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Geriatrics Flashcards

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1
Q

GI changes with age

A

increased stomach pH
decreased GI blood flow
slowed gastric emptying/transit

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2
Q

pharmokinetic GI changes with age?

A

decreased/prolonged absorption of some drugs and nutrients

decrease first pass metabolism (less drug broken down by liver and more drug enters circulation)

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3
Q

skin changes with age

A

thinning of dermis and loss of SQ fat

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4
Q

pharmokinetic skin changes with age?

A

decreased drug reservoir formation with transdermal formulation

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5
Q

body composition changes with age?

A

decreased body water
decreased lean body mass
increased body fat

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6
Q

pharmokinetic body composition changes with age?

A

increased volume of distribution and accumulation of lipid soluble drugs

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7
Q

liver changes with age?

A

decreased liver mass

decreased blood flow to liver

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8
Q

pharmokinetic liver changes with age?

A

increased half life of drugs

decreased clearance of drugs with a high 1st pass metabolism

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9
Q

renal changes with age?

A

decreased GFR
decreaed renal blood flow
decreased tubular secretion
decreased renal mass

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10
Q

pharmokinetic renal changes with age?

A

decreased renal elimination of many drugs

increased 1/2 life of renally eliminated drugs

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11
Q

how is absorption affected by age?

A

slowed absorption

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12
Q

geriatric conditions/practices that affect the rate of absorption of some drugs?

A

DM (slows gastric emptying/prolongs absorption)

OTC laxative and antacid use

decreased SQ fat prevents transdermal reservoir formation (caution with small/cachetic patients)

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13
Q

what vitamins have decreased absorption in the geriatric population why?

A

iron
vitamine B12
Ca

due to decreased stomach acid

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14
Q

how much water soluble drugs be adjusted in the elderly?

A

decreased total body water requires that loading doses of water soluble drugs be decreased (due to a small volume of distribution)

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15
Q

effect on distribution of fat soluble drugs in the elderly?

A

increased accumulation of fat soluble drugs due to increased total body fat can lead to prolonged DOA for fat soluble drugs

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16
Q

example of a lipid soluble drug class that has an increased 1/2 life in the elderly?

A

benzodiazepines (alprazolam, diazepam, flurazepam)

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17
Q

why do higher brain concentrations of some drugs occur in the elderly?

A

decreased p-glycoprotein, a transporter for drugs out of the brain, can lead to higher concentrations in the brain of some drugs

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18
Q

what drugs are metabolized in the liver more slowly by the elderly?

A

benzos
antidepressants
(not all drugs are metabolized more slowly just some)

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19
Q

what is one of the most significant disease found in the elderly that is associated with decreased liver function/metabolism?

A

CHF

it causes:

  • decreased blood flow to the liver
  • decreased metabolism by liver
  • prolonged effects of some liver metabolized drugs
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20
Q

two drugs with substantially reduced clearance due to decreased first pass metabolism?

A

morphine (causes respiratory depression)

propanolol

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21
Q

what is the most important change that affects drug usage in the elderly?

A

decreased kidney function decreases drug elimination (increases half life of drugs and allows for toxic accumulation)

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22
Q

is Cr increased in elderly with decreased kidney function

A

not always due to decreased muscle mass

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23
Q

how to prevent SE related to decreased kidney fxn in the elderly?

A 
#1: increase dosing interval
#2: decrease dose

may undergoes a pt with normal renal fxn

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24
Q

calculation used to decrease estimated creatinine clearance?

