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2014;22(2):64-69

Transl Clin Pharmacol

http://dx.doi.org/10.12793/tcp.2014.22.2.64

Geriatric clinical pharmacology

and clinical trials in the elderly
Jae-Yong Chung*
Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Bundang Hospital, Seongnam 463-707, Korea
*Correspondence: J. Y. Chung; Tel: +82-31-787-3955, Fax: +82-31-787-4045, E-mail: [email protected]
Received 31 Oct 2014
Revised 24 Nov 2014
Accepted 25 Nov 2014

REVIEW

Keywords
clinical trials,
clinical pharmacology,
geriatrics,
elderly
pISSN: 2289-0882
eISSN: 2383-5427

The aging process is linked to changes in the physiological function of organs and changes in body
composition that alter the pharmacokinetics of drugs and pharmacodynamic responses. Comorbidity and polypharmacy in the elderly decreases tolerability of drugs, leading to greater vulnerability
to adverse drug reactions than that observed in younger adults. In geriatric pharmacotherapy, the
general recommendation is dose reduction and slow titration, which is based on pharmacokinetic
considerations and concern for adverse drug reactions, rather than clinical trial data. Older patients
are under-represented in clinical trials. In the absence of evidence, extrapolation of riskbenefit
ratios from younger adults to geriatric populations is not necessarily valid. Sound evidence through
prospective clinical trials is essential, and geriatric societies, governments, and patient advocacy
groups should collaborate to promote the inclusion of older people in clinical trials. It is believed
that all involved in clinical trials have both an obligation and an opportunity to eliminate age discrimination in clinical trial practice.

Introduction

The most important and common medical intervention in the

elderly is drug therapy. Due to unprecedented increases in the
proportion of elderly people in a population, an understanding of geriatric pharmacology has become very important for
drug therapy in elderly patients. In addition to drug treatment
itself for medical problems caused by aging, such as dementia
and degenerative diseases, elderly patients experience many
treatment-related problems compared with younger patients.
Examples of such problems include reduction in physiological
function, change in pharmacokinetics/pharmacodynamics, and
vulnerability to adverse drug reactions, polypharmacy, drug interactions, and low compliance. Understanding the various factors that affect drug treatment outcomes in the elderly requires
knowledge of basic and clinical pharmacology of geriatrics.
Using this knowledge, attention should be applied to providing
appropriate drug therapy.[1]
Organ function is reduced and body composition is altered
with age. The pharmacokinetic processes of absorption, distribution, metabolism, and excretion differ compared with young
Copyright 2014 Translational and Clinical Pharmacology
It is identical to the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/3.0/).
This paper meets the requirement of KS X ISO 9706, ISO 9706-1994 and
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64

adults. Moreover, the elderly have greater risk of disease because

of the aging process, which is accompanied by multiple chronic
conditions. Drug tolerability decreases, while patients are often
exposed to multiple drugs. Therefore, elderly patients are much
more vulnerable to adverse drug reactions than younger adults.
The fifth most common cause of hospitalization in elderly patients is related to drug use, and accounts for approximately 20%
of hospitalizations.[2] Concomitant use of more than 5 drugs
(polypharmacy) is observed in 20 to 40% of elderly patients.[3]
Thus, the risk of adverse drug events due to drugdrug interactions is high. In addition, it is common to administer new drugs
to elderly patients for the relief of an atypical symptom without
appropriate evaluations; this causes new drug-induced side effects and perpetuates a vicious circle.
Prescribing for geriatric patients requires an understanding
of the efficacy of medication in older people, an assessment of
the risk of adverse drug events, and a decision about the dosage
regimen and careful monitoring of the patient's response. This
requires an evaluation of evidence through clinical trials. Given
that most diseases occur in older people, and that this patient
group is the major recipients of drug therapy, more research and
a better evidence base through clinical trials is essential to guide
clinicians who manage geriatric patients.[4] Patients older than
65 years are not well represented in clinical trials,[5] and this
under-representation impacts the care of elderly patients.[6]

