22: Geriatrics Flashcards by Linda Chen

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

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3 priority actions in medication safety include

high risk situations (children, elderly)
polypharmacy
transitions in care

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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

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why is nonadherence an issue when a patient is admitted in hospital

may increase drug levels unknowingly due to mandatory adherence in hospital

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MRCI is

medication regimen complexity index: ↑ # = ↑ risk of mistake/ AE

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3 main populations at risk of ADRs

people with multiple chronic conditions
women
>65yrs

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4 drugs most commonly implicated in ADRs

antibiotics
anticoagulants
antineoplastics
analgesics
NSAIDs

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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

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literal definition of polypharmacy

=>2 meds

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most commonly accepted definition of polypharmacy

=>5 meds

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what is the clinically meaningful definition of polypharmacy

when a medication is not needed

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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

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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

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drug- disease interactions are 2-3x _______ (less/ more) common than drug-drug interactions

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Risk of interaction with 2 meds

low

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risk in intx with 5-7 meds

4x risk

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risk of intx with 8-10 meds

8x risk

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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)

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what are 4 factor categories that are RFs for drug interactions

pt factors
prescriber factors
HCS factors
regimen factors

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use of evidence based medicine and attitudes like agism is an example of _______ factor as a RF for drug interactions

prescriber

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the use of a 70kg male patient as the research prototype for drugs is an example of _______ as a RF for drug intx

HCS

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what is a PIM?

potentially inappropriate medication

A medication/ class where harm outweighs benefit, and there are safer alternatives available

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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

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

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)