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Pharmacology > Chapter 22: Geriatric patient > Flashcards

Chapter 22: Geriatric patient Flashcards

1
Q

Incidence of polypharmacy

A

51% of ages 65-74 use 2+ prescription drugs

12% use 5+

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2
Q

ADRs rate where in causes of death in America

A

4-6th

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3
Q

Results of advances in medicine for the elderly

A

prolonged and improved life

increased risk for adverse drug reactions

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4
Q

what are the most common classes of drugs used by the elderly population living in the community

A

analgesics

diuretics

cardiovascular drugs

sedative hypnotics

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5
Q

what are the most common classes of drugs used by the elderly in nursing homes

A

antipsychotics and sedative-hypnotics

followed by

diuretics, antihypertensives, analgesics, cardiovascular drugs, and antibiotics

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6
Q

changes in pharmacokinetics related to aging

A

slowed renal clearance

slowed metabolism

increased risk of CNS side effects

slowed orthostatic response

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7
Q

changes influencing absorptionin the older adult

A

reduced GI blood flow

reduced gastric acidity

reduced absorptive surface from microvilli atrophy

most drugs are absorbed by passive diffusion

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8
Q

changes influencing distribution in older adults

A

decrease in total body water and extracellular fluid volume

decrease in cardiac output

decrease in brain and cardiac blood flow

increased total body fat percentage

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9
Q

decrease of total body water in the elderly has what effect on distribution

A

water-solubla drugs have a reduced volume of distribution which causes increased plasma concentrations of hydrophillic drugs like lithium

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10
Q

what effect does the increase of total body fat in the elderly have on drug distribution

A

lipohilic drugs have an increased half-life from increased storage in fatty tissue

this can prolong the action of the drug, exacerbate its effect, and increase toxicity

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11
Q

changes influencing metabolism in older adults

A

reduced CYP450 enzymes impacts the oxidation reaction in phase 1 metabolism

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12
Q

what contributes to a smaller liver reserve than expected for age

A

the influence of comorbidities, alcohol, medications, and environmental toxins/pollutants

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13
Q

what metabolic changes result in increasing half-life of medications prolonging their availability

A

ages related reduced hepatic clearance

reduced hepatic blood flow causes reduced first-pass effect

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14
Q

changes influencing excretion in the older adult

A

reduction in renal mass as well as the number and size of nephrons

reduction in blood flow glomerular filtration rate

reduction in tubular secretion

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15
Q

out of the changes r/t aging that affect pharmacokinetics, which is the most important

A

changes that influence excretion

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16
Q

cockcroft-gault equation for estimating creatinine clearance

A

CrCl = (140-age) x (total body weight in kg)

       (72) x (serum creatinine in mg/dL)

*result is multiplied by 0.85 in women because of lower muscle mass

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17
Q

changes in pharmacodynamic in the older adult

A

different effects of a drug on the patient despite identical serum concentrations

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18
Q

what causes the changes in pharmacodynamic in the older adult

A

altered sensitivyt at receptor site

post-receptor effect

impairment of physiologic and homeostatic mechanism

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19
Q

example of altered receptor sensitivity

A

increased CNS sedation with benzodiazepines, opioids, neuroleptics

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20
Q

examples of impaired physiologic reserve

A

more urinary retention and constipation

more blurry vision

increased risk of anticholinergic drugs to glaucoma patients

increased fall risk with sedative hypnotics

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21
Q

examples of some medications that can cause urinary retention d/t anticholinergic effects

A

antihistamines like:

diphenhydramine (Benadryl)

promethazine (Phenergan)

ipratropium (Atrovent)

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22
Q

prevalence of HTN in older adults

A

70%

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23
Q

HTN places the elderly at a higher risk for

A

MI, CHF, CVA, PAD

risk factor for dementia

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24
Q

Is SBP or DBP the primary target for HTN treatment in older adults? why?

A

SBP because it continues to rise

DBP rises until about age 70, then it begins to fall

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25
Q

drug classes used to treat HTN in the older adult

A

diuretics

beta-blockers

CCBs

ACE inhibitors

ARBs

alpha blockers

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26
Q

definition of orthostatic hypotension

A

SBP drop of 20mmHg or more or a drop in DBP of 10mmHg or more

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27
Q

which medication is superior for preventing MI and should be used as first line HTN treatment in older adults

A

thiazide diuretics

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28
Q

what should be monitored for when an older patient is on a diuretic

A

hyponatremia, hypokalemia, metabolic alkalosis

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29
Q

beta-blockers in older adults

A

not first line therapy if uncomplicated HTN

good choice for adjunct therapy with history of HF, MI, or symptomatic coronary disease