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The elderly population in Korea has increased rapidly. In 2011,

the proportion of the population aged over 65 was 12.2%.[7]
Similarly, medical expenses of the elderly have increased exponentially and accounted for 33.3% of the total medical costs for
Korea in 2012.[8] New drugs and treatments that have undergone evaluation during clinical trials will provide great benefit
to the elderly. However, the participation of elderly patients in
clinical trials is not usually favored; therefore, there is a lack of
evidence for optimum therapy for elderly patients, especially
in the cases of comorbidity and polypharmacy. The regulatory
agencies of Europe and the United States have been aware of
the relevance of obtaining information concerning the efficacy
and safety of new drugs in the elderly since the late 1980s. In
1994, the International Conference of Harmonization (ICH E7)
guidance on studies in support of geriatric population clearly
stated that age should not be a barrier to participation in clinical trials.[9] The guidance states that There is no good basis
for the exclusion of patients on the basis of advanced age alone,
or because of the presence of any concomitant illness or medication, unless there is reason to believe that the concomitant
illness or medication will endanger the patient or lead to confusion in interpreting the results of the study. Attempts should be
made to include patients over 75 years of age and those with
concomitant illness and treatments.[9] According to this guidance, separate pharmacokinetic and pharmacodynamic studies
of older populations may be needed, particularly when assessing drugs that target the central nervous system, which implies
special consideration of geriatric pharmacology is necessary.
Good understanding of geriatric clinical pharmacology is
essential for appropriate patient care and clinical trials in the
elderly. This article presents a brief review of principles of geriatric clinical pharmacology and discusses the challenges and
opportunities to participation of the elderly in clinical trials.

Clinical pharmacology of the elderly

Pharmacokinetics

All aspects of pharmacokinetics are affected by aging. The

change in absorption is often not a major clinical problem, but
significant changes can be observed in distribution, metabo-

lism, and excretion of drugs. Decreased drug clearance is an

obvious finding because of reduced renal excretion and hepatic
metabolism in older adults. These pharmacokinetic differences
can be the basis for predicting the safety and efficacy of drugs
commonly used in the elderly. All aspects of pharmacokinetics
are affected by aging (Table 1).
Evidence of the effects of aging on pharmacokinetic parameters can be generated with a dedicated clinical pharmacokinetic
study or population pharmacokinetic data analysis. For drugs
that will be mainly used by elderly patients, a dedicated
pharmacokinetic study in elderly subjects is usually required for
a new drug application according to ICH E7 guidelines. If possible, a population pharmacokinetic approach can be applied by
obtaining a small number of samples per patients in late-phase
clinical trials, followed by an attempt to explore the effects of aging on pharmacokinetics through pharmaco-statistical modeling analysis.[9]

Absorption

Aging can cause changes in the absorption process of the drug.

Gastric acid secretion deceases, intragastric pH increases, gastric emptying time is delayed because of decreased motility of
the gastrointestinal tract, and blood flow in the gastrointestinal
tract is reduced.[4] Such changes may not significantly affect
the extent of drug absorption, and rarely lead to clinically significant changes in the drug absorption process. One exception
is levodopa, which requires particular attention because its absorption may increase due to a reduction in dopa-decarboxylase
in the gastrointestinal mucosa causing an increase in drug levels
in the blood.[10]

Distribution

Changes in body composition in older adults are characterized

by a progressive reduction in total body water and lean body
mass, resulting in a relative increase in body fat.[11] This change
can affect the volume of distribution (Vd) of the drug. For lipidsoluble drugs, such as diazepam and thiopentone, Vd increases,
leading to prolonged half-life and duration of action. In the case
of water-soluble polar drugs, such as digoxin and theophylline,
there is an initial rapid elevation in plasma concentration fol-

Table 1. Pharmacokinetic changes in the elderly

Process

Change

Clinical Significance

Absorption
Distribution (Vd)

Generally unchanged
Hydrophobic drug
Hydrophilic drug
Albumin
Hepatic Blood Flow
Liver mass
Glomerular filtration rate

Little
T1/2
Plasma Concentration
Free Drug Concentration
T1/2

Metabolism
Excretion

T1/2

T1/2 = elimination half-life; Vd = volume of distribution; = increase; = decrease

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lowing drug administration due to decreased Vd.[12]

