Geriatrics

Question 1

Define opportunities for pharmacists in the care of older adults in various settings.

Answer 1

inpatient medical/surgical unit (wards) - consultant based
retail pharmacy - vaccines, medication regimen review
ambulatory care pharmacy - anti-coagulation management, cardiovascular risk reduction, medication review management; retail pharmacy roles stems from this
long term care

Question 2

What are the key roles of the pharmacist when caring for older adult patients in LTC?

Answer 2

support providers to answer questions about meds
consult on medication regimens, recommned initiation or adjustments of medications based on clinical data
serve as a provider with prescriptive authority

Question 3

Pharmacy services in LTC

Answer 3

supply, distribute, secure medications for short-stay (rehab), assisted living, and long-stay/permanent residents

Question 4

Consultant pharmacy services

Answer 4

review medication administration, patient charts, medication storage at monthly or 3-month intervals

Question 5

Sample communication

Answer 5

often multiple copies (chart, provider, pharmacist records)
identify, explain drug therapy problem
recommend action
physician/provider response

Question 6

Identify medications that may result in more adverse events than benefits in older adults.

Answer 6

sedative/hypnotics
neuroleptics/antipsychotics
antidepressants
opioids
loop diuretics
alpha-blockers
medications with anticholinergic properties - focuse on risk of cognitive impairment
sedatives, medications with CNS effects (falls, dizziness)
diabetic agents: sliding scale insulin, long-acting sulfonlyureas
medications that may exacerbate chronic conditions (heart failure)

Question 7

Medication problems in the older adult

Answer 7

age-related increase in chronic conditions = higher medication use
polypharmacy
nonadherence
altered pharmacokinetics

Question 8

Polypharmacy

Answer 8

medications without indication
medications treating ADR
60% understand medications well, leaving 40% that need our attention

Question 9

Nonadherence

Answer 9

over 200 barriers to adherence
aging NOT one

Question 10

Beers criteria

Answer 10

criteria for potentially inappropriate medication use in older adults (age 65 yrs and older)
evaluates risks of medications against benefits with specific considerations for older people

Question 11

Identify safer alternative medications for older adults.

Answer 11

Beers criteria alternatives:
anticholinergies: several, indication specific
sedatives: non-pharmacologic, other treatments for anxiety
sulfonylureas: shorter acting agents, relaxed treatment targets

Question 12

Goals of care for older adults

Answer 12

maintain independence (daily activities, finances, transportation)
avoid need for institutionalization
maintain QOL
maintain functional ability

Question 13

Functional abilities in older adults

Answer 13

activities of daily living (ADLs): dressing, bathing, transferring, feeding, toileting, walking/ambulation
instrumental activities of daily living (IADLs): handling finances, shopping for groceries, meal prep, using a phone, housekeeping/laundry, handling medications, using transportation

Question 14

Risk factors for functional decline

Answer 14

age
immobility/exercise intolerance
poor muscle strength
poor balance
malnutrition, weight loss
hospitalizations
morbidity from chronic disease
cognitive impairment
depression

Question 15

Physiologic changes associated with aging

Answer 15

decreased total body water
decreased lean body mass
increased body fat
decreased baroreceptor response/activity
reduced heart rate variability
decreased hepatic blood flow
decreased renal blood flow
decreased neurotransmitter volume (sensitivity to CNS adverse effects)

Question 16

Pharmacokinetic changes with aging

Answer 16

generally no change in bioavailability of most drugs (but slower Tmax)

Question 17

Water soluble drugs

Answer 17

ex. atenolol
decrease Vd and increase concentration of water-soluble drugs

Question 18

Lipid-soluble drugs

Answer 18

ex. rifampin
increase Vd and increase T1/2 of lipid-soluble drugs

Question 19

Hepatically-cleared drugs

Answer 19

ex. propranolol
decrease clearance and increase T1/2 of most hepatically-cleared drugs

Question 20

Renally-cleared drugs

Answer 20

ex. atenolol
decrease clearance and increase T1/2 of most renally-cleared drugs

Question 21

Rate of change is

Answer 21

unique to each person

Question 22

Describe the roll of palliativce care and advance care directives supporting end of life care in older adults.

Answer 22

palliative care: after diagnosis of terminal illness, disease not responsive to curative treatment or treatment doesn’t exist
hospice care: provided at home, in LTC, or independent facility

Question 23

Palliative care treatment

Answer 23

medical, psychological, social, spiritual care for patient and family
optimize QOL, focus on symptoms only, not life-prolonging
stop meds not improving QOL

Question 24

Hospice care treatment

Answer 24

life expectancy of 6 months or less, certified by MD
home or institution-based, interdisciplinary
diagnostic tests, hospitalizations, labs no longer covered

Question 25

Beers criteria does not apply to

Answer 25

hospice/palliative care

Question 26

What are the key roles of the pharmacist when caring for older adults pts in palliative or hospice care?

Answer 26

align meds with goals ensure effective control of bothersome symptoms educate family and providers of medication regimen activate non-standard dosage forms if needed support financial concerns ensure safe and legal disposal of medications

Question 27

Common conditions and symptons that may be managed

Answer 27

pain anxiety insomnia difficulty swallowing fatigue constipation/diarrhea bowel obstruction delirium dyspnea nausea/vomiting edema dry mouth restlessness respiratory congestion

Question 28

Paths to death

Answer 28

varied, unpredictable contradicts what many perceive planning ahead can mean better QOL

Question 29

Evidence shows that palliative care:

Answer 29

reduces burden of treatment reduces transitions, time in acute care settings optimizes comfort measures - better pain management greater family satisfaction with care

Question 30

Advanced care directives

Answer 30

verbal and written instructions about future medical care & treatment elective, do not take away your right to make current care decisions include: health care representative - names someone to make decisions if you are unable (or prevents someone from making decisions for you); psychiatric advance directive - sets preferences re: mental illness during periods of incapacity; power of attorney - financial or health care grants power to others you choose

Question 31

Physician orders for scope of treatment

Answer 31

legal document declaring: preferences for resuscitation, medical interventions, antibiotics, artificial nutrition agreement between pt (or legal guardian) and physician must be signed and dated to be valid

Question 32

How do we define older adult?

Answer 32

disparities in aging sub-populations - age strata: 60-70, 71-80, 81-90, >90 health & functional status: frail vs. non-frail older adults (# of comorbidities or functional status) living or caregiving environment: community-dwelling, assisted living, comprehensive care, dependent vs independent

Question 33

Healthy aging

Answer 33

process of developing and maintaining the functional ability that enables wellbeing in older age functional ability is about having the capabilities to engage in activities one values

Question 34

Healthy aging - mental health

Answer 34

prevent or treat mood disorders & cognitive impairment

Question 35

Healthy aging - nutritional health

Answer 35

prevent or treat deficiencies, diabetes

Question 36

Healthy aging - cognitive health

Answer 36

education, cognitively stimulating exercises, social activity

Question 37

More healthy aging

Answer 37

stable housing physical health access to health care (preventive)

Question 38

Recommendations for rational prescribing

Answer 38

recognize new symptoms as potential adverse reactions optimize non-pharmacologic treatment options make single changes at a time align medication use with patient values minimize regimen and promote adherence avoid medications with high risk of adverse events and modest benefit review dose and frequency against renal and hepatic function define reasonable targets for chronic disease

Question 39

Considerations in choosing medications

Answer 39

life expectancy goals of care treatment targets time required to benefit

Question 40

Deprescribing

Answer 40

supervised process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes

Question 41

Deprescribing considerations

Answer 41

align medication use with priorities multiple stakeholders to support changes incorporate safer alternatives maintain symptom/management