IMM 23 and 29: Introduction to Geriatrics Flashcards

Question

Physiologic Factors Impacting Pharmacodynamics What are the changes to the central nervous system?

Answer 1

↑ permeability of BLOOD BRAIN BARRIER, resulting in: - more medication crossing blood brain barrier/greater concentration of medication in brain in older adults compared to younger adults - therapeutic effects potentially seen at LOWER doses - INCREASED risk of CNS-related adverse effects (ie. confusion, sedation) ↓ number of neurons/receptors PLUS ↓ levels of neurotransmitters - often an INCREASED susceptibility to effects of medications impacting neurotransmitter - ie. older adults have ↓ dopaminergic neurons/dopamine receptors and ↓ dopamine levels in the brain – RESULT: increased susceptibility to adverse effects from dopamine antagonist (ie. antipsychotics) - ie. older adults have ↓ GABA levels in the brain – RESULT: enhanced response to benzodiazepines (GABA agonist) at lower dose and HIGHER adverse effects

Answer 2

- ↓ number of β1 receptors PLUS ↓ post-receptor activation from β1 receptors - DECREASED response to drugs that are agonists or antagonists of β1 receptors - ie. older adults have decreased antihypertensive effects β1 blockers and as a result, this class of medications is not recommended for managing blood pressure in older adults

Answer 3

an increased heart rate in response to low blood pressure - this prevents orthostatic hypotension (drop in blood pressure upon standing)

Answer 4

decreased baroreceptor, resulting in; - increased response to anti-hypertensives - increased risk of orthostatic hypotension

Answer 5

adverse effects of a drug that was properly administered in the correct dose, for therapeutic or prophylactic use

Answer 6

- account for 57.6% of all ADR-related hospitalizations - 48% of older adults ADR-related hospitalizations occur in aged ≥ 80 years - ADR’s account for 2.7% of all hospitalizations in older adults (vs. 1% for younger individuals)

Answer 7

- older age - male - polypharmacy - ↑ number comorbidities - ↑ number of prescribers - ↑ number of pharmacies - previous hospitalizations in past year - newly started medications - poor kidney function

Answer 8

- plasma protein binding: ↑ free fraction (↓ albumin) - volume of distribution: ↓Vd (hydrophilic drugs) = ↑ concentration - volume of distribution: ↑ Vd (lipophilic drugs) = ↑ duration of action - ↓ phase 1 enzymatic reactions = ↓ hepatic metabolism and ↑ drug accumulation * ↓ Renal Elimination = ↑ Drug accumulation

Answer 9

- ↑ permeability of blood brain barrier = ↑ risk of CNS ADRs - ↓ receptors and neurotransmitters = ↑ susceptibility of ADRs

Answer 10

anticholinergic medications - allergy medications - anti-nauseants - antidepressants - antipsychotics - incontinence medications - sleeping pills - muscle relaxants - cough and cold medications

Answer 11

- eyes: blurred vision, dry eyes - mouth: dry mouth - bowel: constipation - skin: skin-flushing, unable to sweat, overheating - bladder: urine retention (unable to empty bladder) - heart: rapid heart rate - brain: drowsiness, dizziness, confusion, hallucinations

Answer 12

- mental status changes - orthostatic hypotension - gastrointestinal/genitourinary disturbances

Answer 13

broadly defined as the use of multiple medications

Answer 14

traditionally defined numerically: - polypharmacy: ≥ 5 medications - hyper-polypharmacy: ≥ 10 medications may also be categorized based on chronicity of use or appropriateness of therapy

Answer 15

taking at least 5 or more prescription medications concurrently

Answer 16

↑ risk of: - mortality - emergency department visits and hospitalizations - adverse drug events - drug interactions - cognitive and functional impairment - falls - frailty - admission to long term care facility - medication non-adherence - prescribing cascades ↓ quality of life

Answer 17

- older age - ale - ↑ number comorbidities - ↑ number of pharmacies - ↑ number of prescribers - mental health conditions - residing in long-term care facility

