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Fitzgerald Review > CH18 Prescribing in elder adult > Flashcards

CH18 Prescribing in elder adult Flashcards

1
Q

pharmacodynamics

A

what the drug does to the body

DOESN’T change in any age!
just pharmacokinetics change

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2
Q

age related changes in 20-30 years vs 60-80 yrs olds

% body weight as water:
lean body mass:
% fat:
serum albumin:
kidney weight:
hepatic blood flow:

A

% body weight as water: 60% ; 53% (easier for dehydration and sensitive to diuretics)

lean body mass: baseline, >20% reduction (even if active)

% fat: fat increases (lipophilic/sedating meds/benzos will be stored more easily) = 1/2 life lipophilic drugs longer in elderly

serum albumin: drops 4.7 to 3.8 naturally (liver shrinks with aging; albumin comes from liver) coumadin/albumin bound; the lower the albumin, the more free warfarin there is (dose goes down)

kidney weight: 100% to 80% (more prone to nephrotoxicity)

hepatic blood flow: 100% to 55-60% (influences how well liver drug metabolizes work causing meds to hang around more)

things stiff, sink, shrink

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3
Q

highly protein bound meds

A

Warfarin
-99% albumin bound
-therapeutic effect from 1% free drug [need lower dose]

Phenytoin (dilantin)
Valproic acid (Depakote)
diazepam (valium)

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4
Q

caffeine pharmkinetics

A

T 1/2 range: 1.5-9 hrs
Cmax: ~ 15 mins-100 mins
min 1st pass effect
CYP450 1A2 substrate

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5
Q

CYP450 1A2’s activity is influenced by the presence or absence of estrogen in women.

CYP450 isoenyzme levels can drop up to 30% in elders after age 70

A

true

true

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6
Q

BEERS criteria
avoid what meds?

A

-SYSTEMIC anticholinergic (localized anticholinergics are okay like Spiriva or tiotropium) = confusion, urinary retention, constipation, visual disturbances, hypotension = lead to polypharmacy and risk of delirium

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7
Q

AE’s from systemic anticholinergic effects?

A

if elderly comes in with a dry mouth…

dry as a bone (dry mouth/skin)
red as a beet (flushing)
mad as a hatter (confusion)
hot as a hare (hyperthermia)
can’t see (vision changes)
can’t pee (u rention)
can’t spit
can’t poop / constipation

-agitation (peds and elderly)
-tachycardia

OD:
hypernea
mydriasis
flushing
psychosis
seizure
coma
hyperthermia

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8
Q

meds with significant systemic anticholinergic effect

A

1st gen antihistamines
-also almost ALL overactive bladder (OAB) meds (ex: oxybutynin (Ditropan); sustained release better tolerance with similar therapeutic efficacy
-Oxytrol patch for women (OTC) for OAB

TCA

Some SSRI’s

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9
Q

comparing psychotropic meds

citalopram, escitalopram

fluoxetine

paroxetine

sertraline

A

NO paroxetine bc high anticholinergic effect (even tho it has the shortest 1/2 life)

avoid fluoxetine bc long 1/2 life

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10
Q

comparing TCA’s for elderly

amitriptyline

nortriptyline

trazodone

mirtazapine

A

NO amitriptyline

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11
Q

T/F? risk of torsades de pointes with erythromycin or clarithromycin is greater in females than males

A

true

-women don’t offload meds well
-type of vtach that can lead to cardiac arrest
-any drug that prolong QT interval can lead to torsades

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12
Q

citalopram (celexa) cautions!!

A

-dose NOT rec above 40 mg (causes too large an effect on QT interval and no additional benefit)
- NOT rec with congenital QT syndrome, bradycardia, hypoK, hypoMg, recent MI, HF
-pt on other meds prolong QT
- dose MAX 20mg/day IF > 60 years old, CYP2C19 metabolizers, taking cimetidine (Tagamet) or another CYP2C19 inhibitor (many ppi’s)

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13
Q

what med u can give besides citalopram?

A

escitalopram!! (0 drug interactions)
-make note to prior auth insurers since it’s 3rd line: only ssri with 0 d-d inx and lower dose can be given w/o inducing QT prolongation = APPROVED!

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14
Q

sliding scale insulin

A

in BEERS criteria! AVOID bc higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting

do meal time insulin!

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15
Q

sliding scale refers to the use of what insulins?

