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Pharmacology > Chapter 22: Geriatric patient > Flashcards

Chapter 22: Geriatric patient Flashcards

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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
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

Pharmacology (28 decks)

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