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Pharmacology > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

Medications with Geriatric Rx Concerns

A
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2
Q

Eldery = ______ yo

A

65+

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3
Q

______% of the pop is eldery
_____% of all meds are Rx to the eldery
_____% of Eldery take at least 1 Rx, 1 OTC, AND 1 dietary supp
____% of Elderly take at least 5Rx and at least 1 OTC

A
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4
Q

Most commonly Rx drug classes to Eldery

A

Analgesics
Diuretics
Cardiovascular Rx
Sedative Hypnotics

Pain, Pee, Heart, Sedatives

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5
Q

In general, what are the 2 main pharmacokinetic and Dynamic changes in the elderly?

A
  • Decreased clearance
  • Increased sensitivity to meds
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6
Q

How does absorption of must drugs change in geriatrics?

A

unchanged in most drugs
Absorption is slowed down but it will occur. No change in bioavailability

decr absorption of drugs requiring active transport

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7
Q

As pt becomes geriatric, how might you change their dose of albumin-bound drug?

A

decr as they get older bc you have less plasma albumin as you get older. Therefore, need less for it to work. Higher doses will incr risk of SE and overdose/toxicity

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8
Q

How is Drug Distribution different in geriatrics?

A

More free (unbound) drug -> incr SE

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9
Q

How is drug metabolism different in geriatrics?

A

Their liver is slower and doesn’t do first pass metabolism as well -> increases risk for SE

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10
Q

Most significant change in elderly affecting pharmacokinetics? What organ?

A

decr kidney function and excretion

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11
Q

Renal Function
Cockcroft-Gault (C-G) Equation

Will be on test

A

Serum creatinine (Scr) and BUN can be unreliable markers
Creatinine clearance (Clcr) adjusts for patient specific differences

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12
Q

Cockcroft Gault Equation Q

79 yo Male
6’2” 255 lbs
SCr 1.3

A
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13
Q

Why is serum creatinine a great indicator of kidney function?

A

its only secreted by the kidneys

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14
Q

Geriatrics have altered receptor sensitivity. Does this result in increased or decreased diuretic response to loop diuretics?

A

decreased

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15
Q

Cholinergic effects (SLUDGE)
vs
Anticholinergic effects (ABCDS)

A
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16
Q

8 drug classes that have strong anticholinergic properties

A
  • Urinary Incontinence
  • Antihistamines
  • Antiemetics
  • Skeletal Muscle relaxants
  • Anti-spasmodic
  • Antiparkinsonians
  • Antipsychotics
  • Antidepressants

only need to know drug classes for test

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17
Q

When should you not Rx anticholinergics?

A
  • Uncontrolled narrow angle glaucoma, urinary retention, gastric retention, decr gastric motility
  • if taking acetylcholinesterase inhibitor for Alzheimer’s/dementia
  • May worsen confusion -> altered mental status
  • Caution if pts does tasks requiring mental alterness
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18
Q

Alzheimer’s Disease Pathophysiology

Alzheimer’s Dz leads to _____ tangles, ____ plaques, and decreased production of ______

A

Tau tangles
Amyloid plaques
Decr Acetylcholine (ACh)

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19
Q

Alzheimer’s Dz Non-Pharm trmnt

A

Physical activity
Vascular health
Thinking
Healthy diet

NO CURE or TRMNT to STOP DISEASE PROGRESSION

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20
Q

2 drug classes for geriatric Alzheimer’s/Dementia

A
  • Acetylcholinesterase (AChE) Inhibitors
  • N-methyl D-aspartate (NMDA) Inhibitors
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21
Q

Acetylcholinesterase (AChE) Inhibitors:
Meds?
MOA?
SE?

A
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22
Q

Drug class?

Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)

A

Acetylcholine Esterase (AChE) Inhibitors

23
Q

AChE Inhibitors: Drug Interactions

Which drug route formulations show decreased GI SE?

oral capsules? ODT? injections? instant release? ER/XR? patches?