A

short or rapid acting insulins WITHOUT basal or long acting insulin
-does not apply to titration of basal insulin or use of additional short or rapid acting with schedule insulin

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16
Q

1 unit rapid acting insulin to lower blood sugar by 50 mg

A
17
Q

should aspirin be used in elderly for PRIMARY prevention of cardiac events?

A

NO! if they have no history of cardiac events, angina, etc.
NO use in 80 years and older
increase risk of GI bleed

18
Q

apsirin and secondary prevention?

A

not enough data for 85 years older, close monitoring of aspirin related adverse events (GI bleed)!

19
Q

older adult with recurrent UTI in women…

A

topical vaginal cream (low dose intraginal estrogen) for dyspareunia, UTI, and other vaginal sx’s

when estrogen is present in vagina, lactobacilli present and becomes acidic and is baceteriocidal. menopausal causes more prone to UTI

20
Q

can you use vaginal estrogen of dryness in women with breast cancer (dose < 25 twice weekly?

A

yes!

21
Q

A1C gal of older adults who are frail / limited life expectancy

A

8% or less

22
Q

aging changes in vascular, pulmonary, cardiac tissue

A

less Beta adrenergic receptors meaning beta 2 agonist (albuterol, salmeterol) wont’ work as well
-beta antagonist (metoprolol, carvedilol)

23
Q

meds that AREN’T impacted by age

A
24
Q

avoid high intensity statins if…

A
  • > 80 years old
  • impaired renal fxn
  • frailty
  • multiple comorbidities
  • with fibrate
25
Q

moderate intensity statin for…

A

if high risk for AE with high intensity
*lovastatin on $4 list

26
Q

low intensity statin..

A

not recommended

27
Q

76 and older with no hx of CVD or diabetes, with high LDL.. do u start on statin?

A

USPSTF concludes not enough evidence to start

28
Q

if 85 years + and have establised ASCVD…

A

continue statin

29
Q

chronic/long term PPI use consequences…

A

-rebound hypersecretion if use 2 or more months:
GI sx’s will increase once stop PPI
-consider tapering PPI with reducing dose, OR PPI every other day use, or STOP PPI and use ranitidine or famotidine BID x 1-2 months then cut back to HS dose with liberal use of antacids to prevent heart burn. then another month, stop H2RA and stick to antacids and avoid food triggers

  • decrease in micronutrient absorption that requires acidic stomach environment
    = iron, vitamin B12 (PUT ON SUPPLEMENTS if on chronic PPI)
  • increase fracture risk (lower Ca absorption) = put on calcium citrate supplements!
  • Magnesium absorption (hypOmg)
  • digoxin toxicity risk with low mg
    -put on Magnesium tablets QD while on Ca based antacids which helps couteracts the constipation
30
Q

PPI vs histamine 2 blocker

A

PPI better at suppressing post prandral acid surge than h2
-warn pt that if u eat a trigger food, u might get heart burn from H2 so use an antacid

31
Q

PPI per beers criteria

A
  • avoid use longer than 8 weeks unless for high risk pts (oral corticosteroids, chronic NSAID use), erosive esophagitis, barrett’s esophagitis, pathological hypersecretory condition, or need for maintenance tx (failure of drug discontinuation trial or H2 blockers)
32
Q

nearly all PPI’s are CYP450 2C19

A
33
Q

which drug induces hyperkalemia?

A

TMP-SMX (bactrim) induced hyperkalemia
peak tall T waves

-ACEI or ARB with Bactrim (can use flurorqui for UTI in older adults)

34
Q

TMP-SMX warning…

A

AVOID use with spironolactone (Aldactone), ACEI or ARB [all K sparing drugs], especially if elderly or other chronic health conditions == hypERkalemia

35
Q

if theres a warning about dose adjustment if pt has renal impairment, drug is nephrotoxic

A

FALSE - few nephrotoxic drugs

36
Q

if older adult with mild renal impairment taking acei with K 5-5.5, aside with adequate hydration, takingthe once daily ACEI dose in the morning allows for the natural secretion of K at night to avoid hyperK. T/F

A

True! natrual offloading of K in sleep state

BUT poor circulating volume r/t overdiuresis and/or low intake of fluid esp in elderly wouldn’t work

37
Q

meds used in alz type dementia

A

donepizil (Aricept) - cholinesterase inhibitors a/s syncope, bradycardia, pacemaker insertion, hip fracture in older ad with dementia

38
Q

caution about medication for use in elderly (BEERS)

A

dabigatran (Pradaxa)
-greater bleeding than warfarin 75 yrs older
-no evid for eff with CrCl < 30

Fitzgerald Review (22 decks)

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