In addition, protein binding of drug decreases and free fraction increases in the elderly. Such changes may be marked with
acidic drugs, such as cimetidine and furosemide.[13] However,
clinical relevance is probably limited in most cases because the
initial and transient effect of protein binding on free plasma
concentration is rapidly counterbalanced by its effects on clearance.[14]

Metabolism

Studies on human liver tissue showed that cytochrome (CYP)

P450 enzyme activity is maintained even with advanced age.
[15] These results were confirmed by in vivo studies for CYP3A
activity.[16] Aging is associated with a 40% reduction in hepatic
blood flow and 30% reduction in liver mass.[1] Because the
activity of drug metabolizing enzymes is preserved, impaired
hepatic drug clearance in older people is probably represented
by age-related changes in liver size and hepatic blood flow.[17]
Orally administered drugs with large flowdependent firstpass effects (e.g., labetalol, propranolol, verapamil, and morphine) should be used with caution because the reduction in
hepatic blood flow could lower the first-pass effect and increase
drug concentrations in the elderly.

Excretion

It is well known that renal function progressively decreases

with increasing age, and when accompanied by a chronic disease, the decrease in function is further accelerated. However,
serum creatinine concentration in older adults is not high
enough to accurately reflect renal function because of significantly reduced muscle mass.[18] Calculating creatinine clearance as a standard indicator of glomerular filtration should be
conducted to estimate renal function. In the case of drugs mainly excreted via kidney, appropriate dose adjustments should be
made for older patients.

Pharmacodynamics

The action of a drug is derived from its interaction with its target receptor leading to apparent drug responses. Aging is associated with changes in pharmacodynamics and ability to maintain
homeostasis in the body. A well-known example is the reduced
reactivity of -adrenergic receptors in the elderly. The affinity
and number of -adrenergic receptors are reduced,[19] and it is
thought to be due to changes in the signal transduction system
downstream of receptor binding. In contrast, the sensitivity of
neuropsychiatric drugs, including benzodiazepine, is generally
increased in the elderly, resulting in psychomotor dysfunction
at lower doses than in younger adults.[20] It is often difficult to
make generalizations because the effect of age on drug sensitivity varies with the drug studied and the response measured.
Some important age-related changes in pharmacodynamics are
illustrated in Table 2.
The homeostatic response provides important information to

66

Table 2. Selected pharmacodynamic changes in the elderly (quoted

from Ref. 12)

Drug

Pharmacodynamic effect

Age-related
change

Adenosine

Heart-rate response

Diazepam

Sedation, postural sway

Antihypertensive effect

Acute PR interval prolongation

Diltiazem
Diphenhydramine
Enalapril

Postural sway

ACE inhibition

Furosemide

Peak diuretic response

Heparin

Anticoagulant effect

Isoproterenol

Chronotropic effect

Analgesic effect

Respiratory depression

Morphine

Phenylephrine Alpha1-adrenergic responsiveness

Antagonism of chronotropic effects

of isoproterenol

Scopolamine

Cognitive function

Temazepam

Postural sway

Acute antihypertensive effect

Anticoagulant effect

Propranolol

Verapamil
Warfarin

= increase; = decrease; = no significant change

explain the overall reaction of the body to a drug. In the elderly,

homeostatic regulation of the body is reduced. For example,
mean blood pressure is increased, but the occurrence of orthostatic hypotension increases significantly. Two-hour postprandial blood glucose levels increase by about 1 mg/dL every year after 50 years of age. Temperature control function also decreases,
which explains why older adults are less likely to withstand cold
environments.[21]

Adverse drug reactions and drug interactions

Aging brings about changes in pharmacokinetc and pharmacodynamic processes; thus, drug-related adverse effects occur
frequently in the elderly. In addition, the elderly tend to have
multiple chronic diseases requiring polypharmacy leading to
undesirable drug interactions. Risk of drug-related adverse effects increases exponentially with the number of drugs used.
To date, studies that investigate drugdrug interactions in the
elderly population are rarely conducted. Inhibition of drug metabolism by other drugs does not appear to be altered with age.
For example, ciprofloxacin and cimetidine suppress the metabolism of theophylline by about 30% in both healthy elderly
and young adults. The effects of aging on the induction of drug
metabolism are diverse. For example, induction of theophylline

