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Flashcards in geriatrics Deck (43):
1

Leading causes of death in geriatrics are

Heart disease
Cancer
Alzheimer's
Cerebrovascular dz
chronic LR dz

2

What are common problems in older adults (I's)

Immobility, Instability
isolation, incontinence, infection, impaction, impaired senses, intellectual impairment, impotence, immunodeficiency, insomnia, iatrogenesis

3

What are atypical ways elderly present with common ailments

AMI: confusion
CHF: confusion
GI bleed: AMS
URI: confusion
UTI: confusion

4

Slide 7, list all drug families and classes

so annoying

5

What type of meds do most elderly use

OTC
Herbal and supplements
Sharing meds

6

What is polypharmacy*

concomitant use of multiple drugs OR administration of more meds than are clinically indicated
-Be concerned about adherence! If they have to take 10 pills per day, will they really take them all?
-Elderly in nursing homes typically take 7-9 different meds/day

7

How much is spent on side effects of drugs

In nursing homes, $1.33 is spent on ADE for every 1$ spent on meds
AKA, you spend more to fix it than you do to buy it
25% of ADE in elderly are preventable!

8

What are predictors of ADE

6+ chronic conditions
9+ meds
12+ doses of drugs/day
prior ADE
low body weight or BMI
85+ y/o
CrCl <50

9

What are the meds MC involved in ADE

cardiovascular drugs
diuretics
NSAIDs
hypoglycemics
anticoags
-AKA meds with a narrow margin of safety

10

What can you use to ensure the med you give an elderly pt is not inappropriate or unnecessary

Beer's criteria for potentially inappropriate med use in older adults
Published in 1991, most recently revised in 2015, scheduled for 2018
Assesses risk vs benefit

11

Potentially inappropriate meds have

limited effectiveness in older adults and are associated with problems like delirium, GI bleeds, falls, anf fractures

12

Beers criteria overview

1. PIM and classes to avoid in older adults
2. PIM and classes to avoid in older adults due to drug-disease or drug-syndrome interactions
3. PIM to be used with caution in older adults
(should be used as a guide for clinicians, but should not substitute professional judgement)

13

What are commonly used inappropriate drugs for elderly

antihistamines (2/2 anticholinergic ADE)
anticholinergics
GI/antispasmodics
benzos
TCA
sedatives, hypnotics
anticoags/antiplatelets

14

Why should you use caution with HF medications

may promote fluid retention/exacerbate HF

15

Do not use these drugs together in elderly

Benzos and non-benzo benzo receptor agonist hypnotics
-may increase risk of falls and fractures (2+ CNS active drugs)

16

What are challenges in geriatric pharmacotherapy

more drugs available each year
FDA and off label indications expanding
formularies change frequently
prescription costs are rising
knowledge of medication advances
drugs change from Rx to OTC
use of naturaceuticals is increasing
effects of aging physiology on drug therapy

17

Remember pharmacokinetics vs pharmacodynamics

PK: what the body does to the drug as it moves thru
PD: what the drug does to the body

18

How are PD and aging associated

With age, alteration in receptor number, drug receptor affinity, and enhanced or diminished port-receptor response

19

What happens to balance and gait with age

Decreased: stride length (slower gait) and arm singing
Increased: body sway when standing

20

What happens to body composition with age

Decreased: total body water, LBM
Increased: body fat, alpha-acid glycoprotein
Same or decreased: serum albumin

21

What happens to cardiovascular system with age

Decreased: CO, resting max HR
Increased: SVR w/ loss of atrial elasticity and dysfunction of systems maintaining vascular tone

22

What happens to CNS with age

Decreased: number of receptors, short term memory and executive function
Increased sensitivity of remaining receptors
Altered sleep

23

What are other physiologic changes with age

Endocrine: altered insulin signaling, decreased E, T, TSH, and DHEA
GI: decreased motility, vitamin absorption, splanchnic blood flow, bowel surface area
GU: vaginal atrophy (low E), BPH, detrusor hyperactivity (incontinence)
Hepatic: decreased liver size, blood flow, and phase I metabolism (oxidation, reduction, hydrolysis)
Immune: decreased Ab production, increased autoimmunity
Oral: altered dentition, decreased ability to taste salt, bitter, sweet, and sour
Pulm: decreased resp. muslce strength, chest wall compliance, VC. increased residual volume
Renal: decreased GFR, renal blood flow, filtration, tubular secretory fxn, renal mass
Sensory: presbyopia, presbycusis. decreased night vision, sensation of smell and taste
Skeletal: decreased bone mass, joint stiffening
Skin/hair: thin stratum corneum. decreased melanocytes, depth of fat layer. more hair in resting phase= thin grey hair

