Medication Use in the Geriatric Population

First Pharmacy Conference at Baycrest Centre for Geriatric Care

Christine Oyugi, BSc, Managing Editor, Geriatrics & Aging.

Speakers

1. Osteoporosis Update:
   Tom Brown, PharmD, Pharmacist, Women's Health Pharmacy Department, Sunnybrook & Women's College Health Sciences Centre, Toronto, ON.
2. Diabetes and the Elderly:
   Dr. Christine Papoushek, PharmD, University Health Network, Department of Family and Community Medicine/Pharmacy, Toronto, ON.
3. Pharmacological Management of Congestive Heart Failure:
   Fran L. Paradiso-Hardy, BScPhm, MSc Pharm, Clinical Co-ordinator/Infectious Diseases, Department of Pharmacy, Sunnybrook Health Sciences Centre, Toronto, ON.
4. New Evidence and Guidelines in Osteoarthritis:
   Natalie Kennie, PharmD, Primary Care Pharmacist, St. Michael's Hospital Health Centre, Toronto, ON.

Elderly patients are at high risk for medication-related problems due to age-related physiological changes, a higher incidence of comorbid illnesses and greater use of both prescription and over-the-counter medications. As a result, older adults are at increased risk of developing adverse drug events. It is important for physicians to regularly review the drug regimen of any older patient, in order to determine if the drug is effective, monitor for adverse drug events and recommend newer alternative therapies, as they become available. These points were addressed at the 'First Pharmacy Conference on Medication Use in the Geriatric Population' held at the Baycrest Centre for Geriatric Care. This article summarizes some of the major points addressed at this conference.

I. Osteoporosis Update

The objectives of this talk were to illustrate the role of combination therapy in the management of osteoporosis; discuss the value of guidelines in managing osteoporosis; and demonstrate the application of new evidence to managing complex patients. Dr. Brown presented four case studies by way of achieving these objectives.

Case Synopses
Case One
A 57-year-old Caucasian female who has been on Hormone Replacement Therapy (HRT) for the past four years for vasomotor symptoms. She was diagnosed with osteopenia two years ago and takes conjugated equine estrogen (CEE) 0.625mg, and Medroxyprogesterone acetate 2.5mg daily. She has a familial history of osteoporosis, myocardial infarct (MI) and breast cancer, and smokes a pack of cigarettes a day. Her BMD was -2.3 spine and -1.8 hip in January 2000, -2.6 spine and -2.2 hip in January 2002.

Should we add a bisphosphonate to the HRT regimen? Several studies indicate beneficial effects of adding a bisphosphonate to ongoing HRT in postmenopausal women. Patients on HRT and etidronate have a significantly greater BMD when compared to women on monotherapy. A study of 428 postmenopausal women with osteoporosis, who had been receiving HRT for at least one year, demonstrated that adding a bisphosphonate (alendronate) significantly increased bone mass at both spine and hip trochanter.¹ Therefore, patients who have failed both HRT and bisphosphonate monotherapy should be considered for combination therapy. Although BMD improves, several sub-group analyses demonstrate that changes in BMD cannot fully account for anti-fracture efficacy.

Case Two
A 70-year-old Asian women with osteoporosis. Her mother fractured a hip at the age of 86 years and her father developed colon cancer at 64 years. Her BMD is spine -2.8 and hip -1.9. Her total cholesterol is 6.85 mmol/L, LDL 4.97mmol/L, HDL 1.32 mmol/L and triglyceride 1.84mmol/L.

Currently, several guidelines exist for the treatment of osteoporosis. Unfortunately, the guidelines have varying recommendations, are often outdated and tend to focus on risk factors and initiating therapy, without proper advice on monitoring or follow-up. The guidelines from several organizations are listed below:

1. The National Osteoporosis Foundation (NOF)--First consider HRT and then Alendronate in patients who are unwilling or unable to take HRT, or who fail on HRT. If both bisphosphonates and HRT fail, then consider calcitonin. Raloxifene, a selective