22: Geriatrics Flashcards
what are the top 10 drug classes used in seniors
HMG-CoA reductase inhibitors > PPIs > dihydropyridine derivatives > ACEi > BB > thyroid hormones > angiotensin 2 antagonists > biguanides > other ADs > SSRIs
3 priority actions in medication safety include
high risk situations (children, elderly)
polypharmacy
transitions in care
list 2 RFs for ADRs
age (esp >85yrs)
comorbidities
caregiving (dependent)
# of meds (esp =>15) and doses/ day (MRCI)
high risk meds
nonadherence (then ↑ issues when forced to adhere in hospital)
recent start of new meds
# of pharmacies used
# of prescribers involved
recent hospitalizations in past year
why is nonadherence an issue when a patient is admitted in hospital
may increase drug levels unknowingly due to mandatory adherence in hospital
MRCI is
medication regimen complexity index: ↑ # = ↑ risk of mistake/ AE
3 main populations at risk of ADRs
people with multiple chronic conditions
women
>65yrs
4 drugs most commonly implicated in ADRs
antibiotics
anticoagulants
antineoplastics
analgesics
NSAIDs
which of the following is false
1. Seniors have the highest mortality rate from toxicologic exposures
2. ⅓ of elderly who experience an ADE never fully recover
3. 30-80% ADE in elderly are preventable
4. seniors are more prone to type D ADRs
4- type C
literal definition of polypharmacy
=>2 meds
most commonly accepted definition of polypharmacy
=>5 meds
what is the clinically meaningful definition of polypharmacy
when a medication is not needed
describe a polypharmacy prescribing cascade
use of one drug to treat the AEs of another
NSAID for arthritis → NSAID causes HPTN → CCB tx HPXN → CCB causes ankle swelling → diuretic to treat swelling → diuretic causes gout → allopurinol to tx gout → falls due to postural hypotension, restricted activity, loss of confidence, indigestion
3 proposed definitions of polypharmacy
The use of 2 or more drugs without_____________ or ________
The use of a drug to treat the _____________
The use of 2 or more drugs from the ___________________
without indication or for the same purpose
AEs of another drug
same class to treat different indications
drug- disease interactions are 2-3x _______ (less/ more) common than drug-drug interactions
more
Risk of interaction with 2 meds
low
risk in intx with 5-7 meds
4x risk
risk of intx with 8-10 meds
8x risk
list 3 pt risk factors for drug interactions in older adults
PK/PD changes
decreased organ system reserve,
nutrition status,
comorbidities,
aged heterogeneity (lifelong habits, environment, genetics),
atypical disease presentation, or
assumption that it is an aging problem,
masks detection of interactions,
communication (ex- not informing providers of meds taken)
what are 4 factor categories that are RFs for drug interactions
pt factors
prescriber factors
HCS factors
regimen factors
use of evidence based medicine and attitudes like agism is an example of _______ factor as a RF for drug interactions
prescriber
the use of a 70kg male patient as the research prototype for drugs is an example of _______ as a RF for drug intx
HCS
what is a PIM?
