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Keynote lectures / European Geriatric Medicine 6S1 (2015) S1
–
S4
S3
dependent changes in pharmacokinetics and pharmacodynamics
are progressive, pharmacogenetic differences are inherent (lifelong)
sources of pharmacological variability
Aims:
(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
people.
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.
Reference(s)
[1] Waade RB, Hermann M, Moe HL, Molden E. Eur J Clin Pharmacol. 2014
Aug;70(8):933–40.
KL-13
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
America
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.
KL-14
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
population
2. To understand the impact of this clinical profile on postoperative
outcomes
3. To consider the deficiencies of the traditional cancer surgical
pathway
4. To understand the benefits of new approaches to delivery of care
for older cancer surgical patients
KL-15
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.