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30
Q

Calcium Channel blockers in older adults

A

2nd or 3rd line treatment for HTN

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31
Q

most common side effect of CCBs in the elderly

A

peripheral edema that does not respond to diuretics

will resolve with discontinuation of medication

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32
Q

ACE inhibitors

A

2nd or 3rd line therapy

Avoid with drugs that raise potassium levels

watch for hyperkalemia or worsening renal function

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33
Q

ARBs in older adults

A

non-peptide selective blocker that is generally well-tolerated

monitor for hyperkalemia

caution with renal insufficiency

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34
Q

alpha blockers in older adults

A

should NOT be used as 1st or 2nd line therapy

do not use for BPH as there are safer drugs

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35
Q

when should clonodine be avoided for HTN treatment

A

when there is underlying heart block d/t its bradycardic effect

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36
Q

what does diagnosis of dementia require

A

losses in multiple cognitive domains as well as functional losses

Alzheimers disese is most common

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37
Q

pathological findings in AD

A

plaques and neurofibrillary tangles

deficiency of acetylcholine

38
Q

drug classes used to treat dementia

A

cholinesterase inhibitors (ChEs)

NMDA Inhibitors: Memantine (Namenda)

39
Q

examples of cholinesterase inhibitors

A

donepezil (Aricept) - mild-severe stages

rivastigmine (Exelon) - mild-mod

galantamine (Razadyne) - mild-mod

40
Q

cholinesterase inhibitors are only indicated for

A

treatment of alzheimers

41
Q

cholinesterases mechanism of action

A

inhibits the enzyme acetylcholineserase to increase acetylcholine concentrations at the synaptic cleft

minor delay in progression of the disease

42
Q

contraindications for cholinesterases

A

seizure disorder and COPD

43
Q

major side effects of cholinesterase inhibitors

A

n/v, diarrhea, abdominal pain, anorexia

44
Q

cholinesterase inhibitors interactions

A

avoid drugs with anticholinergic effects like antihistamines and antimucarinic drugs used for irinary incontinence as the two will cancel each other out because their mechanism of action is so similar

45
Q

Memantine (Namenda)

A

only drug in its class (NMDA inhibitors)

used for mod-severe dementia

46
Q

when should namenda be avoided

A

HTN

severe liver or renal impairment

47
Q

when should Namenda be discontinued

A

end-stage dementia

48
Q

why is there increased presence of urinary incontinence in dementia

A

loss of frontal lobe inhibition so reliance of sympathetic and parasympathetic urine control in purely on brainstem

49
Q

medication class used to treat urinary incontinence

A

muscarinics

50
Q

non-pharmacologic treatment options for urinary incontinence

A

correct underlying problem

void at regular intervals

kegels

avoid caffeine, alcohol, artificial sweetners

drug treatment may not be very effective

51
Q

examples of muscarinics

A

oxybutynin (Detrol, Oxytro patch)

tolterodine (Detrol)

trospium (Sanctura)

darifenacin (Enablex)

solifenacin (VESIcare)

fesoterodine (Toviaz)

52
Q

muscarinics mechanism of action

A

reversible acetycholine receptor blockers that block PNS endings on detrusor muscle of bladder to reduce spasms of smooth muscle, reducing the urge to urinate

53
Q

muscarinic clinical use

A

urge incontinence in cognitively intact patients

54
Q

muscarininc interactions

A

cholinesterase inhibitors

other anticholinergic can cause increased drowsiness

all except trospium interact with drugs that use CYP3A4 or 2D6 systems

trospium interacts with digoxin, triamterene, and trimethoprim

55
Q

muscarininc contraindications

A

bowel/bladder obstruction

myasthenia gravis

untreated angle-closure glaucoma

56
Q

drugs classes that require special consideration in older adults

A

antiarrhythmics

anticoagulants

antihistamines

antiparkinson agents

antipsychotics

anxiolytics

corticosteroids

digoxin

NSAIDs

opioid analgesics

tricyclic antidepressant

57
Q

antiarrhuthmic use

A

only for rhytm disorders that are both symptomatic and life threatening

should always be initiated and monitored by a cardiologist

58
Q

adverse effects of amiodarone in older adults

A

cough, progressive dyspnea, hypo-and hyperthyroidism, liver toxicity, GI effects, corneal microdeposits, confusion, slurred speech, photosensitivity

59
Q

examples of anticoagulants used in the elderly

A

ASA

clopidogrel (Plavix)

dipyridamole (Aggrenox

warfarin (Coumadin)

60
Q

ASA use

A

all patients with established vascular disease should take ASA 81mg daily unless contraindicated

