Geriatrics

Question 1

Main challenges in elderly

Answer 1

multiple co-morbidities, polypharmacy, compliance, cost, new drugs

Question 2

Leading causes of mortality

Answer 2

CVD, CA, respiratory

Question 3

Leading causes of morbidity

Answer 3

arthritis, HTN, hearing loss, heart disease

Question 4

Gastrointestinal changes w/ elderly

Answer 4

inc stomach pH, dec blood flow, slowed gastric emptying

Question 5

Skin changes w/ aging

Answer 5

thinning of dermis, loss of SQ fat

Question 6

Body composition changes w/ againg

Answer 6

decreased total body water, decreased lean body mass, body fat percentage changes

Question 7

Liver changes w/ aging

Answer 7

dec liver mass, dec blood flow, dec or no change to CYP 450

Question 8

Renal changes w/ aging

Answer 8

dec glomerular filtration rate, dec blood flow, dec tubular secretion, dec mass, dec functional nephrons

Question 9

Absorption problems

Answer 9

rate of absorption decreased, little change in extent of absorption

Question 10

Decreased body water causes

Answer 10

higher drug concentrations and affects hydrophilic drugs

Question 11

Decreased lean body mass effects

Answer 11

lipid soluble drugs increased half-life

Question 12

Decreased plasma protein effects

Answer 12

highly protein bound drugs increased free fractions

Question 13

Effects of metabolism changes

Answer 13

reduction in first-pass metabolism, phase II metabolism is less affected by age

Question 14

limitations in measuring CrCl

Answer 14

not everyone has decline in renal function, muscle mass reductions

Question 15

Pharmacodynamic changes

Answer 15

reduced sensitivity to B-adrenergic stimulation, impaired baroreceptor reflex, more sensitive to antagonism of cholinergic receptors, CNS disorders, increased effects on some meds

Question 16

CNS changes w/ aging

Answer 16

volume loss, slower processing, more activation required more simple tasks, dopaminergic decrease, serotonergic changes with depression, memory and cognition changes, sympathetic outflow increased

Question 17

Drugs that affect bone and muscle integrity

Answer 17

glucocorticosteroids, PPIs, phenytoin

Question 18

Drugs that affect balance

Answer 18

sedative hypnotics, antiHTN, long T1/2 or large dose benzos, TCAs, antipsychotics, anticonvulsants

Question 19

Drugs that affect mental state

Answer 19

anticholinergics, benzos, pentazocine, muscle relaxants, TCAs, amitryptyline, antispasmodics, diphenhydramine, antihistamines

Question 20

Drugs that affect emotional state

Answer 20

methyldopa, reserpine, anastrozole, interferon a-2b, tamoxifen

Question 21

Drugs that affect continence

Answer 21

anticholinergics, a-blockers, a-agonists, alcohol, acetylcholinesterase inhibitors, diuretics

Question 22

Prescribing in the elderly

Answer 22

start w/ low dose, avoid starting multiple agents at same time, reach therapeutic dose before switching agents, consider non-pharm approaches

Question 23

Enhancing medication adherence

Answer 23

limit prescribing newer, expensive drugs, simplify regimen, pill organizers, educate pt on benefits, assess appropriateness of meds

Question 24

Causes of constipation

Answer 24

dietary, failure to heed reflex, impaired physical mobility, disease, age, drugs

Question 25

Drugs that cause constipation

Answer 25

analgesics, antacids, anticholinergics, antidepressants, verapamil, clonidine, iron

Question 26

Non-pharm treatment

Answer 26

fluid, fiber, fitness

Question 27

Bulk laxatives

Answer 27

psyllium (Metamucil), Methylcellulose (Citrucel), Polycarbophil (Fibercon) -1250 mg PO 1-4/day

Question 28

MOA of bulk laxatives

Answer 28

increase bulk volume and water content of stool, stimulating peristalsis and decrease colonic transit time; 12-72 hr onset

Question 29

Pearls of bulk laxatives

Answer 29

must have adequate fluid intake, not good for bed ridden pts or opioid induced, great for chronic management, as good as stool softener

Question 30

Surfactant/emollient

Answer 30

Docusate (Colace)- 100 mg PO BID

Question 31

MOA of surfacant/emollient

Answer 31

decrease fecal surface tension, stool softener

Question 32

Pearl of surfacant/emollient

Answer 32

onset- 24-72 hr, mostly PO, sometimes enema, combo (senna- Peri- colace), very safe, OTC

Question 33

Saline laxatives (Cathartics)

Answer 33

magnesium citrate (300 ml), Magnesium hydroxide (MOM, 30 ml), sodium bi/phosphate (Fleets phospho-soda), fleets enema

Question 34

MOA of saline laxatives

Answer 34

draws fluid into colon and stimulates activity

Question 35

pearls of saline laxatives

Answer 35

onset- 30min-3 hr, great for acute, avoid in pt w/renal disease, citrate and fleets used for prep (green bullet)

Question 36

Hyperosmotics

Answer 36

glycerin- infants, lactulose (Chronulac)- chronic, liver failure, polyethylene glycol (Miralax), polyethylene glycol-electrolyte solution (GoLytely)

Question 37

Stimulants

Answer 37

bisacodyl (Ducolax)- 5-15 mg po, Senna (senokot), castor oil

Question 38

MOA of stimulants

Answer 38

irritates nerves in colon, stimulates motility

Question 39

Bisacodyl mostly used

Answer 39

for short term, once daily if chronic, OTC, also prep

Question 40

Senna used for

Answer 40

opioid induced constipation, OTC

Question 41

Lubricants

Answer 41

mineral oil, lubricates intenstine, decreases water absorption, onset 6-8 hrs, not used often

Question 42

Laxative ADRs

Answer 42

abd cramping, bloating, flatulence, distension, diarrhea, saline lxatives can cause diuresis, dehydration, electrolyte imbalances, bulk lax can cause GI obstruction

Question 43

General treatment guideline for constipation

Answer 43

first bulk-forming, surfactant/emollient or lubricant, saline cathartic, hyperosmotic agent, then stimulant

Question 44

Special populations

Answer 44

elderly-docusate, lactulose, fiber, pregnancy-fiber, children- glycerin suppositories, polyethylene glycol, diabetics- metoclopramide, stimulant, post op- MOM, maybe stimulant

Question 45

Restless leg syndrome non-pharm

Answer 45

avoid EtOH, tobacco, Fe, avoid drugs that alter serotonin, follow regular sleep patterns, exercise, avoid prolonged sedentary activities, stretch, massage leg

Question 46

RLS pharm approach

Answer 46

dopaminergic agents, give before bed, levodopa/carbidopa- may be best option, dopamine agonists (Pramipexole (Mirapex), Ropinirole (requip)), sedatives, hypnotics, anticonvulsants, opioids