Answer 18

- lack of primary care physician - poor medical record keeping - poor transitions of care - prescribing to meet disease-specific quality metrics - use of automated refill systems

Answer 19

- adverse effect from one medication is misinterpreted as a new condition, and a new treatment (drug or medical device) is used to treat the adverse effect - adverse effect from a drug is anticipated and a new drug prophylactically prescribed

Answer 20

- is one of the patient’s current medications causing the signs/symptoms that new medication is being prescribed to treat - is the medication causing the reaction necessary, can it be stopped or substituted for something else - what are the risks and benefits of continuing the medication that led to the cascade

Answer 21

- mis-prescribing - over-prescribing - under-prescribing

Answer 22

use of medication where there is increased risk of adverse drug events

Answer 23

use of medication when no clear indication exists

Answer 24

lack of prescription of indicated, potentially useful medications

Answer 25

medications that should generally be avoided in older persons - ineffective - pose unnecessarily high risk while safer alternatives are available

Answer 26

- falls - cognitive impairment - adverse drug events - hospitalizations - emergency department visits - ↑ prescription costs - ↑ health care costs

Answer 27

- older age - female - polypharmacy - ↑ number of prescribers - ↑ number of comorbidities - mental health conditions

Answer 28

- minimize adverse effects - improve medication selection - educate health care practitioners - help evaluate quality of medication use

Answer 29

all individuals 65 years and older in ambulatory, acute, or long-term care - not applicable in hospice or palliative care

Answer 30

medications that: - should generally be avoided in most older people - avoided in older people with specific health conditions - avoided in combination with other treatments (high interaction risk) - should be used with caution - should be dosed differently or avoided in older people with renal dysfunction - are highly anticholinergic

Answer 31

- medications are POTENTIALLY inappropriate, not definitely inappropriate - always read the rationale and recommendations to determine if it is applicable to your patient - optimal care involves not only identifying PIMs, but also offering safer alternatives - remember that it is an American resources and there are differences in drug availability between the US and Canada

Answer 32

dual set of criteria outlining: - Screening Tool of Older Person’s Prescriptions (STOPP) criteria: potentially inappropriate medications - Screening Tool to Alert doctors to Right Treatment (START) criteria: commonly encountered errors of omission

Answer 33

systems-based approach (cardiovascular, central nervous system, gastrointestinal system)

Answer 34

stopping medications or adjusting dosages down to the minimum effective dosage

Answer 35

- improving patient outcomes - minimizing polypharmacy

Answer 36

- medications are unnecessary - medications are causing adverse effects/putting patient at risk of adverse effects - shortened life expectancy - increased frailty - treatments no longer align with patient goals and preferences

Answer 37

1. identify medication to deprescribe (often start with 1 at a time) 2. engage patient and prescriber in deprescribing 3. identify if medication can be stopped abruptly 4. create a tapering schedule (if needed) - if a taper algorithm is not available – consider the pharmacokinetics, pharmacodynamics, patient stability and monitoring to create your own plan 5. support patients through medication discontinuation 6. monitor for discontinuation symptoms or need to restart medications 7. document outcomes

Answer 38

- favourable perception of medication - fear of medication discontinuation - discouragement from healthcare professionals - complexity of healthcare system

Answer 39

- clear benefits of deprescribing - safety concerns - deprescribing education - follow up - relationship with prescriber - deprescribing strategies – ‘trial’ of deprescribing, tapering, one medication at a time

Answer 40

- independent living - assisted living - nursing home/residential care facility

Answer 41

living in their own home, primarily independent - may receive informal care from family/friends, or formal care from homecare services

Answer 42

living in a facility that provides some supports (meals, cleaning, managing medications), but clients are mostly independent

Answer 43

living in a facility that provides 24H nursing care, clients are mostly dependent for their personal care

Answer 44

- bathing - grooming - dressing - toileting - feeding

Answer 45

- cooking - cleaning - taking medications - laundry - shopping - finances - transportation