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metabolism by phenytoin can occur in a similar manner in the

young and the elderly; however, the induction effect of rifampin
on drug metabolism is decreased in the elderly.[22] This information is reflected relatively well in the label of drugs recently
approved by the United States Food and Drug Administration
that are commonly prescribed to elderly patients. In the case
of the anticoagulant dabigatran, the effect on CYP enzyme
based metabolic interaction is minimal; however, the drug is
a substrate for P-glycoprotein, so attention should be paid for
potential P-glycoproteinmediated inhibition or induction.[23]
There is a possibility that the use of 2 or more agents with
similar adverse event profiles causes serious toxicity in the elderly. For example, concomitant use of 2 or more drugs among
anti-parkinson agents, tricyclic antidepressants, antipsychotics,
anti-arrhythmics, and antihistamines can cause or exacerbate
anti-cholinergic symptoms such as dry mouth, blurred vision,
constipation, and urinary retention.[24] Indeed, elderly patients
should avoid many drugs because adverse events outweigh the
benefits of taking the drug. The American Geriatrics Society expert panel periodically updates and publishes the Beers Criteria
for potentially inappropriate medication use in older adults.[25]

Considerations for effective pharmacotherapy

in the elderly

The amount of a drug required to achieve a desirable effect differs between individuals. Greater variation is observed between
elderly patients, and the consensus is that drug doses should be
lowered in elderly patients. When prescribing drug therapies it
is important to use the minimal dose required to obtain clinical benefit. The start low and go slow rule is recommended
and involves minimizing the initial dosage, dose titration, and
close monitoring according to the condition of the patient.[26]
In addition, elderly patients frequently have prescriptions for
multiple drugs from more than one doctor; thus, a thorough
medical and medication history is important.
Medication non-adherence is a major problem with geriatric

patients. Approximately 50% of elderly patients do not follow

directions for taking medication, and often take a lower dose
than prescribed.[27] Barriers to compliance include chronic
medical conditions, polypharmacy, complex regimens, a higher
prevalence of adverse drug reactions, cognitive impairment,
and dysphagia.[28] Therefore, it may be necessary to simplify
the dosage regimen in order to increase compliance.

Under-representation of the elderly in clinical

trials

Older patients are under-represented in clinical trials because

they are considered a socially vulnerable population. However,
it is not necessarily valid to extrapolate riskbenefit ratios from
younger adults to geriatric populations in the absence of evidence. In 1997, a descriptive investigation of 4 major medical
journals reported that approximately 35% of clinical studies did
not involve elderly patients and did not offer a valid reason.[29]
A similar investigation was performed in 2004 and revealed
that 15% of clinical studies still excluded the elderly population
without legitimate reason.[30] Despite the fact that the elderly
represent the majority of patients who die of cancer, they represent one quarter of participants for cancer therapy clinical
trials conducted in the United States.[31,32] According to the
PREDICT (increasing the PaRticipation of the ElDerly in Clinical Trials) study, 64 out of 251 heart failure clinical trials (25.5%)
arbitrarily determined the upper age limit of trial participants.
Elderly patients were prevented from participating in 109 clinical trials (43.4%) by constraints other than age. For example,
patients were excluded because of mild concomitant disease,
visual impairment, and hearing impairment, even though there
was no cause for concern with the safety of these subjects in the
participating clinical trials.[33]
Compared with their younger counterparts, elderly people
have increased rates of comorbidities and complications. Besides physical disadvantages, the perceptions of health care professionals and family members can make it difficult for elderly

Table 3. Selected barriers and solutions for participation of the elderly in clinical trials (quoted from Ref.36)

Patient-Related

Barriers

Solutions

Physician-Related

Trial-Related

Logistics

Perceptions

Strict inclusion criteria

Finances

Culture

Poor methods for evaluating functional status

Lack of understanding of benefits

Complex pharmacokinetics/pharmacodynamics

Lack of funding dedicated to elderly population

Autonomy

Lack of evidence

Provide transportation

Elder-focused studies

Create geriatric-focused trials

Provide lodging

Improved communication

Increase/fund studies of elderly population

Research nurses, trial coordinators

Increase physician training in geriatrics specialty

Improved communication

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patients to participate in clinical trials.[34] Such enrollment barriers have gained interest in the past decades.[6] Although numerous solutions have been proposed, implemented solutions
have had limited success. It has been suggested that a larger,
more succinct effort is necessary from the medical community.
[6,35] Barriers and solutions for inclusion of elderly patients in
clinical trials are summarized in Table 3.[36] Older participants
representative of those seen in clinical practice must be included
in clinical trials to better understand the benefits and potential
adverse effects of new drugs in the elderly population.[37]

