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Pharm Final > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

GI changes with age

A

increased stomach pH
decreased GI blood flow
slowed gastric emptying/transit

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2
Q

pharmokinetic GI changes with age?

A

decreased/prolonged absorption of some drugs and nutrients

decrease first pass metabolism (less drug broken down by liver and more drug enters circulation)

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3
Q

skin changes with age

A

thinning of dermis and loss of SQ fat

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4
Q

pharmokinetic skin changes with age?

A

decreased drug reservoir formation with transdermal formulation

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5
Q

body composition changes with age?

A

decreased body water
decreased lean body mass
increased body fat

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6
Q

pharmokinetic body composition changes with age?

A

increased volume of distribution and accumulation of lipid soluble drugs

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7
Q

liver changes with age?

A

decreased liver mass

decreased blood flow to liver

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8
Q

pharmokinetic liver changes with age?

A

increased half life of drugs

decreased clearance of drugs with a high 1st pass metabolism

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9
Q

renal changes with age?

A

decreased GFR
decreaed renal blood flow
decreased tubular secretion
decreased renal mass

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10
Q

pharmokinetic renal changes with age?

A

decreased renal elimination of many drugs

increased 1/2 life of renally eliminated drugs

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11
Q

how is absorption affected by age?

A

slowed absorption

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12
Q

geriatric conditions/practices that affect the rate of absorption of some drugs?

A

DM (slows gastric emptying/prolongs absorption)

OTC laxative and antacid use

decreased SQ fat prevents transdermal reservoir formation (caution with small/cachetic patients)

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13
Q

what vitamins have decreased absorption in the geriatric population why?

A

iron
vitamine B12
Ca

due to decreased stomach acid

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14
Q

how much water soluble drugs be adjusted in the elderly?

A

decreased total body water requires that loading doses of water soluble drugs be decreased (due to a small volume of distribution)

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15
Q

effect on distribution of fat soluble drugs in the elderly?

A

increased accumulation of fat soluble drugs due to increased total body fat can lead to prolonged DOA for fat soluble drugs

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16
Q

example of a lipid soluble drug class that has an increased 1/2 life in the elderly?

A

benzodiazepines (alprazolam, diazepam, flurazepam)

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17
Q

why do higher brain concentrations of some drugs occur in the elderly?

A

decreased p-glycoprotein, a transporter for drugs out of the brain, can lead to higher concentrations in the brain of some drugs

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18
Q

what drugs are metabolized in the liver more slowly by the elderly?

A

benzos
antidepressants
(not all drugs are metabolized more slowly just some)

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19
Q

what is one of the most significant disease found in the elderly that is associated with decreased liver function/metabolism?

A

CHF

it causes:

  • decreased blood flow to the liver
  • decreased metabolism by liver
  • prolonged effects of some liver metabolized drugs
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20
Q

two drugs with substantially reduced clearance due to decreased first pass metabolism?

A

morphine (causes respiratory depression)

propanolol

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21
Q

what is the most important change that affects drug usage in the elderly?

A

decreased kidney function decreases drug elimination (increases half life of drugs and allows for toxic accumulation)

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22
Q

is Cr increased in elderly with decreased kidney function

A

not always due to decreased muscle mass

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23
Q

how to prevent SE related to decreased kidney fxn in the elderly?

A 
#1: increase dosing interval
#2: decrease dose

may undergoes a pt with normal renal fxn

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24
Q

calculation used to decrease estimated creatinine clearance?

A

cockcroft-gault

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25
Q

how should drugs eliminated through GFR be dosed in patients with decreased renal fxn?

A

based on estimated creatinine clearance

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26
Q

what drugs are the elderly more sensitive to due to increased receptors or affinity for receptors?

A

benzos
opioids
warfarin

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27
Q

what drugs are the elderly less sensitive to due to decreased receptors or affinity for receptors?

A

beta blockers

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28
Q

what are 3 age-related changes to homeostatic responses?

A

decreased baroreceptor response (orthostatic hypotension)
sodium/water retention
mobility and balance issues

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29
Q

what are two decreased homeostatic responses often interpreted as increased sensitivity to drugs?