Answer 46

decline in multiple systems, resulting in increased vulnerability to stressors and increased functional impairment/loss of functional reserves - multifactorial, including changes in physical, psychological and/or social health - chronic, progressive, dynamic spectrum – can be delayed or in some patients improved

Answer 47

- reduced muscle mass and strength - reduced energy and exercise tolerance - cognitive impairment

Answer 48

increased risk for: - hospitalization - loss of activities of daily living - premature mortality - physical limitation - falls and fractures

Answer 49

sociodemographic: - advanced age - female - low educational achievement - low socioeconomic status - living alone/social isolation lifestyle: - physical inactivity - poor nutrition/low protein intake - smoking - increased alcohol intake clinical: - multi-morbidity - polypharmacy - cognitive decline - functional decline - muscle weakness - reduced gait speed - weight loss - depression - geriatric syndromes

Answer 50

- activity - vaccination - optimize medications - interact - diet and nutrition

Answer 51

conditions occurring predominantly in the elderly

Answer 52

multifactorial - multiple organ systems - age-related risk factors - situation specific stressors

Answer 53

- ↑ frailty - ↓ quality of life - significant disability - ↓ independence +/- institutionalization

Answer 54

in both older and younger individuals

Answer 55

mobility, mind, medications, multicomplexity, matters most - framework to identify areas of care for all older adults - provides broader context than focusing only on individual health conditions - promotes alignment of care with patient’s health and life goals

Answer 56

sudden and unintentional change in position resulting in an individual landing at a lower level such as on an object, the floor, or the ground, with or without injury

Answer 57

look for drugs that cause: - dizziness, sedation, confusion, gait abnormalities, weakness - hypotension, bradycardia - orthostatic hypotension - hypoglycemia - bowel/bladder urgency or incontinence

Answer 58

mental processes of thinking, attention, language, learning, memory and perception - certain declines in cognition are expected

Answer 59

occurs when changes in cognition impact daily functioning (ADL’s and iADLs) - Alzheimer’s disease is the most common type of dementia - many patients with dementia are community-dwelling - dementia diagnosis does not automatically indicate treatment de-escalation

Answer 60

- patient is a 'poor historian' – having trouble remembering or answering questions - provides vague answers - unable to answer questions on own/often deferring to family member/caregiver - not filling medications on schedule - mixing up appointment times - difficulty following instructions - getting lost - decreased self-care (more disheveled or decreased hygiene than previous) - unexplained weight los

Answer 61

drugs that cause dizziness, sedation, confusion, cognitive impairment, impaired judgement, delirium, depression

Answer 62

- keeping track of medications - taking medications at the right time - missing doses of medications

Answer 63

- identify potentially inappropriate medications/prescribing, prescribing cascades and adverse effects - deprescribe - modify complex regimens to improve adherence - check dexterity (ability to open vials, use inhalers, inject medications, etc) and ability to swallow medications - ensure medications are meeting client-specific goals - look for drugs that are worsening other geriatric syndromes/5M’s

Answer 64

- consider the impacts of physiologic changes of aging on medical conditions and medications - avoid thinking about a medication/medical condition in isolation - be aware that some medical conditions present atypically in older adults - thoroughly assess and manage geriatric syndromes and frailty - considering modifying targets (i.e. BP, A1c) depending on life expectancy and time-to-benefit - individualize recommendations

Answer 65

due to age-related physiological changes, multiple comorbidities and unrecognized/reported symptoms, older adults with common medical conditions may present atypically

Answer 66

- what’s most important with your health - what are your healthcare goals - what concerns do you have about your health - what are the most important parts of your day - how do medications help/hinder

Answer 67

extent to which a person’s behaviour agrees with the medication regimen from a health care provide

Answer 68

- ↓ therapeutic benefits - ↑ adverse effects - ↑ hospitalizations - over-treatment of medical conditions - ↑ health care utilization and cost

