April 28, 2023

Dear colleagues:

In this installment of UH EMSI’s Pharmacy Phriday, we do not focus on one specific medication in our protocols but review the issue of medications and the geriatric patient.  As a patient ages, it is common to find multiple diagnoses and multiple chronic medications within their medical history.  Along with the normal process of aging, the altered response to medications within the body and the frequent drug-to-drug or drug-to-food, natural herbs, and supplement interactions can be a huge concern.  Medications can improve the quality of life for these patients, but they can also lead to complications or adverse drug events (ADE).

Through the aging process, the pharmacokinetics and pharmacodynamics can be altered drastically for the geriatric patient.  Pharmacokinetics is how a medication is absorbed, distributed, metabolized, or eliminated in the body.  Pharmacodynamics is how the body responds to a medication.  

Absorption of a medication can be affected by decreased GI activity in the aging patient as well as possible drug binding interactions associated with other medications, vitamins, or supplements.  The distribution of a medication can be affected by factors such as decreases in cardiac output, blood flow, lean body mass, and total body water.  An increase in adipose tissue can also affect distribution as high fat can cause medications to accumulate in the body fat and cause delayed, inconsistent levels of the medication in the bloodstream.  Metabolism of medications in the body can be affected by decreased liver function, while elimination or excretion can be significantly decreased due to impaired kidney function.

Another factor in geriatric pharmacology is the concept of polypharmacy.  Polypharmacy is a term that describes the simultaneous use of multiple medicines by a patient for their conditions. Most commonly, it is defined as regularly taking five or more medicines.  Concerns associated with this concept include drug interactions that increase with the number of drugs prescribed or taken by a patient, multiple medications being prescribed by multiple providers and filled at multiple pharmacies, and the number of prescription medications a patient may have is a correlation to poor health outcomes. 

How does this change our care in the prehospital setting?  One of the most important considerations should include the need for a thorough assessment.  Such an assessment should include gathering a medication history that includes prescriptions, over-the-counter medications, vitamins, herbal supplements, etc. Other points to consider during the assessment might include determining if the patient is aware of the reasons for their medications, if their medication list is current and up to date, if they are taking medications as prescribed, and if they have had any recent changes in medications, doses, etc. 

Noncompliance with medications is also a common concern with the geriatric patient.  Areas of concern related to nonadherence can include failure to fill prescriptions due to financial reasons, discontinuance due to improved symptoms, and improper administration related to wrong times, with or without food, etc.  Geriatric patients can also simply forget to take their meds or take the wrong dose. Along with asking patients about medications and acquiring lists, it is recommended that the prehospital provider locate all prescription bottles, perform a pill count when there are questions, and bring all medications found in the home with the patient when transported.

Noncompliance and medication errors account for a large percentage of medical emergencies within the geriatric population.  Several resources regarding the topic suggest the provider consider an adverse drug event (ADE) as a potential underlying cause of any complaint within the geriatric patient until proven otherwise, even within skilled nursing or other advanced care settings.  The risk of an ADE increases in the case of multiple disease states and the use of multiple chronic medications.  The number of medications taken is often thought to be the greatest predictor of an ADE. 

When considering medications prescribed to the patient, the provider should also consider how those medications may affect the patient in the present emergency.  An example is that related to patient falls and the regular use of a blood thinner.  Another may include the trauma patient who is regularly using a beta blocker and how the medications interfere with the body’s normal responses to the injury. Many medicines and classes of medications are concerning in the geriatric population, and a knowledge of some of the more common or concerning meds can be useful.  The American Geriatrics Society publishes and regularly updates a list referred to as the Beers List, a guideline for healthcare professionals to help improve the safety of prescribing medications for adults 65 years and older. 

And finally, the prehospital provider should take caution in administering emergency medications.  A common theme in prescribing medications to the geriatric patient is “start low, go slow.”  The prehospital provider can use this same concept in administering medications. An example of such an instance is pain management.  Consider the use of fentanyl.  Within the UH protocols, the paramedic may administer a dose ranging from 25 to 100 mcg.  It is typically recommended that the provider start at the lower dose and titrate to affect when treating the geriatric patient.  Ultimately the best dosage is the lowest dosage that achieves the therapeutic effect. 

When administering medication to the geriatric patient, it is wise for the provider to be aware of and check for specific references within UH protocols.  These references can often be found listed under contraindications (such as with Toradol and Brilinta), precautions (such as with Labetalol, Zyprexa, and TNK), key points (such as with Morphine), and dosing (such as with Dilaudid, Lidocaine, and Versed).  Additional considerations when medicating the geriatric patient are precautions referenced in the protocols relating to disease processes common in the elderly such as a cardiac history, renal disease, or impairment, etc. We encourage you to thumb through the pharmacy section of the protocols and see how many references you can find regarding medication administration and the geriatric patient.

In the prehospital setting, we have a distinct advantage over other providers in recognizing this common problem in the geriatric patient.  Your attention to this concern, in the setting of the prehospital environment,  may be the only time such a concern is recognized.  Continue to make a difference in this and all patient populations. 

Thank you for your time and all that you do!  And as always, stay safe!!

Sincerely,



The UH EMS-I Team

University Hospitals