A
  • Patches
  • Orally disintegrating tablets (ODT)
  • Extended release (ER, XR)
24
Q

AChE Inhibitors: Drug interactions

give Donepezil (Aricept) at night to decrease _____ or in the morning to decrease _____

A

night -> decr nausea
morning -> decr insomnia

25
Q

geriatric pt is taking Donepezil (Aricept) and reports new onset nausea. What 2 things can they do?

A

take with food at night

26
Q

Pt is taking Donepezil (Aricept) for Geriatric Alzheimer’s/Dementia. Her son asks you if it will improve her symptoms and help her return to her old self. what do you say?

A

It may not help her improve clinically, but it may slow progression.

slows inevitble downhill progression

27
Q

AChE-I Drug interactions

AChE-I + BB/CCB/Digoxin =

A

BRADYCARDIA RISK
in drugs that already decr HR

28
Q

Combining an AChE-I + any of the following Rx may cause _____

▪ Anti-psychotics
▪ Anti-hypertensives
▪ Alpha-blockers
▪ Hypnotics
▪ Opioids
▪ Alcohol
▪ Muscle relaxants

A

Dizziness

those drugs already cause dizzy

29
Q

N-methyl D-aspartate (NMDA) Inhibitors:
Drugs?
MOA?
SE?

A

Memantine (Namenda)
MOA: There is too much Glutamate in Alzheimer’s Dz. Decreasing Glutamate will decrease the avail Ca+ -> prevent nerve damage
SE: Sleepy, Hallucinations, Constipation, Confusion, H/A, Dizzy

30
Q

Drug class and indication

Memantine (Namenda or Namenda XR)

A

NMDA Inhibitor
Moderate/Severe Alzheimers Disease

31
Q

2 big Drugs classes to avoid or use with care in dementia patients

A

Anticholinergics (AcH receptor blockers)
Sedatives

32
Q

Which Alzheimer’s Dz Med treats all 3 stages?

A

Donepezil (AChE-I)

33
Q

Which Alzheimer’s Dz med ONLY treats mild/Mod stage?

A

Rivastigmine & Galantamine

34
Q

Urinary Incontinence Non-Pharm Trmnt

A

Behavioral therapies: 1st line
* Bladder training
* Delayed or scheduled voiding
* Pelvic floor muscle exercises (Kegel): may be effective for OAB
* Urge control techniques
* Fluid management
* Dietary changes (avoiding caffeine, alcohol and artificial sweeteners)
* Weight loss

Surgical intervention
* Reserved for rare non-neurogenic patient who has failed all other options

35
Q

Urinary Incontinence Drug Targets

A

M3
B3
A1

36
Q

Which receptor(s) are on the detrusor smooth muscle?

A1? M3? B3?

A

M3
B3

A1 are on bladder outlet (bladder neck)

37
Q

Anticholinergic: M2 and M3 Antagonists should only be used for what types of Urinary problems?

A

Urge incontinence
OAB (overactive bladder)

Using these anticholinergic agents for other types of incontinence such as obstructive incontinence can be dangerous, as it could lead to damaging urinary retention. These meds inhibit parasympathetic detrusor muscle contractions so you pee less often. If there is a bladder obstruction, these meds would just let your bladder overfill too much! Your bladder should be contracting harder to overcome the urethral obstruction to avoid this

38
Q

Pt with urge incontinence is taking a M2/M3 antagonist. They complain of dry mouth, blurry vision, and constipation. How can you change the formulation to decrease anticholinergic effects throughout the rest of the body?

A

Minimize this by using ER formulations, patches, or newer, more M3-selective agents

39
Q

Pt is on a M2/M3 antagonist for OAB. They report dry mouth. What drug can you switch them to?

