Chapter 22: Geriatric patient Flashcards Preview

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Flashcards in Chapter 22: Geriatric patient Deck (90):
1

 

 

Incidence of polypharmacy

 

 

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

12% use 5+

2

 

 

ADRs rate where in causes of death in America

 

 

4-6th

3

 

 

Results of advances in medicine for the elderly

 

 

prolonged and improved life

increased risk for adverse drug reactions

4

 

 

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

 

 

analgesics

diuretics

cardiovascular drugs

sedative hypnotics

5

 

 

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

 

 

 

 

antipsychotics and sedative-hypnotics

followed by

diuretics, antihypertensives, analgesics, cardiovascular drugs, and antibiotics

6

 

 

changes in pharmacokinetics related to aging

 

 

slowed renal clearance

slowed metabolism

increased risk of CNS side effects

slowed orthostatic response

7

 

 

changes influencing absorptionin the older adult

 

reduced GI blood flow

reduced gastric acidity

reduced absorptive surface from microvilli atrophy

most drugs are absorbed by passive diffusion

8

 

 

changes influencing distribution in older adults

 

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 

9

 

 

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

 

 

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

10

 

 

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

 

 

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

11

 

 

changes influencing metabolism in older adults

 

 

reduced CYP450 enzymes impacts the oxidation reaction in phase 1 metabolism

 

12

 

 

what contributes to a smaller liver reserve than expected for age

 

 

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

13

 

 

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

 

 

ages related reduced hepatic clearance

reduced hepatic blood flow causes reduced first-pass effect

14

 

 

changes influencing excretion in the older adult

 

 

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

reduction in blood flow glomerular filtration rate

reduction in tubular secretion

15

 

 

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

 

 

changes that influence excretion

16

 

 

cockcroft-gault equation for estimating creatinine clearance

 

 

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

17

 

 

 changes in pharmacodynamic in the older adult

 

 

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

18

 

 

what causes the changes in pharmacodynamic in the older adult

 

 

 

altered sensitivyt at receptor site

post-receptor effect

impairment of physiologic and homeostatic mechanism

19

 

 

example of altered receptor sensitivity

 

 

increased CNS sedation with benzodiazepines, opioids, neuroleptics

20

 

 

examples of impaired physiologic reserve

 

 

more urinary retention and constipation

more blurry vision

increased risk of anticholinergic drugs to glaucoma patients

increased fall risk with sedative hypnotics

21

 

 

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

 

 

antihistamines like:

diphenhydramine (Benadryl)

promethazine (Phenergan)

ipratropium (Atrovent)

22

 

 

prevalence of HTN in older adults

 

 

70%

23

 

 

HTN places the elderly at a higher risk for

 

 

MI, CHF, CVA, PAD

risk factor for dementia

24

 

 

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

 

 

SBP because it continues to rise

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

25

 

 

drug classes used to treat HTN in the older adult

 

diuretics

beta-blockers

CCBs

ACE inhibitors

ARBs

alpha blockers

26

 

 

definition of orthostatic hypotension

 

 

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

27

 

 

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

 

 

thiazide diuretics

28

 

 

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

 

 

hyponatremia, hypokalemia, metabolic alkalosis

29

 

 

beta-blockers in older adults

 

 

not first line therapy if uncomplicated HTN

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

30

 

 

Calcium Channel blockers in older adults

 

 

2nd or 3rd line treatment for HTN

 

31

 

 

most common side effect of CCBs in the elderly

 

 

peripheral edema that does not respond to diuretics

will resolve with discontinuation of medication

32

 

 

ACE inhibitors

 

 

2nd or 3rd line therapy

Avoid with drugs that raise potassium levels

watch for hyperkalemia or worsening renal function

33

 

 

ARBs in older adults

 

 

non-peptide selective blocker that is generally well-tolerated

monitor for hyperkalemia

caution with renal insufficiency

 

34

 

 

alpha blockers in older adults

 

 

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

do not use for BPH as there are safer drugs

35

 

 

when should clonodine be avoided for HTN treatment

 

 

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

36

 

 

what does diagnosis of dementia require

 

 

losses in multiple cognitive domains as well as functional losses

Alzheimers disese is most common

37

 

 

pathological findings in AD

 

 

plaques and neurofibrillary tangles

deficiency of acetylcholine

38

 

 

drug classes used to treat dementia

 

 

cholinesterase inhibitors (ChEs)

NMDA Inhibitors: Memantine (Namenda)

39

 

 

examples of cholinesterase inhibitors

 

donepezil (Aricept) - mild-severe stages

rivastigmine (Exelon) - mild-mod

galantamine (Razadyne) - mild-mod

40

 

 

cholinesterase inhibitors are only indicated for

 

 

treatment of alzheimers

 

41

 

 

cholinesterases mechanism of action

 

 

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

minor delay in progression of the disease

42

 

 

contraindications for cholinesterases

 

 

seizure disorder and COPD

43

 

 

major side effects of cholinesterase inhibitors

 

 

n/v, diarrhea, abdominal pain, anorexia

44

 

 

cholinesterase inhibitors interactions

 

 

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

 

 

Memantine (Namenda)

 

 

only drug in its class (NMDA inhibitors)

used for mod-severe dementia

46

 