24

What PK changes are associated with aging

GI absorption: decreased active transport and first pass metabolism. unchanged passive diffusion and bioavailability of most drugs
Distrib: decreased volume of distrib. increased plasma concetration of water soluble, Vd and increased deposition of lipid soluble
Hepatic metabolism: decreased clearance
Renal excretion: decreased clearance

25

What is the phase I metabolic pathway

oxidation, reduction, and hydrolysis converts drugs to metabolites
MOST affected pathway with age
CYP3A4 is involved in >50% of drugs on the market

26

What is the phase II metabolic pathway

conjugate drugs to inactive metabolites that do not accumulate
Less affected with age
Usually, phase I path drugs are preferred for elderly

27

Key concepts in drug elimination

Half life: time for serum concentration to decline by 50%
Clearance: volume of serum from which drug is removed per unit of time

28

Pearl she gave us

In an elderly patient, always consider serum creatinine 1 if they are just slightly below it (0.7, 0.8, etc)

29

What is CrCl

used to make dosing adjustments in patients with renal dysfunction
decreased LBM = lower Cr production and lower GFR
This means in older people, SrCr does NOT reflect CrCl

30

What are the PD changes of aging

In CNS:
reduced dopamine (increased EPS Sx)
reduced serotonin receptor fxn (more sensitive to antidepressants)
altered GABA-benzo receptor fxn (more sensitive to benzos, alcohol, and barbituates)
reduced ACh (enhanced anticholinergic ADE, sedation, confusion, psychosis, delirium, urinary retention, constipation. decline in cognitive fxn)

31

What happens to skin in elderly

epidermis thins and subQ fat decreases
Topical absorption increases!

32

What are commonly overRx and inappropriately used drugs

antiinfectives
anticholinergics
antispasmodice
antipsychotics
benzos
digoxin
dipyridamole
H2 antagonisrs
laxatives and fecal softeners
NSAIDs
PPI
sedating antihistamines
TCA
vitamins, minerals

33

What is STOPP

screening tool of older persons potentially inappropriate prescriptions criteria
Focuses on avoiding use of meds that are potentially inappropriate in elderly

34

Examples of STOPP criteria

Theophylline ad monotherapy for COPD
NSAIDs with HF
NSAIDs with warfarin
Vasodilators with postural hypotension
Bladder antimuscarinics with dementia

35

What are commonly underprescribed drugs

ACE with DM and proteinuria
ARB
Anticoags
antiHTN and diuretics for uncontrolled HTN
BB after MI or w/ HF
Bronchodilators
PPI or misoprostol to protect tummy from NSAIDs
statins
vitamin D and calcium for high risk osteoporosis

36

What is START

screening tool to alert docs to right treatment
focuses on ID undertreatment of Rx omissions in elderly
criteria is organized by organ!

37

What is dangerous that elderly dont realize about taking different meds

Duplicate meds contain the same active ingredient! Ex: vicodin and tylenol PM
Aleve and ibuprofen (same drug class)

38

How do you effectively dose an elderly patient

based on age, functional status, renal and hepatic function, comorbid conditions, concurrent drug regimen, goal of care
*Start LOW go SLOW*

39

Explain a prescribing cascade

You give metoclopramide
Pt develops parkinsonism ADE that is mistaken for a new condition
You give CCB and anti-parkinsons Rx
Pt gets peripheral edema from new drugs, and is thought to be a new condition
You give the patient diuretics
etc. etc. etc.

40

What can drug-drug interactions lead to

decreased efficacy, unexpected ADE, increased activity of a drug
May lead to ADE: confusion, delirium, cognitive impairment, hypotension, acute renal failure
Likelihood increases as number of meds increases

41

List drugs and their common risks

Benzos, TCA, antipsychotics: falls and fractures
TCA, anticholinergics: cognitive impairment
NSAIDs: AKI
NSAIDs or ASA: GI bleeding
non-DHP CCB: pulmonary edema, worsening CHF
TCA: urinary frequency
Opioids: worsening constipation

42

What are common food interactions

dairy
coffee, tea
grapefruit juice
alcohol
charcoal broiled foods
green leafy veggies
licorice
ginseng

43

In summary...

Rational prescribing means choosing correct dose of correct drug for condition and individual pt
Age alters PK (ADME)
ADE are common and can be minimized with attention to RF, drug-drug, and drug-disease interactions