emergent illness
Sensation
Hypotension
Rx (drug-related): psychotropic agents, steroid, NSAIDs
, vasoconstriction
Endothelial function
Pressure ulcer
43. Frontiers in Aging Neuroscience2013.
Geriatrics for the family pharmacist: part I
44. Identification of
preclinical disease &
development of
treatments
-> prevent or delay
the onset of
dementia
Geriatrics for the family pharmacist: part I
52. Geriatrics for the family pharmacist: part I
“Progressive neurodegenerative disorder “
“Loss of dopaminergic neurons of
the substantia nigra pars compacta”
2nd most common neurodegenerative disorders
Cold Spring Harb Perspect Med 2012;2:a008870
2006 Royal
College of
Physicians of
London
53. Geriatrics for the family pharmacist: part I
J Med Assoc Thai 2011; 94 (6): 749-55.
4 Common causes of Parkinsonism
PD
Drug-induced Parkinsonism
Dementia with Parkinsonism
Vascular Parkinsonism
54. Geriatrics for the family pharmacist: part I
Cold Spring Harb Perspect Med 2012;2:a008870.
Motor symptoms