A

BP: orthostatic hypotenstion amplified by meds
BS: unable to compensate for carb load appropriately (may loos like resistant to diabetes medicines)

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30
Q

probability of SE when taking 10 drugs?

A

100%

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31
Q

risk for SE in the elderly?

A 
low body weight
greater than 85 yo 
decreased renal fxn
6 or more illnesses
hx of prior SE
9 or more medications
12 or more doses per day
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32
Q

guidelines to avoid SE

A

take a careful drug Hx (ID all drugs, have pt bring updated list)

give meds only for specific indications (evidence based)

define goals

start low and gradually increase dose

evaluate for proper therapy duration

suspect SE

simplify drug regimens (few and qD dosing best)

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33
Q

when to stop a drug if goal not being met?

A

when adult dose has been met (means it isn’t working)

when SE presents

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34
Q

describe metabolism, elimination, and sensitivity of benzos and barbiturates in the elderly?

A

metabolism: slowed
half-life: increased
elimination: decreased
sensitivity: increased

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35
Q

problems with barbituates in the elderly?

A

high rate of physical dependence

tolerance to sleep benefits

risk of OD at low doses

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36
Q

SE of benzos and barbituates in elderly?

A 
cog. impairment
delirium
falls
fx
motor vehicle accidents
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37
Q

when to give elderly barbiturates?

A

never

38
Q

when to give benzos to the elderly?

A 
seizure disorders
generalized anxiety
periprocedural anesthesia
ethanol/benzo withdrawal 
end of life care
39
Q

do not use benzos for?

A

insomnia
agitation
delirium

40
Q

which benzos to use in the elderly?

A

lorazepam
oxazepam
(short half life)

DONT USE: clorazepate, flurazepam (long acting benzodiazepines) or phenobarbital, butalbital (long acting barbiturates)

41
Q

what SE is common with narcotics in the elderly?

A

respiratory depression due to metabolic changes (use caution when prescribing)

42
Q

narcotics that have been removed from using with geriatrics? or anyone for that matter?

A

propoxyphene
pentazocine
merperidine

43
Q

responsiveness to antipsychotics in the elderly?

A

increased

44
Q

BBW for antipsychotics in patients with dementia?

A

increased risk of stroke and mortality

45
Q

when to use antipsychotics in the elderly?

A

psychosis (not dementia)
talk to family about risks
start with a SMALL dose

46
Q

depression is _____ and _____ in the elderly

A

underdiagnosed and undertreated

47
Q

risk of toxicity to antidepressant in elderly is? especially concerning?

A

increased especially when given antidepressants with anticholinergic effects

48
Q

what antidepressants to use in elderly? which to avoid?

A

use: SSRI
dont use: TCAD

start with low dose and increase

49
Q

risk of using anticholinergic drugs in the elderly?

A

increased risk for anticholinergic side effects (confusion, dry mouth, constipation)

50
Q

antidiarrheal drugs with anticholinergic SE that should be avoided in the elderly?

A

lomotil

51
Q

Class Ia, Ic, and III antiarrythmic drugs with anticholinergic SE that should be avoided in the elderly?

A

amiodarone

quinidine

52
Q

first gen. antihistamines drugs with anticholinergic SE that should be avoided in the elderly?

A

diphenhydramine and chlorpheniramine

53
Q

antispasmodic drugs with anticholinergic SE that should be avoided in the elderly?

A

dicyclomine, belladona

54
Q

skeletal mm relaxant drugs with anticholinergic SE that should be avoided in the elderly?

A

cyclobenzaprine, carisoprodol

55
Q

antiemetic drugs with anticholinergic SE that should be avoided in the elderly?

A

promethazine

56
Q

sensitivity to anti-HTN meds in the elderly?

A

increase, balance against morbidity and mortality risk

57
Q

how to prescribe anti-HTN meds to elderly?

A

start with low dose

1st line: diuretics (12.5 to 25 mg)

CCB also good choice

58
Q

bad anti–HTN choices?

A

ACEI and bblockers

59
Q

what should you check every visit for elderly pt on anti-HTN?

A

orthostatic hypotension

60
Q

when to use digoxin in elderly?

