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Topics in Geriatrics > week 4 > Flashcards

week 4 Flashcards

1
Q

(4) General physiological changes in elderly

A
  • inc fat
  • dec skeletal muscle
  • dec bone; more in women
  • dec intracellular water
  • extracellular water stays the samw
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2
Q

CV changes (3), diagnosis

A
  • dec cardiac outpt
  • dec function; changes in conduction (arthymias)
  • atherosclerosis
  • inc HTN and TIA/CVA
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3
Q

CNS changes (5)

A
  • dec rate of conduction
  • dec strength of transmission
  • threshold for arousal blurred
  • reduced adaptation to physiologic stressors
  • inc recovery time
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4
Q

respiratory changes (2)

A
  • dec expiration
  • dec function ( dec ventilation & PaO2)
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5
Q

kidney function changes and diagnosis

A
  • nephron degeneration (starts at 35)
  • dec rBF
  • diseases: inadequate fluid intake, fluid loss, shock, cardiac failure, sepsis
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6
Q

consequence of dec kidney function

A
  • dec clearance leads to supra therapeutic levels @ norm doses of renally eliminated drugs
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7
Q

gynecologic changes in older woman and diagnosis

A
  • abrupt estrogen deprivation
  • atrophy
  • dec secretions
  • lead to diagnosis of urinary incontinence, dyspareunia, s/s menopause
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8
Q

reproductive changes in older men and diagnosis

A
  • gradual dec testosterone
  • dec libido, muscle mass, body hair
  • diagnosis: DM, CVD, metabolic syndrome, BPH, ED
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9
Q

gastrointestinal changes

A
  • dec stomach acid
  • malnutrition state
  • dec liver metabolism ( dec size, BF, cyp450 enzyme)
  • dec motility
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10
Q

skeletal changes

A
  • atrophy, erosion, dec o2
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11
Q

skin and derm changes

A

dec elasticity
dec turgor
inc pigmentation

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12
Q

sensory changes

A
  • dec vision
  • dec hearing
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13
Q

homeostenosis

A

diminished homeostatic reserve capacity of all organ systems

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14
Q

geriatric syndrome

A

polypharmacy and iatrogenesis

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15
Q

5 indicators of frailty

A

weight loss
self- reported exhaustion
low energy expenditure
slow galt
weak grip strength

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16
Q

absorption changes in elderly

A

delayed stomach emptying time
dec rate of absorption
less stomach acid production

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17
Q

bioavailability changes in elderly and effect on prodrugs

A

reduced 1st pass effect = inc bioavailability for some drugs but dec bioavailability of prodrugs
no change to oral absorption or bowel metabolism. examples clopidogrel, quinapril

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18
Q

transdermal changes

A

drier and fatter= less prefusion
-less absorption of hydrophilic compounds
- dec absorption and overall drug conct of fentanyl NOT A GOOD OPTION.

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19
Q

Distribution changes in elderly

A
  • dec lean mass- leads to dec vd of skeletal muscle distribution, leads to inc digoxin conct
  • inc fat, leads to inc vd of lipophilic drugs, longer 1/2 life - benzos
  • dec water- leads to dec vd, inc conct of hydrophilic drugs- aminoglycosides
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20
Q

Albumen changes

A

dec in older pts with underlying, sever or chronic illness
- major binding protein, a dec leads to inc of unbound fraction = inc drug effects ex. sertraline

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21
Q

AAG changes

A

elevated in acute illness, CA, infection, inflammation
- no change with age
- high affinity for basic drugs
- dec unbound concts
- TCAs, lidocaine

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22
Q

CYP3A4 activity

A

reduced

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23
Q

phase 1 activity in elderly

A

reduced hydroxylation and demethylation

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24
Q

phase 2 activity in elderly

A

glucuronidation reduced in >80 yo

25
Q

high clearance and low clearance drugs

A

high- fentanyl, labetalol
low/mod=- NSAIDS, CCBs, Benzos

26
Q

causes for dec metabolism in elderly

A

frailty
dec phase 1
dec cardiac output due to HF

27
Q

CNS effects

A

pgp activity dec leads to inc CNS drug cont and inc time in CNS

28
Q

anticoag changes

A

dec doses of warfarin needed for response due to
- dec clearance
- inc sensitivity

29
Q

what is prescribing/iatrogenic cascade

A

using meds to treat a side effect of another med

30
Q

beers table 2

A

Antihistamine
Anti-infective (nitrofurantoin)
CV (Aspirin, warfarin, rivaroxaban , doxazosin, clonidine, amiodarone, digoxin)
Antidepressants
Antipsychs
Benzos and z-drugs
Barbiturates
testosterone
estrogen
insulin sliding scale
Sulfonylareas
Growth hormone
PPIs
Metoclopramide
Antispasmodics (atropine)
non cox2 selective NSAIDs (diclofenac, IBU, naproxen, indomethacin)
Smooth muscle relaxants

