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tech talk ce
the national continuing education program for pharmacy technicians
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.75 CEU free
april/may 2009

Approved for
.75 CE unitS
The Aging Population and
Approved for .75 CE units
by the Canadian Council
on Continuing Education in
the Impact on Pharmacy
Pharmacy. File #009-1008
Tech. Not valid for CE By Rosemarie Patodia, BScPhm, CGP Pharmacist and Manager,
credits after Nov. 25, 2011.
Pharmacy Marketing and Professional Services, Shoppers Drug Mart
Answer this CE online for instant
results and accreditation. Visit
[Link] Learning Objectives:
Upon completion of this lesson, the pharmacy technician will be able to:
CE just for technicians
Tech Talk CE is the only national
1. Describe in general how physiological changes that occur with aging can impact on
continuing education program for medication use and outcomes
Canadian pharmacy technicians. 2. Summarize common functional problems that elderly patients can develop, which can
As the role of the technician expands, affect their daily lives and impact on their interactions with the pharmacy team
use Tech Talk CE as a regular part of
your learning portfolio. Note that a
3. Discuss the role of the pharmacy technician in helping to optimize medication use in seniors
passing grade of 70% is required to
earn the CE credit.
Introduction: The aging demographic multiple medications than younger adults, and
Tech Talk CE is generously sponsored
by Novopharm Limited. Download back in Canada in fact, in Canada 20–40% of medications
issues at [Link] or It is no surprise that the Canadian demographic prescribed are used by people over 65 years of
[Link].
is shifting toward an increasing number of people age.3,4 Various data demonstrate why it is
over 65 years of age. In 2001, one in every eight important for healthcare providers to place more
Answering Options
1. A
 nswer the lesson online and Canadians was over the age of 65; by the year emphasis on medication management in this
get your results instantly at 2021, one in five Canadians is expected to be 65 population. For instance:
[Link].
2. Use the reply card inserted with this
years of age or older.1 Despite advancing age, an • 11–46% of seniors receive at least one
CE lesson. Circle the answers on increasing number of older adults continue to prescription considered inappropriate for this
the card and mail in the prepaid, be very active and healthy. The fastest growing age group, per year;5,6
self-addressed card or fax to
Mayra Ramos, 416-764-3937. segment of the population is people over 85 years • 19–28% of hospital admissions for people
To pass this lesson, a grade of 70% of age, and the percentage of people in this age over 50 years of age are due to medication-
(7 out of 10) is required. If you pass, group is projected to rise to 4% (1.6 million related problems;7,8
you will receive .75 CEU’s. You will be
advised of your results in a letter from people) by the year 2041 from the latest figure • in one study, more than 1/3 of hospital
Tech Talk. Please allow 8 to 12 weeks. of 1.4% in 2001.1 Most of these seniors reside admissions in people over 50 were related to
in their homes (about 93%) rather than long- the use of warfarin, insulin and digoxin.9
CE Faculty
term care facilities.2 This means that pharmacy The most common types of medication-
CE Coordinator:
Margaret Woodruff, [Link], technicians, particularly in community pharmacy related problems that have been documented in
[Link]., MBA settings, have an important role in helping to older patients are mood changes, constipation,
Humber College
meet the health care needs of seniors. falls, immobility, confusion and hip fractures.10
Clinical Editor:
Lu Ann Murdoch, [Link]. Beers criteria for appropriate medication use
Author: Medication use in the elderly in the elderly have been developed to reflect
Rosemarie Patodia, BScPhm
Older patients are more likely to be taking expert opinions with respect to medications,
Reviewer:
Tim Fleming, President, CAPT

An educational service for Canadian pharmacy technicians,

brought to you by Novopharm Limited
[Link]

CE1 tech talkce APRIL/MAY 2009

 lithium and digoxin. As a result, they are

tech talk ce
Table 1: Some examples of inappropriate medications in the elderly more likely to experience prolonged
Type of medication Examples effects or adverse effects, since these
medications remain in circulation longer
long-acting benzodiazepines diazepam, flurazepam,
chlordiazepoxide compared to younger people.12
Other changes that occur with aging
tertiary amine tricyclic amitriptyline
antidepressants include: sensory deficits (e.g., visual changes,
hearing changes); greater sensitivity of the
sedating antihypertensives methyldopa, clonidine
central nervous system due to reduced levels
muscle relaxants cyclobenzaprine of chemicals in the brain called
nonselective NSAIDs used long term, naproxen, ibuprofen, neurotransmitters; a decrease in the pressure

Continuing Education
without stomach protection diclofenac sensitivity of the circulatory system (referred
antispasmodics dicyclomine, hyoscyamine to as baroreceptor sensitivity); and a decrease
in short-term memory.12
dosages or medication-disease combinations fat-soluble can accumulate in the fat tissue,
that should be avoided in this population. which may lead to longer-lasting Common functional problems
Healthcare professionals who care for effects in these individuals. Examples in older adults
elderly patients should follow of some of these fat-soluble medications are Since the vast majority of older people in
these guidelines to minimize drug-related benzodiazepines, lithium and theophylline. Canada live at home rather than in
problems.11 Some examples of medications Some elderly people, particularly those institutions, such as retirement homes and
that are considered inappropriate by this who are frail, produce reduced amounts of other long-term care facilities, they are often
consensus group are listed in Table 1. albumin, a protein that binds many managing their health conditions and
medications. This results in less “protein- medications independently. Commonly,
Physiological changes with aging binding” of drugs that are considered “highly elderly people are increasingly isolated as a
Inevitably, the human body changes with protein bound” and subsequently greater result of losing their spouse and other social
age, and a number of these changes can amounts of “free active drug” are available supports such as friends and colleagues. In
increase a person’s risk of having in the body, which leads to increased some cases, they may be fortunate to have
medication-related problems. therapeutic effects and possible adverse effects a caregiver or other family member who
Often the impact of these physiological or toxicity. Examples of highly protein plays an integral role in their health care.
changes on medication disposition is described bound drugs are NSAIDs and warfarin.12 Seniors are often faced with a variety of
using the acronym ADME (absorption, functional health-related problems—often
distribution, metabolism and excretion). Changes that affect medication metabolism: referred to as “geriatric syndromes”—
The liver is a major organ responsible for associated with age that are not always
Changes that affect medication absorption: metabolism or processing of medications. treated and recognized. Table 2 describes
As the body ages, there is a reduction in Certain enzymes in the liver help to break how some of these problems can affect a
the amount of acid that is produced in down medications and, as aging occurs, patient’s medication therapy.
the gastrointestinal system. An acidic some of these enzymes become less Other functional challenges can impact
environment is required to absorb certain effective. Medications cleared from the on medication taking in elderly people.
medications, such as calcium supplements, body in this manner subsequently become The incidence of osteoarthritis increases
so this change due to aging may result in more likely to accumulate and cause with age and this can result in joint stiffness
reduced effectiveness of these medications. adverse effects or toxicity. Examples of and reduced manual dexterity that can
Also, in general, older people have reduced such medications include benzodiazepines make it difficult to open prescription vials.
blood flow through the gastrointestinal and beta-blockers such as metoprolol. People who have a history of stroke or
system, thus potentially affecting how Also, decreased blood flow through the Parkinson’s disease, for example, may have
much drug is absorbed or how quickly it liver due to aging further reduces the swallowing difficulties that can create
is absorbed.12 metabolism of certain medications.12 problems with oral medications. It is
important to identify which medications
Changes that affect medication distribution: Changes that affect medication elimination: can be split or crushed to facilitate
With aging, the ratio of fat to muscle in the The kidneys are very critical for medication medication administration for people with
body increases, so older people are more likely elimination. Kidney function declines swallowing problems. Also, changes in
to have a greater percentage of fat relative to with age and thus many older people are visual and hearing abilities can impact on
muscle compared to when they were younger. less effective at excreting certain many older adults’ knowledge and
This means that certain medications that are medications, such as hydrochlorothiazide, understanding of their medications.

APRIL/MAY 2009 tech talkce CE2

 Risks for Medication-Related
tech talk ce
Table 2: Some functional problems associated with aging15,16,17
Problems
It is important to consider how changes Functional problem Impact
associated with aging manifest in the day-
Cognitive impairment Not necessarily dementia, but people can have memory
to-day lives of the older people that pharmacy loss and confusion that can be further worsened by
technicians see in the pharmacy. certain medications. This can also affect their ability to
Changes in kidney, liver and take medications appropriately.

gastrointestinal function, as well as body Falls About 30% of Canadians over 65 years of age experience
composition and central nervous system one fall each year.18 This can lead to disability or fear of
falling, which can limit the person’s trips to the pharmacy.
sensitivity, usually mean that dosages of Medications that cause drowsiness, low blood sugar or
medications should be lower, at least to low blood pressure can increase this risk, as can conditions
Continuing Education

start, for older patients. The general such as Parkinson’s disease. Falls can have significant
impact on quality of life and can, in many cases, lead to
recommendation for geriatric medication institutionalization.
dosing is “start low, go slow”. Dosages that
Depression This is often not diagnosed for a variety of reasons.
are too high can lead to increased risk of Elderly people can present with different symptoms than
adverse effects. younger people; noted changes might include general
For a variety of reasons, elderly people aches and pains, social withdrawal and weight changes.
They may also be less likely to report symptoms to their
tend to be more sensitive to the adverse
healthcare providers. Certain medications can worsen
effects of medications. This is particularly symptoms of depression (e.g., certain beta-blockers like
seen in response to medications that have propranolol, sedating medications like opioid pain
central nervous system effects (e.g., those relievers, and corticosteroids such as prednisone).
Depression has also been associated with chronic
that can cause drowsiness or confusion), medical conditions. Patients with mood changes may be
those with gastrointestinal effects (e.g., less motivated to take medications appropriately.
NSAIDs that can cause bleeding), Malnutrition This can affect day-to-day functioning and may be
and medications with anticholinergic aggravated by certain medications. For example,
effects (e.g., some antidepressants, medications that cause swallowing problems (e.g.,
certain antipsychotics), nausea (e.g., digoxin) and taste
antispasmodics). Anticholinergic effects disturbances (e.g., some seizure medications) may result
include the spectrum of dry mouth, in greater difficulty eating or less desire to eat.
confusion, blurred vision, urinary
retention and constipation. Some of these simply taking it incorrectly. information can assist pharmacists and other
effects can be particularly detrimental to Elderly people can be at higher risk of healthcare providers in flagging patients who
older people, especially those with pre-existing orthostatic hypotension (a significant decrease may require more intensive follow-up and
cognitive impairment or dementia. in blood pressure seen on rising, e.g., when monitoring to prevent problems. The
Although memory loss is associated getting out of bed), as a result of changes in following factors can increase the risk of
with Alzheimer’s dementia, it is important their circulatory pressure sensitivity. People medication-related problems:13,14
to note that some short-term memory taking medications that can decrease blood • greater than 85 years of age;
impairment can occur as a result of aging pressure, such as antihypertensives, certain • taking six or more medications;
alone, in the absence of dementia. This angina medications and medications for • frail (low body mass index);
means that some instructions and Parkinson’s disease, for example, should be • prior history of adverse drug reactions;
information provided at the pharmacy monitored for these blood pressure changes • more than six chronic health conditions;
could be forgotten later at home, potentially and counselled by the pharmacist on strategies • cognitive impairment;
leading to medication-related problems due to reduce the impact. • reduced kidney function;
to taking the medication inappropriately. Age-related changes in vision, as well • living alone and with few social contacts
Hearing loss is commonly associated as ophthalmologic conditions such as or supports; and
with aging, although this may not be macular degeneration, can have an impact • low literacy.
outwardly apparent in an older person. on the older patient’s ability to read
This change can have an impact on the prescription labels as well as print Considerations for pharmacy
elderly patient’s ability to understand information. Once again, this can lead to technicians
instructions and other information errors in medication administration. As pharmacy technicians are often the first-
provided during their visit to the pharmacy. Specific criteria or risk factors for line contact for patients visiting the
Ultimately this can result in medication- medication-related problems in the elderly community pharmacy, they have an important
related problems that could include taking have been identified through analysis in both role in ensuring that the needs of elderly
too much or too little medication or nursing home and community settings. This patients are met in a timely fashion.

CE3 tech talkce APRIL/MAY 2009

 The following tips can help technicians Where feasible, pharmacy technicians 5. Canadian Association on Gerontology.

tech talk ce
Policy Statement. Seniors and Prescrip-
optimize the care of their senior can coordinate medication reviews with tion Drugs. 1999. [Link]
patients. the pharmacist to help older patients publications/551_e.php Accessed August
• Sensory changes that occur with aging sort through all of their medications and 29, 2008.
can affect medication taking (e.g., ensure that they have a good 6. Steinman MA, Landefeld S, Rosenthal
GE et al. Polypharmacy and prescribing
inability to read labels, difficulty listening understanding of how and why they quality in older people. J Am Geriatr Soc
to instructions), so, where possible, should be used. 2006;54(10):1516-1523.
adapt service and care to accommodate • Pharmacy technicians usually have an 7. Grymonpre RE, Mitenko PA, Sitar
these differences. Be proactive by opportunity to form close relationships DS, Aoki FY and Montgomery PR. Drug
associated hospital admissions in
providing written information when with patients and thus are in a good older medical patients. J Am Geriatr Soc
available to support the pharmacist’s position to note behavioural or physical 1988;36:1092.

Continuing Education
counselling, trying to minimize changes in these people. In light of the 8. Col N, Fanale JE, Kronholm P. The role
background noise when communicating fact that they may be more susceptible of medication non-compliance and adverse
drug reactions in hospitalizations of the
with the patient to maximize their ability to medication-related problems, elderly. Arch Intern Med 1990;150:841-
to hear and increasing font sizes on pharmacy technicians should discuss any 845.
prescription labels and accompanying significant changes or concerns with 9. Hanlon JT. Schmader KE, Koronkows-
materials where possible. these patients with the pharmacist. ki MJ et al. Adverse drug events in
high-risk older patients. J Am Geriatr Soc
• In many cases, older patients may have • Assist pharmacists in identifying 1997;45:945-948.
a spouse or caregiver who handles their and flagging potentially high-risk 10. Budnitz DS, Shehab N, Kegler
medications and administers them; it is individuals as candidates for follow-up SR et al. Medication use leading to
important to ensure that communication by the pharmacist. emergency department visits for adverse
drug events in older adults. Ann Intern Med
is appropriate for this situation (e.g., in 2007;147(11):755-765.
the event that instructions are conveyed Summary 11. Fick DM, Cooper JW, Wade WE et
to the patient by caregiver—written An increasing number of patients visiting al. Updating the Beers criteria for po-
information is most helpful). Of course, pharmacies over the next several years will tentially inappropriate medication use in
older adults. Arch Intern Med. 2003;163:
it is important that patient confidentiality be over the age of 65, and even over the 2716-2724.
is considered when dealing with family age of 85, so it is important for pharmacy 12. Miller SW, Anderson RJ. Geriatric
members or other caregivers. technicians to become familiar with some drug therapy. In: Herfindal ET, Gourley DR,
• Older patients tend to be on multiple of the health- and medication-related editors. Textbook of therapeutics, drug and
disease management. 6th ed. Baltimore:
medications. They may require extra challenges faced by this demographic. Williams and Wilkins, 1996.
attention to things such as specialized Through gaining a basic understanding 13. Fouts M, Hanlon J, Pieper C et al. Iden-
vial lids, pill splitting, dossettes or blister of the unique needs of older adults, tification of elderly nursing facility residents
packs. Pharmacy technicians can help pharmacy technicians can help to optimize at high risk for drug-related problems. Con-
sult Pharm 1997; 12(10).
pharmacists determine what specific the care of these individuals.
14. McElnay JC, McCallion CR, Al-Deagi F
challenges the patient may have with et al. Development of a risk model for ad-
respect to their medication schedule. For REFERENCES verse drug events in the elderly. Clin Drug
example, if they are confused about all 1. Public Health Agency of Canada. Divi- Invest 1997;13:47-55.
sion of Aging and Seniors. Canada’s Aging 15. Flacker JM. What is a geriatric
of their medications and when to take Population. [Link] syndrome anyway? Geriatrics and Aging
them, dossettes or blister packs can help seniors-aines/pubs/fed_paper/index_e.htm 2003;6(9):58-59.
to minimize this issue. Patients who have Accessed August 29, 2008. 16. Tinetti ME, Inouye SK, Gill TM et al.
difficulty taking their medications 2. Public Health Agency of Canada. Shared risk factors for falls, incontinence,
Division of Aging and Seniors. Canada’s and functional dependence. Unifying the
because the pills are too large to swallow Seniors at a Glance. [Link] approach to geriatric syndromes. JAMA
may have improved adherence if the [Link]/seniors-aines/pubs/seniors_at_ 1995;273(17):1348-53.
pharmacy team takes the initiative to glance/poster5_e.html#c Accessed August 17. Inouye SK, Studenski S, Tinetti ME et
29, 2008. al. Geriatric syndromes: clinical, research
help them by cutting their tablets in half
3. Quinn, K., Baker, M. and Evans, B. Clini- and policy implications of a core geriat-
when appropriate.
cal and Community studies. A Population ric concept. J Am Geriatr Soc 2007;55(5):
• Callbacks or refill reminder services can Wide Profile of Prescription Drug Use in 780-791.
be beneficial to patients who are taking Saskatchewan 1989. Canadian Medical 18. Public Health Agency of Canada.
multiple medications; they may forget to Association Journal, 1992, 146(12), 32. Division of Aging and Seniors. Enhancing
4. Anderson G and Lavis J. Prescription Safety and Security for Canadian Seniors.
refill their medications regularly, ultimately
drug use in the elderly: expenditures and [Link]
leading to medication-related problems patterns of use under Ontario and British pubs/enhancing/chap3_e.htm Accessed
• Lack of awareness of their medications Columbia provincial drug benefit programs. August 29, 2008)
is a major reason for nonadherence. Queen’s/University of Ottawa Economic
Projects. February 1994.

APRIL/MAY 2009 tech talkce CE4

 Please select the best answer for each question or answer online
tech talk ce
➤QUESTIONS
at [Link] for instant results.

1. Which of the following is one of b. Call them at home to reinforce c. Medications that affect taste in the
the conditions that have been most medication instructions and refill mouth can reduce desire to eat.
commonly associated with times. d. All of the above
medication-related problems in c. Suggest that they use a dossette or
older people? offer specialized medication 12. Which of the following is an
a. Constipation packaging if feasible. example of an antidepressant not
b. Asthma flare-ups d. All of the above recommended for the elderly?
c. Dermatological problems a. Diazepam
d. Urinary incontinence 6. Medication disposition can be b. Amitriptyline
Continuing Education

affected by: c. Digoxin

2. Which of the following is a. Vision problems d. Methyldopa
accurate? b. Hearing problems
a. Kidney changes that occur with c. Stomach acid 13. Why are elderly people more
aging can affect the dose of d. Social supports likely to experience digoxin toxicity?
medication required for older adults. a. They’re prescribed too high a
b. The liver metabolizes medications 7. Which of the following is an dose of digoxin
more effectively with age thus anticholinergic effect? b. This medication is not safe in
increasing the risk of side effects. a. Cough the elderly
c. Elderly people are less likely to have b. Dry mouth c. Digoxin may be eliminated less
low blood pressure due to diseases c. Urinary incontinence effectively
and medications than younger adults. d. High blood pressure d. Digoxin requires an acidic
d. Older adults produce more stomach environment to be absorbed
acid than younger people. 8. What is orthostatic hypotension?
a. A drop in blood pressure on rising 14. Why are medication reviews a
3. Why do some medications stay in b. High blood pressure at night good idea for elderly people?
the system of an elderly person longer c. Low blood sugar a. They are at higher risk of
than they would in a younger person? d. Drowsiness with blood pressure medication-related problems,
a. Elderly people have more protein medications especially if they are taking
binding of medications which several medications.
causes accumulation. 9. Why is depression an issue in b. They are more isolated and
b. Elderly people take higher doses of older people? appreciate quiet time with the
medications. a. Drug treatment is not pharmacist.
c. Elderly people have more efficient recommended in this population c. They are more likely to be on
metabolism by the liver. b. It is often undiagnosed and not multiple medications and have
d. Elderly people have more fat than treated some short-term memory
muscle, so are more likely to c. It can affect medication adherence impairment than younger people.
accumulate certain medications in d. B and C d. A and C
fat tissue.
10. Medication elimination is most 15. Which of the following is correct?
4. How can medications increase the affected by: a. Older people who are overweight
risk of falls in an older person? a. Kidney function are at higher risk of medication-
a. Reduce blood pressure b. Stomach acid related problems than those who
b. Reduce blood sugar c. Muscle to fat ratio are frail.
c. Cause drowsiness d. Hearing problems b. Most elderly people in Canada live
d. All of the above in long-term care facilities.
11. How may nutritional status be c. Seniors who are over 85 years of
5. How can pharmacy technicians affected by medication therapy? age are at high risk of medication-
help older patients with memory a. Medications can cause nausea, related problems.
impairment? reducing appetite. d. All of the above
a. Assist pharmacists in providing b. Antipsychotics that cause
patients with written information swallowing difficulties can affect
about their medications. ability and desire to eat.

For information about CE marking, please contact Mayra Ramos at (416) 764-3879 or fax
(416) 764-3937 or email [Link]@[Link]. All other inquiries about Tech Talk CE should be directed
to Tanya Stuart at (416) 764-3944 or [Link]@[Link].

CE5 tech talkce APRIL/MAY 2009

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Pharmacy Practice, Pharmacy Post, Drugstore Canada, Novopharm CE Series,
More CCCEP-approved CEs or Tech Talk CEs (English and French)
Fax: (416) 764-3937
Email: [Link]@[Link]

Francine Beauchamp
Quebec Pharmacie and L’actualite Pharmaceutique
Fax: (514) 843-2183
Email: [Link]@[Link]