Effort for promoting the inclusion of representative older participants in clinical trials

Many challenges are faced when conducting clinical trials

in the elderly. The removal of specific upper age limits from
clinical trial protocols, while strongly recommended, was not
thought to be sufficient to resolve the under-representation of
this patient population [38]. There has been some effort to overcome this through active discussion by experts. A roundtable
discussion on the participation of older adults in clinical trials
took place at the American Geriatrics Society annual meeting in
2009. It provided an opportunity to discuss the shared views of
the American Geriatrics Society, the European Union Geriatric
Medicine Society, and regulatory agencies of Europe and United
States. The main discussion points are summarized here.[39]
The first challenge is the need to justify inclusion and exclusion criteria clearly. Selection criteria results in the exclusion of
older adults with complex illnesses and multiple diseases, who
are common in clinical practice. To address this bias, inclusion
and exclusion criteria should be clear, simple, and aimed at
limiting the number of participants who are considered ineligible because of comorbidity and concomitant medications.
The second challenge is the need to reduce dropouts during
follow-up. Study design should support the participation of
older people who may have difficulty with multiple study visits
(e.g., providing transportation or performing home followup). The third issue that must be addressed is the difficulty of
obtaining informed consent from elderly participants who are
often cognitively impaired or have psychiatric problems, such as
depression.[40] Careful attention to screening for cognitive impairment, determining that the individual is capable of understanding the risks and benefits of participation, use of objective
observers in the consent process, and involving proxy decisionmakers when appropriate can help overcome these challenges.
The fourth challenge is the need for measurement and adjustment for comorbidity. There are no standards or agreement on
how to measure comorbidity in clinical trials. Comorbidity and
multiple medications contribute to increased susceptibility to
adverse drug events, which can result in selective attrition and
missing data. The complexity and heterogeneity of the geriatric
population make this standard approach challenging. There are
no easy solutions to these concerns, but they highlight the necessity for future research to refine the methodology of clinical

68

trials performed in older adults with multiple morbidities.[41]

Finally, the choice of outcomes relevant to older adults is critical. Some outcomes are likely to be more relevant for assessing
efficacy (e.g., cognitive decline and quality of life); others might
be more relevant for safety assessment (e.g., falls and delirium).
Because older adults are heterogeneous and their response to
interventions variable, many outcome measures may not be
normally distributed. This possibility must be taken into account in the design and analysis of clinical studies.
Despite challenges, it is imperative that geriatric society organizations and patient advocacy groups work together to halt
age discrimination in clinical trials. Older people who are more
characteristic of those seen in clinical practice must be included
in clinical trials to achieve the goal of safe and effective drug
therapy for this growing patient population.[39]

Conclusion

Ultimately, the goal of medical intervention in older patients is

to improve the quality of the remainder of their life. Drug therapy is the most important intervention directed toward this goal.
Clinical pharmacology, drug efficacy, and drug safety differ
in elderly patients compared with their younger counterparts.
Therefore, a different approach is necessary to provide optimal
care to these complex patients. The geriatric dosing axiom, start
low and go slow is based on pharmacokinetic considerations
and concern for adverse drug reactions, rather than clinical trial
data. Sound evidence through prospective clinical trials is essential especially in elderly patients with multiple comorbidities
and polypharmacy who are more typical of the patients seen in
clinical practice. The design of clinical trials should consider the
inclusion of these complex older patients and make provisions
for concerns about the higher complexity of the trials, such as
multiple measurements, higher attrition rate, multicenter heterogeneity, and higher costs. Therefore, geriatric societies, governments, and patient advocacy groups should collaborate to
generate widespread support to promote the inclusion of older
people in clinical trials. It is believed that all involved in clinical
trials have both an obligation and an opportunity to eliminate
age discrimination in clinical trial practice.

Conflict of Interest

The author has no conflicts of interest.

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