 

when should namenda be avoided

 

 

HTN

severe liver or renal impairment

47

 

 

when should Namenda be discontinued

 

 

end-stage dementia

48

 

 

why is there increased presence of urinary incontinence in dementia

 

 

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

49

 

 

medication class used to treat urinary incontinence

 

 

muscarinics

 

50

 

 

non-pharmacologic treatment options for urinary incontinence

 

correct underlying problem

void at regular intervals

kegels

avoid caffeine, alcohol, artificial sweetners

drug treatment may not be very effective

51

 

 

examples of muscarinics

 

oxybutynin (Detrol, Oxytro patch)

tolterodine (Detrol)

trospium (Sanctura)

darifenacin (Enablex)

solifenacin (VESIcare)

fesoterodine (Toviaz)

52

 

 

muscarinics mechanism of action

 

 

 

 

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

 

 

muscarinic clinical use

 

 

urge incontinence in cognitively intact patients

54

 

 

muscarininc interactions

 

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

 

 

muscarininc contraindications

 

 

 

bowel/bladder obstruction

myasthenia gravis

untreated angle-closure glaucoma

56

 

 

drugs classes that require special consideration in older adults

antiarrhythmics

anticoagulants

antihistamines

antiparkinson agents

antipsychotics

anxiolytics

corticosteroids

digoxin

NSAIDs

opioid analgesics

tricyclic antidepressant

57

 

 

antiarrhuthmic use

 

 

only for rhytm disorders that are both symptomatic and life threatening

should always be initiated and monitored by a cardiologist

58

 

 

adverse effects of amiodarone in older adults

 

 

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

59

 

 

examples of anticoagulants used in the elderly

 

ASA

clopidogrel (Plavix)

dipyridamole (Aggrenox

warfarin (Coumadin)

60

 

 

ASA use

 

 

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

61

 

 

clopidogrel (Plavix)

 

 

maintains patency od stented coronary arteries

62

 

 

dipyridamole (Aggrenox)

 

 

combo of ASA 25mg and ER dipyridamole

prevents stroke in patients with history of TIA

63

 

 

warfarin (Coumadin)

 

reduces stroke risk

significant risk of bleeding

usually co-managed by coumadin clinic

64

 

 

most common indication for coumadin usage

 

 

nonvalvular A-fib

65

 

 

antihistamines

 

generally avoid

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

Zyrtec is acceptable for chronic allergies

diphenhydramine is particularly harmful

66

 

 

standard antiparkinson agents used for treatment

 

 

pramipexole (Mirapex)

ropinorole (Requip)

carbidopa-levodopa (Sinimet)

67

 

 

symptoms of too much dopamine

 

 

uncontrolled movements, worsened confusion, visual hallucinations

68

 

 

medications that can cause parkinson-like symptoms

 

antihistamine/antinauseants (phenergan, compazine, reglan)

older antipsychotics (haldol, chlorpromazine)

newer atypical antipsychotics (risperidone, olanzapine, quetiapine)

69

 

 

two directly aticholinergic drugs that should be avoided in the elderly

 

 

cogentin

artane

70

 

 

most common use of antipsychotic in the elderly

 

 

behavior treatment in dementia

71

 

 

cons of antipsychotic use in the elderly

 

 

high risk of toxicity

increases risk of MI, CVA, vascular mortality

can cause EPS

can cause tardive dyskinesia

neuroleptic malignant syndrome

72

 

 

signs of antipsychotic toxicity

 

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

73

 

 

anxiolytics to avoid with the elderly

 

 

 

 

 

long-acting benzodiazepines:

diazepam (Valium)

chlordiazepoxide (Librium)

Chlorazepate (Tranxene)

Flurazepam (Dalmane)

74

 

 

anxiolytics are stongly associated with

 

 

confusion, weakness, slurred speech, ataxia, falls

75

 

 

shorter-acting benzodiazepines in the elderly

 

safer but still have risk of toxicity

lorazepam (Ativan)

temazepam (Restoril)

oxazepam (Serax)

76

 

 

pharmaceutical drugs with less toxicity than benzodiazepines in the elderly

 

 

Buspirone and SSRIs

77

 

 

corticosteroids in the elderly

 

 

can be life saving

78

 

 

chronic use of corticosteroids in the elderly

 

 

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

79

 

 

all older adults on chronic corticosteroid therapy should have what monitored

 

 

bone density

ensure adequate intake of calcium and vitamin D

80

 

 

Digoxin clinical use in the elderly

 

for systolic heart failure

rate control of A-fib

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

81

 

 

major side effects of digoxin

 

 

anorexia, confusion

 

82

 

 

serum digoxin level

 

 

should stay below 1ng/mL

83

 

 

NSAIDs

 

 

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

 

 

frequent adverse effects with NSAIDs

 

  • 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

 

 

NSAID interactions

 

 

avoid cox-2 inhibitors (Celebrex)

86

 

 

opioid analgesics in the elderly

 

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

 

 

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

 

 

meperidine (Demerol)

pentazocaine (Talwin)

propoxyphene (Darvocet)

88

 

 

tricyclic antidepressants in the elderly

(Elavil)

 

rarely indicated

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

89

 

 

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

 

  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