A

CHF

61
Q

problem with digoxin?

A

narrow therapeutic window

62
Q

things to consider when prescribing digoxin to the elderly?

A

slow renal clearance may lead to toxicity

more susceptible to arrythmias

63
Q

what should be the max dose of digoxin used in elderly?

A

125 mcg (higher doses have no benefit and will increase risk of toxicity)

64
Q

what is the major problem with Abx use in elderly?

A

renally excreted so prolonged half life

65
Q

Abx to use cautiously with elderly?

A

aminoglycosides
beta-lactams
fluoroquinolones

66
Q

should mm relaxants be used in the elderly? which ones should be avoided? why

A

No

avoid: cyclobenzaprine, orphenadrine, carisoprodol, metaxalone, methocarbamol
problems: anticholinergic SE, sedation, fx risk, not very effective

67
Q

Risks with NSAID use in elderly?

A

GI bleed and PUD in high risk groups

increased kidney toxicity

68
Q

groups at high risk of NSAID toxicity

A

using steroids
using anticoagulants
using antiplatlets

69
Q

what reduces risk of GI bleeding in high risk groups taking NSAIDs

A

PPI (doesn’t eliminate risk)

70
Q

how to use NSAIDs in elderly (what to monitor)

A

use carefully:
watch BP
ask about bleeding
check serum Cr

71
Q

risks with insulin sliding scale in geriatric pt?

A

higher risk of hypoglycemia without improvement of hyperglycemia

72
Q

risk of sulfonureas in geriatric patients?

A

chlorpropamide: prolonged half life with prolonged hypoglycemia
glyburide: greater risk for prolonged hypoglycemia

73
Q

sulfonureas that shouldnt be used in geriatric patients?

A

chlorpropamide

glyburide

74
Q

cause of alzheimers?

A

destruction of cholinergic neurons

from: 
Genetics and the apo E4 allele
Environment
Inflammation
Neurotransmitter deficiency
Vascular damage
75
Q

what enzyme and NT is decreased in patients with alzheimers

A

acetyltransferase enzyme (helps make ACh)

ACh is decreased in CNS (supported by their sensitivity to anticholinergic drugs)

76
Q

what enzyme is increased in alzheimers? how is this treated

A

glutamate (excitatory NT that destroys neurons when high)

Tx: NMDA receptor blockers

77
Q

cholinesterase inhibitors

A

donepezil
rivastigmine
glantamine

78
Q

mechanism of cholinesterase inhibitors

A

slows deterioration of cognitive fxn (don’t affect underlying disease process)

79
Q

which cholinesterase inhibitors to use for mild to moderate disease? severe?

A

mild to moderate:
donepezil
rivastigmine
glantamine

severe: donepezil

80
Q

what drugs should you try to avoid giving to alzheimers patients on cholinesterase inhibitors?

A

anticholinergics

81
Q

what happens when cholinesterase inhibitors are stopped suddenly?

A

worse cognition

worse behavior

82
Q

SE of cholinesterase inhibitors?

A

GI: N/V
cholinergic: urinary incontinence, dizzy, HA, syncope, bradycardia, salivation, sweating

83
Q

how to reduce SE of cholinesterase inhibitors?

A

start slowly

84
Q

only NMDA receptor blocker on the market?

A

mematine

85
Q

MOA of NMDA receptor blocker

A

reduces excitotoxic effect of glutamate

86
Q

which is better tolerated NMDA receptor blocker or cholinesterase inhibitors?

A

NMDA receptor blocker

87
Q

SE of NMDA receptor blocker ?

A

constipation, dizzy, HA, hallucination, HTN

88
Q

when are NMDA receptor blocker used in alzheimers?

A

moderate to severe (NOT MILD)

89
Q

which drug is used for mild to moderate alzheimers?

A

cholinesterase inhibitors

90
Q

what is PRIMARY tx for alzheimers disease

A

nonpharmacologic: education for caregiver, reduction in environmental triggers, manage other dz

91
Q

can you use two cholinesterase inhibitors together?

A

no

92
Q

can you use a cholinesterase inhibitor and NMDA receptor blocker together?

A

yes

Pharm Final (3 decks)

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