Drug Use In The Elderly Flashcards
Elderly patients are:
> 65 years old
What are some physiological functions that decrease with age?
1) Maximal breathing capacity
2) Cardiac index
3) Glomerular filtration
When the volume of distribution increases, the plasma concentration ___(increases/decreases).
Decreases
The volume distribution of lipid soluble drugs will ___(increase/decrease) in the elderly. Why?
Increase, due to higher body fat
Clinical manifestations of normal aging include:
1) Changes in biochemical makeup of tissues
2) Reduced functional capacity of body systems
3) Reduced ability to adapt to physiological stress
4) Increased vulnerability to disease
5) Frailty (weakness, fatigue, weight loss and functional decline)
What are some examples of impaired homeostatic functions in the elderly?
1) Postural or gait instability
2) Orthostatic blood pressure responses
3) Thermoregulation impairment
4) Reduction of cognitive reserve
5) Bowel or bladder dysfunction
The bioavailability of drugs absorbed ___(actively/passively) may not be significantly affected.
Passively
The bioavailability of drugs absorbed ___(actively/passively) may have impaired absorption.
Actively
Which drugs are absorbed actively?
1) Iron
2) B12
3) Magnesium
4) Calcium
In the elderly, the first pass effect is:
Decreased
A decrease in the first pass effect results in a(n) ___(increase/decrease) of the bioavailability of some drugs.
Increase
A decrease in the first pass effect results in an ___(increase/decrease) of the plasma concentration of some drugs.
Increase
A decrease in the first pass effect results in an ___(increase/decrease) of the bioavailability of some pro-drugs.
Decrease
Which drugs are affected by a decrease of the first pass effect?
1) Propranolol
2) Labetelol
Which pro-drugs are affected by a decrease of the first pass effect?
1) Enalapril
2) Codeine
Which drugs need an acidic environment in order to be absorbed?
1) Iron
2) Digoxin
3) Conazoles
What might reduce the acidic pH of the stomach in the elderly?
1) Atrophic gastritis
2) Gastric acid lowering drugs
What are the factors that influence drug distribution in the elderly?
1) Altered plasma protein concentrations
2) Individual body composition (body fat and intracellular fluid content)
3) Decreased muscle and tissue mass
4) Reduced blood flow to tissues and organs
5) Active uptake into tissues
What are some examples of water soluble drugs?
1) Ethanol
2) Gentamycin
What are some examples of lipophilic drugs?
1) Metronidazole
2) Benzodiazepines
3) Rifampin
Changes in the volume of distribution affect ____ of drugs.
Loading doses
The brain of elderly patients may be exposed to ___(lower/higher) concentrations of drugs and toxins. Why?
Higher; Because of age-related changes in the blood-brain-barrier.
Hepatic metabolism of drugs depends on:
1) Liver perfusion
2) Activity and capacity of drug metabolizing enzymes
3) Protein binding
Drugs that have a high intrinsic clearance have:
High hepatic extraction ratios
Hepatic clearance depends on:
Hepatic blood flow (flow-limited metabolism).
If hepatic blood flow decreases, the metabolism of high extraction ratio drugs ___(increases/decreases).
Decreases
What are some high extraction ratio drugs?
1) Propranolol
2) Amitriptyline
3) Diltiazem
4) Lidocaine
5) Metoprolol
6) Morphine
7) Verapamil
Serum ___ is a poor indicator of renal function in the elderly. Why?
Creatinine; Creatinine is produced by muscles and there is reduced muscle mass in the elderly.
Which equation may be used to calculate creatinine clearance?
Cockcroft and Gault
What should you multiply the Cockcroft and Gault equation with for females?
0.85
Accurate measurement of _____ is required for dose adjustment in patients with reduced renal function.
Creatinine clearance
Dosing guidelines of drugs that are eliminated by the kidney are based on ____.
Creatinine clearance
Which drugs should be avoided when Creatinine Clearance (CLcr) < 30 mL/min?
1) Colchicine
2) Co-trimoxazole
3) Glyburide
4) Nitrofurantoin
5) Probenecid
6) Spironolactone
7) Triamterene
Which drugs need dose reduction in reduced renal function?
1) Acyclovir
2) Amantadine
3) Ciprofloxacin
4) Gabapentin
5) Ranitidine
Changes leading to altered
pharmacodynamics of drugs may include:
1) Changes in drug concentration at the receptor
2) Changes in receptor numbers
3) Changes in receptor affinity
4) Post-receptor changes
5) Age-related changes in homeostatic mechanisms
Why are older adults more sensitive to the CNS effects of drugs?
1) Changes in size and weight of brain
2) Changes in the neurotransmitter systems
3) Drugs penetrate CNS easier than in young adults
Why do the elderly show increased sensitivity to the adverse effects of antipsychotic drugs?
1) Decreased levels of dopamine transporters
2) Decreased number of dopaminergic neurons
3) Decreased density of dopamine receptors
Which drugs show increased sensitivity in the elderly?
1) Benzodiazepines
2) Opioids
3) General anesthetics
4) Antipsychotics
5) Lithium
6) Anticholinergics
The elderly are more likely to develop ___ as an adverse effect of some antihypertensive drugs.
Orthostatic hypotension
The elderly are more likely to develop ___ as an adverse effect of some calcium channel blockers.
Increased hypotensive and bradycardic effect
The elderly are more likely to develop ___ as an adverse effect of some β-blockers.
Reduced blood pressure response
The elderly are more likely to develop ___ as an adverse effect of some diuretics.
Reduced effectiveness
The elderly are more likely to develop ___ as an adverse effect of Warfarin.
Increased risk of bleeding
State 3 important, potentially preventable, negative outcomes of drugs in the elderly.
1) Withdrawal effects
2) Therapeutic failure
3) