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Keynote lectures / European Geriatric Medicine 6S1 (2015) S1



dependent changes in pharmacokinetics and pharmacodynamics

are progressive, pharmacogenetic differences are inherent (lifelong)

sources of pharmacological variability


(i) To illustrate how the effect of aging may depend

on pharmacogenetic factors, and (ii) outline future potential of

pharmacogentic analyses for individualized drug treatment in older


Key points:

Aging causes a general decline in pharmacokinetic

processes, e.g. drug metabolism, renal filtration and P-glycoprotein-

mediated efflux transport. The impact of pharmacogentics in terms

of pharmacological vulnerability is therefore increased by age, as

secondary/backup processes are reduced in the elderly. We recently

showed that the impact of age on serum concentrations of the

antidepressant venlafaxine was much stronger in the subgroup

born without CYP2D6 metabolism (‘poor metabolizers’, i.e. 8-fold

higher levels in patients


65 years vs.


40 years, than those with

normal CYP2D6 phenotype (‘extensive metabolizers’, i.e. ~1.5-fold

age-difference) [1]. This illustrates that the clinical relevance of

pharmacogenetic variability is boosted by age.

Today, several pharmacogenetic analyses are available as routine

tests at many laboratories. To bring out the full potential of these

tests in terms of improving drug therapy, it is necessary with

clinical guidelines providing indications and practical information

for the application of pharmacogenetic analyses. In such guidelines,

multiple drugs in the elderly should be considered as an

independent indication for requisition of pharmacogenetic analyses.

For the benefit to be maximized, it is important that information

from pharmacogenetic analyses follows the patient through the

health care system and that sufficient expertise for the use of the

information is available.


[1] Waade RB, Hermann M, Moe HL, Molden E. Eur J Clin Pharmacol. 2014



Surgical care for older people, the present and future role

of the geriatrician

D.E. Forman

University of Pittsburgh Medical Center, Pittsburgh, United States of


The demographics of aging create a very important role for the

geriatrician as an integral part of surgical care. Older adults are

most likely to become surgical candidates, but due to the inherent

intricacies of aging, the expertise of an excellent surgeon and

hospital is not sufficient to provide excellent surgical care. The

geriatrician provides expertise to enhance the care provided by

surgeons, anesthesiologists, and others in the traditional surgical

team by supplying key perspectives in regard to each patient’s

personal and health parameters, and also to the broader context of

their lives. The geriatrician can help clarify critical detail in regard

baseline health issues (e.g., cardiovascular, renal, pulmonary, and

neurologic) as well as those that are especially age-related (e.g.,

frailty, cognition, multi-morbidity, polypharmacy, weight changes,

and family supports). Even more fundamentally, the geriatrician

provides expertise to clarify if surgery is truly aligned with each

patient’s goals and whether or not those goals are feasible. Likewise,

the geriatrician provides expertise to enrich pre-op (nutrition, pre-

habilitation) and post-op (rehabilitation, home-care, medication

and pain management, family support) management to best ensure

optimal outcomes. In general, the geriatrician facilitates a holistic

approach to surgery that expands the orientation from a procedure

into an extended process that is commensurate with the needs

of older patients. Overall, the geriatrician provides broad medical

insight and expertise which facilitates patient-centered approaches

as a basic part of surgical management.


Surgery in older people

the present and future role of the

geriatrician. Cancer surgery

J. Dhesi

Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom

Increasing numbers of older people are undergoing both elective

and emergency surgery for cancer. This is related in part to changing

demographics and patient expectations, but also to advances in

surgical and anaesthetic technique. The benefits of cancer surgery

in the older population are comparable to the younger, namely

improvements in mortality, morbidity, symptom and pain control,

functional status, and quality of life. However in comparison to

younger patients, older people have higher rates of post-operative

complications, longer length of stay and higher postoperative

mortality. Recent reports have demonstrated deficiencies in the

care we provide for this vulnerable group of patients. These

findings have led to the suggestion that we need to radically

review the traditional model of care for surgical patients. This

presentation will describe the evidence base relating to older cancer

surgical patients in the context of recent reports, will consider the

challenges we face in delivering safe and effective clinical services

and describe approaches being taken by geriatricians working with

multidisciplinary teams to improve outcomes.

Learning objectives:

1. To understand the changing profile of the cancer surgical


2. To understand the impact of this clinical profile on postoperative


3. To consider the deficiencies of the traditional cancer surgical


4. To understand the benefits of new approaches to delivery of care

for older cancer surgical patients


Surgery in older people

the present and future role of the

geriatrician: Orthopaedic surgery

F. Frihagen

Orthopaedic Department, Oslo University Hospital, Oslo, Norway

Orthopaedic patients are getting older and orthopaedic surgeons

operate on older patients in all areas of orthopaedic surgery.

The present role of the geriatrician varies widely across Europe,

as does the role of the orthopaedic surgeon. The archetypical

orthogeriatric diagnosis is hip fracture. This is also where most

of the clinical experience for orthogeriatric co-management, and

most of the science, is found. Other patient groups that may be

labeled orthogeriatric due to the complexity of the treatment

and an increased risk of complications, medical as well as

surgical, would be other elderly patients with fractures and elderly

and/or multimorbid elective patients undergoing major orthopaedic

surgery (e.g. hip or knee arthroplasty, or major revision surgery).

The potential benefit for these groups is less studied. Various

models of collaboration between orthopaedic surgeons and geriatric

teams exist, some with a high degree of integration with a joint

responsibility, and some with the one party functioning in a

consultative role and the other assuming the main responsibility for

the patients. It may be that the large variation in the systems for

implementing orthogeriatric care is only in part due to medical

knowledge, and also dependent on local treatment traditions,

organizational factors and budget. The best functioning systems

seem to be the ones with a high degree of integration, or the ones

where the geriatric teams have a leading role. It remains unclear if

sub groups of patients benefit more or less from orthogeriatric care,

for instance according to pre-surgical functional level or morbidity.