potentially inappropriate medication
A medication/ class where harm outweighs benefit, and there are safer alternatives available
which of the following is true
1. men care consistently affected more by PIM than women
2. all antipsychotics are PIMs
3. the BEERs criteria is used to identify PIMs in older adults
4. 2+3
4
what are the 7 classes of PIM
BZDs
nonBZD hypnotics
antipsychotics
sulfonylurea oral hypoglycemics
TCAs
1st gen antihistamine
cardiovascular/ diuretic drugs
3 reasons why ADR/ ADE are common but underdetected in elderly
lack of recognition
attitudes/ ageism
atypical presentation
what is physiologic aging
measurement of level of development, health, or deterioration of pt in terms of functional norms for various body systems
physiological aging changes typically start in
5th decade (40-49)
4 things one might see in 5th decade of physiological aging
↓ tissue/ organ function
Functional decline
↑ susceptibility to disease
Δ in behaviour and PK/PD
describe changes in taste with aging
Loss of lingual papillae
↓ of ability to taste
↓ Salivation
Use of dentures
↓ interest in food
↓ taste of salt- may use salt excessively
which of the following is not a change that occurs with aging
1. ↓ of ability to taste
2. ↑ salivation
3. ↓ depth perception
4. ↑ fat
5. ↑ gastric emptying time
2- decreased salivation
those =>85yrs old typically have the following hearing condition
presbycusis
general phys changes with aging include
Body composition: ↑ ___
CV: ↓ _______________
GI: ↓ _____, ↑ __________
Renal: ↓ __________
Hepatic: ↓ _____________
↑ fat
↓ CO, beta sensitivity
↓ H+, ↑ gastric emptying time
↓ GFR, nephrons
↓ size, blood flow
general phys changes with aging include
Nervous: ↓ ___________
Pulmonary: ↓ _______
Endocrine: ↓ ___________
Nervous: ↓ blood flow to CNS
Pulmonary: ↓ cilia
Endocrine: ↓ hormonal secretions
loss of muscle mass starts at ___yrs and accelerates in ___. by the time a person is 90 years old, they have lost ___________ their muscle mass
40s
50s
half
with aging, ___ gastric pH and _____ gastric acid secretion, GI blood flow, gastric SA, and GI motility
increased pH
decreased all else
rate of absorption of drugs will be _______ in elderly
delayed
in the elderly, there is
1. minimal impact of aging on passively absorbed drugs
2. minimal impact of aging on actively absorbed drugs
3. potential for increase in absorption due to delayed gastric emptying
4. 1+3
1
in the elderly, there is typically _____ absorption of topical steroids
higher
lipophilic drugs see ____ in Vd in elderly
increase
T or F: protein changes with aging often impact drug tx
F- rarely impact, are often insignificant
how does CYP content change in elderly
decreases
how does aging affect phase 2 metabolism
not much effect- conversion stays intact
may decrease if pt is frail
in the elderly, drugs metabolized by ___________ are preferred
phase 2
knowing characteristics of metabolism in the elderly, the following adjustments should be made (select all that apply)
1. reduce doses of drugs that are metabolized by conjugation
2 .be aware that acute illness may dramatically affect metabolism
3. doses should be lowered for high and low hepatic extraction ratio drugs
4. drugs that are primarily metabolized by phase 2 metabolism should have a dose adjustment if the pt is frail
5. none of the above
2, 3, 4
_________________ is the single most clinically important change in PK due to aging
↓ renal elimination
the majority of drug dose adjustments in elderly are due to
renal function
due to decreased muscle mass in older adults, __________ is an estimate
CrCL
what is the paradox of exposure
↑ exposure = ↑ sensitivity
Ex- postural control, orthostasis, thermoregulation, visceral muscle function, cognition, anticoagulation, TD, arrhythmias
CNS changes in elderly
neuronal loss, receptor downreg
what is the MOA in postural control changes in the elderly
fewer dopamine (D2) receptors in striatum
what is the MOA in change of movement control with aging
impaired or decreased dopamine synthesizing neurons
orthostasis in elderly is due to
blunting of b response, receptor down regulation, changes in vascular tree and ANS
arrythmias in elderly is due to
cardiac hypersensitivity
coagulation in elderly is due to
poor hepatic production of coagulation factors, dietary intake
what is the MOA in difficulties with thermoregulation in elderly
poor temp regulating mechs like shivering, ↓ metabolic rate, ↓ vasoconstriction, ↓ thirst response, ↓ awareness of temp
list 4 ways to reduce risk of ADE in elderly
BPMH
Med reviews
Time to discuss and SDM
Integration of RPh
Flagging for # of meds, PIMs (use of software)
Rational/ rationing prescribing (preventing polypharmacy, minimizing PIMs, DeRx)