A

cockcroft-gault

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25
how should drugs eliminated through GFR be dosed in patients with decreased renal fxn?
based on estimated creatinine clearance
26
what drugs are the elderly more sensitive to due to increased receptors or affinity for receptors?
benzos opioids warfarin
27
what drugs are the elderly less sensitive to due to decreased receptors or affinity for receptors?
beta blockers
28
what are 3 age-related changes to homeostatic responses?
decreased baroreceptor response (orthostatic hypotension) sodium/water retention mobility and balance issues
29
what are two decreased homeostatic responses often interpreted as increased sensitivity to drugs?
BP: orthostatic hypotenstion amplified by meds BS: unable to compensate for carb load appropriately (may loos like resistant to diabetes medicines)
30
probability of SE when taking 10 drugs?
100%
31
risk for SE in the elderly?
``` low body weight greater than 85 yo decreased renal fxn 6 or more illnesses hx of prior SE 9 or more medications 12 or more doses per day ```
32
guidelines to avoid SE
take a careful drug Hx (ID all drugs, have pt bring updated list) give meds only for specific indications (evidence based) define goals start low and gradually increase dose evaluate for proper therapy duration suspect SE simplify drug regimens (few and qD dosing best)
33
when to stop a drug if goal not being met?
when adult dose has been met (means it isn't working) when SE presents
34
describe metabolism, elimination, and sensitivity of benzos and barbiturates in the elderly?
metabolism: slowed half-life: increased elimination: decreased sensitivity: increased
35
problems with barbituates in the elderly?
high rate of physical dependence tolerance to sleep benefits risk of OD at low doses
36
SE of benzos and barbituates in elderly?
``` cog. impairment delirium falls fx motor vehicle accidents ```
37
when to give elderly barbiturates?
never
38
when to give benzos to the elderly?
``` seizure disorders generalized anxiety periprocedural anesthesia ethanol/benzo withdrawal end of life care ```
39
do not use benzos for?
insomnia agitation delirium
40
which benzos to use in the elderly?
lorazepam oxazepam (short half life) DONT USE: clorazepate, flurazepam (long acting benzodiazepines) or phenobarbital, butalbital (long acting barbiturates)
41
what SE is common with narcotics in the elderly?
respiratory depression due to metabolic changes (use caution when prescribing)
42
narcotics that have been removed from using with geriatrics? or anyone for that matter?
propoxyphene pentazocine merperidine
43
responsiveness to antipsychotics in the elderly?
increased
44
BBW for antipsychotics in patients with dementia?
increased risk of stroke and mortality
45
when to use antipsychotics in the elderly?
psychosis (not dementia) talk to family about risks start with a SMALL dose
46
depression is _____ and _____ in the elderly
underdiagnosed and undertreated
47
risk of toxicity to antidepressant in elderly is? especially concerning?
increased especially when given antidepressants with anticholinergic effects
48
what antidepressants to use in elderly? which to avoid?
use: SSRI dont use: TCAD start with low dose and increase
49
risk of using anticholinergic drugs in the elderly?
increased risk for anticholinergic side effects (confusion, dry mouth, constipation)
50
antidiarrheal drugs with anticholinergic SE that should be avoided in the elderly?
lomotil
51
Class Ia, Ic, and III antiarrythmic drugs with anticholinergic SE that should be avoided in the elderly?
amiodarone | quinidine
52
first gen. antihistamines drugs with anticholinergic SE that should be avoided in the elderly?
diphenhydramine and chlorpheniramine
53
antispasmodic drugs with anticholinergic SE that should be avoided in the elderly?
dicyclomine, belladona
54
skeletal mm relaxant drugs with anticholinergic SE that should be avoided in the elderly?
cyclobenzaprine, carisoprodol
55
antiemetic drugs with anticholinergic SE that should be avoided in the elderly?
promethazine
56
sensitivity to anti-HTN meds in the elderly?
increase, balance against morbidity and mortality risk
57
how to prescribe anti-HTN meds to elderly?
start with low dose 1st line: diuretics (12.5 to 25 mg) CCB also good choice
58
bad anti--HTN choices?
ACEI and bblockers
59
what should you check every visit for elderly pt on anti-HTN?
orthostatic hypotension
60
when to use digoxin in elderly?
CHF
61
problem with digoxin?
narrow therapeutic window
62
things to consider when prescribing digoxin to the elderly?
slow renal clearance may lead to toxicity more susceptible to arrythmias
63
what should be the max dose of digoxin used in elderly?
125 mcg (higher doses have no benefit and will increase risk of toxicity)
64
what is the major problem with Abx use in elderly?
renally excreted so prolonged half life
65
Abx to use cautiously with elderly?
aminoglycosides beta-lactams fluoroquinolones
66
should mm relaxants be used in the elderly? which ones should be avoided? why
No avoid: cyclobenzaprine, orphenadrine, carisoprodol, metaxalone, methocarbamol problems: anticholinergic SE, sedation, fx risk, not very effective
67
Risks with NSAID use in elderly?
GI bleed and PUD in high risk groups increased kidney toxicity
68
groups at high risk of NSAID toxicity
using steroids using anticoagulants using antiplatlets
69
what reduces risk of GI bleeding in high risk groups taking NSAIDs
PPI (doesn't eliminate risk)
70
how to use NSAIDs in elderly (what to monitor)
use carefully: watch BP ask about bleeding check serum Cr
71
risks with insulin sliding scale in geriatric pt?
higher risk of hypoglycemia without improvement of hyperglycemia
72
risk of sulfonureas in geriatric patients?
chlorpropamide: prolonged half life with prolonged hypoglycemia glyburide: greater risk for prolonged hypoglycemia
73
sulfonureas that shouldnt be used in geriatric patients?
chlorpropamide | glyburide
74
cause of alzheimers?
destruction of cholinergic neurons ``` from: Genetics and the apo E4 allele Environment Inflammation Neurotransmitter deficiency Vascular damage ```
75
what enzyme and NT is decreased in patients with alzheimers
acetyltransferase enzyme (helps make ACh) ACh is decreased in CNS (supported by their sensitivity to anticholinergic drugs)
76
what enzyme is increased in alzheimers? how is this treated
glutamate (excitatory NT that destroys neurons when high) Tx: NMDA receptor blockers
77
cholinesterase inhibitors
donepezil rivastigmine glantamine
78
mechanism of cholinesterase inhibitors
slows deterioration of cognitive fxn (don't affect underlying disease process)
79
which cholinesterase inhibitors to use for mild to moderate disease? severe?
mild to moderate: donepezil rivastigmine glantamine severe: donepezil
80
what drugs should you try to avoid giving to alzheimers patients on cholinesterase inhibitors?
anticholinergics
81
what happens when cholinesterase inhibitors are stopped suddenly?
worse cognition | worse behavior
82
SE of cholinesterase inhibitors?
GI: N/V cholinergic: urinary incontinence, dizzy, HA, syncope, bradycardia, salivation, sweating
83
how to reduce SE of cholinesterase inhibitors?
start slowly
84
only NMDA receptor blocker on the market?
mematine
85
MOA of NMDA receptor blocker
reduces excitotoxic effect of glutamate
86
which is better tolerated NMDA receptor blocker or cholinesterase inhibitors?
NMDA receptor blocker
87
SE of NMDA receptor blocker ?
constipation, dizzy, HA, hallucination, HTN
88
when are NMDA receptor blocker used in alzheimers?
moderate to severe (NOT MILD)
89
which drug is used for mild to moderate alzheimers?
cholinesterase inhibitors
90
what is PRIMARY tx for alzheimers disease
nonpharmacologic: education for caregiver, reduction in environmental triggers, manage other dz
91
can you use two cholinesterase inhibitors together?
no
92
can you use a cholinesterase inhibitor and NMDA receptor blocker together?
yes

Pharm Final (3 decks)

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