Answer 69

- treatment understanding, knowledge and beliefs - lack of support and interpersonal relationships - older age - lower education level - poor physical, cognitive or mental health

Answer 70

- drug regimen - drug formulation and packaging issues - lack of immediate consequences of missed doses - cost/coverage - adverse drug reactions

Answer 71

- poor communication - lack of confidence in health care providers - lack of patient involvement in decision making

Answer 72

- multi-modal, individualized education - patient empowerment in management of their medical conditions - individualizing medication regimens - active participation in decision making - offer patients choices in treatment - consider economic barriers - building trusting relationships - inquire about non-adherence - adherence devices – pill boxes/dosettes, blisterpacking - administration of medication by family/caregiver or home care/care aide - automatic pill dispensers

Answer 73

- hearing impairment - visual impairment - speech impairment - cognitive impairment - technological barriers

Answer 74

- eliminate background noise/distractions - speak loudly and clearly, check for volume and tone - allow face and mouth to be visible if lip-reading - portable amplifier systems

Answer 75

- explain what you are doing - ask what might help (increasing light, reading document, etc) - write instructions in large font with dark marker

Answer 76

- allow more time for response - eliminate background noises/distractions - allow them to write down answers - open ended vs. close ended questions

Answer 77

- introduce yourself and your role each time - use short simple sentences or questions - redirection - maintain calm demeanor - open ended vs. close ended questions

Answer 78

- allow extra time - minimize distractions - sit face to face - make eye contact - listen without interrupting - check to ensure your volume, tone and enunciation is clear - avoid medical jargon - stick to one topic at a time - simplify and write down instructions (check font size) - frequently summarize most important points - check for understanding - give opportunities to ask questions - ensure comfortable, accessible seating - be prepared to assist patient to sit/stand - be prepared to escort patients

Answer 79

- make sure to have the person's attention before speaking - keep voice at normal level unless the person indicates otherwise - reduce communication complexity but be adult – simplify sentence structure and reduce rate of speech, don't talk down - minimize background noise - give them time to speak – resist urge to finish sentences or offer words - confirm that you are communicating successfully by using 'yes' and 'no' questions – use facial expressions and/or pictures

Answer 80

stereotyping, prejudice and discrimination against people on the basis of age

Answer 81

- negative attitudes and opinions of elderly by health care providers - different treatments and diagnostics offered based on age - ↓involvement in patient in clinical decision making - less respectful, use of demeaning or patronizing tone

Answer 82

- ↓ access to medical care - limited financial resources to pay for medical care/medications - ↓ participation in clinical trials - inadequate health care professional training

Answer 83

ie. beliefs that pain and suffering are normal parts of aging

Answer 84

- enhances intergenerational conflict - creates negative stereotypes of aging - impacts availability and quality of services for elderly

Answer 85

- self-reported fair or poor health status and deterioration in self-reported health status over time - more likely to have chronic health conditions: coronary heart disease, chronic lung disease, arthritis, life-limiting illness - more likely to have depressive symptoms

Answer 86

- multiple comorbidities and polypharmacy - communication issues - difficulty obtaining consent - physical mobility and transportation challenges - adherence concerns - ageism - lack of policy requirements for data in older adults

Answer 87

- generalizability of clinical findings to older adults or those with frailty - data on pharmacokinetics in older adults - safety data in older adults - medication dosing in older adults - data on drug interactions - clinical practice guidelines less likely to have guidance specific to older adults

Answer 88

- older adults are more prone to negative healthcare outcomes due to physiological changes, polypharmacy and multi-morbidity - pharmacists should consider the geriatric 5M’s when caring for older adults - many older adults have complex drug regimens, leading to adverse drug reactions and adherence issues - pharmacists must recognize the clinical signs and symptoms of adverse events and prescribing cascades - pharmacists must know which medications contribute to poor clinical outcomes in older people and avoid these medications, when possible - frequent medication reviews and frequent follow are necessary