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Flashcards in Geriatric Pharmacotherapy Deck (27):
1

Pharmacokinetic Changes in the Elderly in regards to Absorption

- Unchanged Passive Diffusion (most drugs)
- Decreased Active Transport
- Decreased Bioavailability (some drugs)
- Decreased First-Pass Metabolism
- Increased Bioavailabilty (some drugs)

2

Pharmacokinetic Changes in the Elderly in regards to Distribution

Water-soluble:
- Decreased Volume of Distribution(Vd)
- Increased Plasma Concentration

Lipid-soluble:
- Increased Vd
- Increased half-life

3

Pharmacokinetic Changes in the Elderly in regards to Metabolism

- Decreased Hepatic Metabolism
- Increased Half Life (Some drugs)

4

Pharmacokinetic Changes in the Elderly in regards to Elimination

- Decreased Clearance
- Increased Half-Life of Renally Eliminated Drugs
- Increased Half-Life of Active Metabolites

5

What is the most important thing to check in the elderly patients?

- Assess GFR!

6

In terms of pharmacodynamics, what should be known about elderly patients?

May be more sensitive to the effects of medications (therapeutic and side effects)

- Such as anticoagulants, antiplatelets, sedatives, antihypertensives, antidiabetics, etc.

7

In terms of pharmacodynamic properties with the elderly, how should we start medications.

Start at a lower dose and then titrate up slowly.

8

This is the use of multiple drugs or the administration of more medications than are indicated clinically.

Polypharmacy

9

Polypharmacy and the Elderly

- Occurs in approx. 50-60% of older outpatients
- May lead to drug/drug or drug/disease interactions (inc. risk of SE, multiple providers, OTCs)
- Avoid treating SE with another drug
- Dietary Supplements increase polypharmacy (and often not noted)

10

What types of medications are avoided because they are potentially inappropriate medications (PMI)

1. First generation antihistamines
2. Antispasmodics
3. Digoxin
4. Alpha 1 Blockers
5. Central Alpha Blockers
6. Tertiary TCA
7. Antipsychotics
8. Barbituates
9. Benzodiazepine
10. Non-benzzo hypnotics
11. Insulin - Sliding Scale
12. NSAIDs
13. Sulonylureas
14. Muscle Relaxants

11

What are the three categories of recommendations in Beer's List?

1. Meds to avoid regardless of indication
2. Meds to avoid if certain disease(s) are present
3. Meds to be used cautiously in older adults

12

What can anticholinergics cause that the elderly should avoid is possible

- Sedation
- Confusion
- Mental Clouding
- Delirium
- Memory Problems
- Difficulty Concentrating
- Dry mouth
- Tachycardia
- Falls

13

Medications with Dz Interactions:
Heart Failure

- NSAIDs
- Verapamil/diltiazem
- Pioglitazone/Rosiglitazone
- Dronedarone

14

Medications with Dz Interactions:
Syncope

- Alpha blockers
- Tertiary TCAs
- Chlorpromazine
- Olanzapine

15

Medications with Dz Interactions:
Delirium

- TCAs
- Anticholinergics
- Benzodiazepines
- H-2 Blockers
- Sedatives

16

Medications with Dz Interactions:
Dementia and Cognitive Impairment

- Anticholinergics
- Benzodiazepines
- H2 blockers
- Zolpidem

17

Medications with Dz Interactions:
Hx Fall or Fx

- Anticonvulsants
- Benzodiazepines
- Sedatives
- TCAs
- AntiHTN
- Hypoglycemic Agents

18

Advantages of Beers

- Lists Meds to Avoid
- Relatively evidence-based
- Only needs med review

19

Disadvantages of Beers

- Hasn't prove to improve overall outcomes (mortality)
- Doesn't discuss appropriate medications

20

Why do we avoid Anticoagulants?

- More sensitive; increasing age is risk factor for bleeding
- Risk increases when combined with other agents that increase risk for bleeding (NSAIDs, antiplatelets, etc.)

21

Why do we avoid meds in Pain Management?

- Sensitive to constipating and sedating effects of opioids; exacerbated by concomitant anticholinergic medications
- Many have active metabolites (morphine) which are renally cleared
- NSAIDs can worsen renal function, CHF, hypertension, increase risk for bleeding, and increase risk for cardiovascular events (almost all agents)

22

Why do we avoid meds in HTN?

- Risk for orthostatic hypotension higher with specific agents and/or classes
- More sensitive to blood-pressure lowering effects
- Diuretics may exacerbate incontinence issues or lead to dehydration

23

Why do we avoid meds in Depression/Anxiety?

- Certain agents have high anticholinergic burden
- Certain agents can be strongly sedating

24

Why do we avoid meds in Heart Failure?

- Metoprolol succinate may be better option vs. carvedilol
- Diuretics may cause hypotension and/or electrolyte abnormalities

25

Why do we avoid meds in Osteoporosis with fall risk?

- Proper treatment essential (bisphosphonate, calcium and vitamin D) to reduce future risk
- Minimize risks for additional falls/fracture by avoiding medications which increase risk for falls

26

Why do we avoid meds in DM?

- Sliding scale insulin and glyburide (Beers List); start at lower insulin doses
- Hypoglycemia increases risk for syncope, falls
- Metformin and SCr cutoffs

27

Why do we avoid meds in Allergies?

- Antihistamines: 1st generation vs. 2nd generation