31
Q

safety issues caused by anticholinergics and drugs in this class

A
  • significant SEs, impair ADL
  • ex. Muscle relaxants (cyclobenzaprine, methocarbamol), TCAs, Antispasmodics (dicyclomine), antihistamines (diphenhydramine), Urinary incontinence ( Oxybutynin)
  • Higher cumulative anticholinergic use is associated with an increased risk for dementia
    Atropine good
32
Q

safety issues caused by benzodiazepines

A
  • risk of cognitive impairment, delirium, falls/fractures, motor vehicle crashes
  • inc risk of falls w/in 2 weeks of initiation and more after 1 month of continuous use with doses 3mg and up
  • same risk between short and long acting
33
Q

safety issues caused by antidepressants

A
  • falls and anticholinergic ADR
  • inc risk of fall with inc dose - SSRI
34
Q

safety issues caused by NSAIDs

A
  • gi toxicity (ulcers and mortality due to PUD), cv risks, renal considerations
  • worst: piroxicam>indomethacin> naproxen>slindac
    best ibuprofen
  • dose dep
  • cv risk highest during 1st month and with higher doses ; has FDA warning
  • avoid in HF pts
  • do not use w/ diuretics due to inc risk of hospitalization in CHF pts
35
Q

NSAID induced injury prevention and what to do in high risk pts

A
  • misoprostol 800 mcd/day (less effective)
  • h2ra (double dose effective)
  • ppi (standard dose)
  • high risk = cox2 alone or Nsaid+PPI ; cox 2 + ppi
36
Q

what are the steps to the process of deprescribing

A
  • comprehensive medication hx
  • identify potentially inappropriate med
  • determine eligibility for deprescribing and prioritize
  • plan and initiate w/drawal
  • monitor, support and document
37
Q

drug factors associated with potential drug induced harm

A
  • number of meds prescribed
  • use of potentially inappropriate or high risk meds
  • past or current toxicity
38
Q

patient factors associated with potential drug induced harm

A
  • age >80 yo
  • cognitive impairment
  • multiple comorbidities
  • multiple prescribers
39
Q

how to prioritize deprescribing

A
  • 1st: meds with likelihood of greatest harm and least benefit
  • 2nd: easiest to discontinue (no w/drawal or rebound)
  • 3rd: patient most willing to discontinue first
40
Q

time to benefit vs time to harm

A
  • benefit is reported in years, harm is reported in minutes
    *consider life expectancy w/ Time to benefit
41
Q

time to benefit of bisphosphonates for osteoporosis

A

8-19 months

42
Q

time to benefit of statins for primary benefit

A

2-5 yrs

43
Q

time to benefit for primary prevention for hypertension

A

1-2 years

44
Q

time to benefit of aspirin for primary prevention

A

10 years

45
Q

time to benefit of intensive glycemic control in DM

A

10 years

46
Q

deprescibing benzos algorithm

A
  • slow taper: 25% every 2 weeks, 12.5% reduction near the end, possible drug-free days
  • monitor every 1-2 weeks for duration of tapering
  • use non drug approaches to manage w/drawal insomnia symptoms
  • if symptoms relapse continue dose for 1-2 weeks then continue taper at slow rate
47
Q

who should you continue benzos

A
  • sleeping disorders
  • unmanaged anxiety, depression, physical or mental condition
  • alcohol w/drawal
48
Q

who should be deprescibed benzos

A
  • 65 and up taking BZRA regardless of duration
  • 18-64 taking benzos for over 4 weeks
49
Q

marker of fall

A

hip fracture

50
Q

intrinsic risk factors for falls

A
  • age related: muscle weakness
  • comorbidities: impaired balance/mobility, arthritis, stroke, HTN, Heart disease and dementia
51
Q

extrinsic risk factors

A
  • medication use
  • poor foot care
  • unsafe footwear
  • impaired vision
  • hearing problems
  • an unsafe environment
52
Q

trends in fall related mortality and fall risk increasing drugs

A

are directly proportional

53
Q

cardio drugs that cause falls

A

loop diuretics

54
Q

FRIDS

A
  • any psychotropic
  • antidepressants (TCA & SSRI)
  • benzos
  • antipsychotics
  • sedative/hypnotics
  • tranquilizers
  • smooth muscle relaxants (carisoprodol, cyclobenzaprine, methocarbamol)
55
Q

Benzos risk for falls

A
  • doses 3 and more/ day inc risk of hip fracture by 50%
  • inc risk with longer duration of time
56
Q

possible/small/no frids drugs

A

statins, ppis, antihypertensive, diuetics, b-blockers, opioids, nsaids

57
Q

best model for fall reduction

A

multi-factorial, then individualized interventions, then follow up in 30-90 days

58
Q

STEADI and fall risk aspects

A
  • for providers
  • measure orthostatic pressure, visual activity, assess feet/footwear, assess vit d intake, comorbidies (depression, osteoporosis) , home hazards
59
Q

What is considered a high risk score on AHRQ

A

6 or more

Topics in Geriatrics (4 decks)

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