61
Q

clopidogrel (Plavix)

A

maintains patency od stented coronary arteries

62
Q

dipyridamole (Aggrenox)

A

combo of ASA 25mg and ER dipyridamole

prevents stroke in patients with history of TIA

63
Q

warfarin (Coumadin)

A

reduces stroke risk

significant risk of bleeding

usually co-managed by coumadin clinic

64
Q

most common indication for coumadin usage

A

nonvalvular A-fib

65
Q

antihistamines

A

generally avoid

if neede short-ter use of chlorpheniramine may help with URI

Zyrtec is acceptable for chronic allergies

diphenhydramine is particularly harmful

66
Q

standard antiparkinson agents used for treatment

A

pramipexole (Mirapex)

ropinorole (Requip)

carbidopa-levodopa (Sinimet)

67
Q

symptoms of too much dopamine

A

uncontrolled movements, worsened confusion, visual hallucinations

68
Q

medications that can cause parkinson-like symptoms

A

antihistamine/antinauseants (phenergan, compazine, reglan)

older antipsychotics (haldol, chlorpromazine)

newer atypical antipsychotics (risperidone, olanzapine, quetiapine)

69
Q

two directly aticholinergic drugs that should be avoided in the elderly

A

cogentin

artane

70
Q

most common use of antipsychotic in the elderly

A

behavior treatment in dementia

71
Q

cons of antipsychotic use in the elderly

A

high risk of toxicity

increases risk of MI, CVA, vascular mortality

can cause EPS

can cause tardive dyskinesia

neuroleptic malignant syndrome

72
Q

signs of antipsychotic toxicity

A

sedation, orthostatic hypotension, weight gain, hyperlipidemia, development of diabetes

73
Q

anxiolytics to avoid with the elderly

A

long-acting benzodiazepines:

diazepam (Valium)

chlordiazepoxide (Librium)

Chlorazepate (Tranxene)

Flurazepam (Dalmane)

74
Q

anxiolytics are stongly associated with

A

confusion, weakness, slurred speech, ataxia, falls

75
Q

shorter-acting benzodiazepines in the elderly

A

safer but still have risk of toxicity

lorazepam (Ativan)

temazepam (Restoril)

oxazepam (Serax)

76
Q

pharmaceutical drugs with less toxicity than benzodiazepines in the elderly

A

Buspirone and SSRIs

77
Q

corticosteroids in the elderly

A

can be life saving

78
Q

chronic use of corticosteroids in the elderly

A

can cause serious side effects of sodium retention, agitation, psychosis, diabetes, skin ecchymosis, and osteoporosis

79
Q

all older adults on chronic corticosteroid therapy should have what monitored

A

bone density

ensure adequate intake of calcium and vitamin D

80
Q

Digoxin clinical use in the elderly

A

for systolic heart failure

rate control of A-fib

only after using a vasodilator, diuretic, and beta-blocker

81
Q

major side effects of digoxin

A

anorexia, confusion

82
Q

serum digoxin level

A

should stay below 1ng/mL

83
Q

NSAIDs

A

used for pain relief when pain is interfering with function

consider acetominophen first flowwled by glucosamine/chondroitin

consider tramadol

can cause serious toxicity in older adults

84
Q

frequent adverse effects with NSAIDs

A
  • GI: gastric bleeding, perforation, and obstruction
  • RENAL: acute renal failure, interstitial nephritis, nephritic syndrome
  • CARDIAC: frequently raised BP, may worsen volume overload in disease like HF
85
Q

NSAID interactions

A

avoid cox-2 inhibitors (Celebrex)

86
Q

opioid analgesics in the elderly

A

can be safer options than the alternatives

long-term never cause GI bleeding or renal dysfunction

major toxicities: CNS and respirtatory side effects and constipation

87
Q

opioid analgesics to NOT use in older adults due to their serious side effects

A

meperidine (Demerol)

pentazocaine (Talwin)

propoxyphene (Darvocet)

88
Q

tricyclic antidepressants in the elderly

(Elavil)

A

rarely indicated

side effects: dry mouth, blurry vision, constipation, urinary retention, orthostatic hypotension, quinidine-like effects (serious ventricular arrhythmias)

89
Q

questions to ask before prescribing a new drug for an elderly patient

A
  1. do I have a comprehensive list of medications?
  2. is the patient compliant?
  3. are drugs appropriate?
  4. are side effects an issue (could new symptom or lab simply be a side effect)
  5. polypharmacy?
  6. undermedicated?
  7. reassess frequently
90
Q
A

Pharmacology (28 decks)

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