A

Beta 3 agonist Mirabegron (Myrbetriq)

40
Q

Urinary Incontinence

If taking M2 or M3 antagonists (Anticholinergics) fail, try ____

A

Beta 3 Agonist -> Mirabegron (Myrbetriq)

less dry mouth
HTN risk

41
Q

How do Beta 3 Agonists interact with metoprolol?

A

B3 agonists are Moderate CYP450 2D6 inhibitors and may increase levels of metoprolol.

might want to lower metorpolol dose

42
Q

How might you want to change a digoxin dose when starting a Beta 3 Agonist?

A

decrease digoxin

Beta 3 agonists increase digoxin levels

43
Q

Geriatric Considerations

Anticoagulants

A
  • might not be worth it if gonna die soon anyways
  • risk of major bleed
  • Warfarin req INR monitoring, has many drug interactions
  • consider co-managing pts with anticoagulation therapy unit (ATU)

Most common indication: reduce risk of stroke in chronic non-valvular atrial fibrillation

44
Q

Blood Brain Barrier

A

The BBB is a is a diffusion barrier, which impedes influx of most compounds from blood to brain or CNS; it allows some materials to cross, but prevents others from crossing

  • Protects the brain from “foreign substances”in the blood that may injure the CNS.
  • Protects the brain from hormones and neurotransmittersin the rest of the body.
  • Maintains a constant environmentfor the CNS.
45
Q

Geriatric Considerations

1st gen Antihistmaines (Benadryl, Unisom, etc)

A
  • avoid in older adults
  • Crosses blood brain barrier
  • SHOULD NOT use as a sleep aid
  • risk of falls, confusion
46
Q

Geriatric Considerations

2nd Gen Antihistamines

A
  • doesnt readily cross blood brain barrier (safer)
  • generally safe in seniors
  • some anticholinergic effects: drowsiness, dry mouth
  • short term trmnt preferred
47
Q

Geriatric Considerations

NSAIDs

A

chronic use may lead to
* GI bleed or PUD in high-risk grps (PPIs dont decr this risk)
* Kidney damage
* HTN
* HF

High risk: Age >75 years old, taking PO or IV corticosteroids, anticoagulants, or antiplatelet agents

Alternatives -> short term acetaminophen or topical analgesics

If alt fail -> use low dose NSAID chronically + gastroprotective agent

48
Q

Geriatric Considerations

Opiods

A
  • NOT 1st line for CHRONIC pain
  • may be safer for pain than large chronic doses of tylenol or NSAIDs

Major Toxicities
- Resp depression
- Constipation (stimulant laxative (senna)) to treat and prevent)

49
Q

Geriatric Considerations

Antipsychotics

A
  • Elderly Dementia + Psychosis + Antipsychotics -> incr risk of DEATH
  • may still be okay for eldery with Schizophrenia or bipolar disorder
  • Also appropriate for acute agitation as an alternative to benzodiazepines
50
Q

Geriatric Considerations

First Generation Antipsychotics “typicals”

A
  • Extrapyramidal SE (EPS)
  • Anticholinergic effects: sedation, confusion, urinary retention
  • QTc prolongation (*highest risk)

EPS Examples
Dystonia, akathisia, parkinsonism, bradykinesia, tremor
Tardive dyskinesia

51
Q

Geriatric Considerations

Second Generation Antipsychotics “atypicals”

A

Lower risk of EPS compared to typicals

52
Q

Geriatric Considerations

Anxiolytics

A
  • AVOID ALL BENZOS (alprazolam, midazolam, diazepam, lorazepam, temazepam)
  • RISKS: of cognitive impairment, delirium, falls, fractures and motor vehicle crashes
53
Q

Geriatric Considerations

Antihypertensives

A

Start low and go slow

1ST LINE MONOTHERAPY
THIAZIDES
ACE-I/ARBs
Long acting CCBs

54
Q

Beer’s List

A

general list of drugs to avoid in geriatrics
NOT A BIBLE

Can use Beer’s list as a clinical rational if insurance is being a bitch

Pharmacology (14 decks)

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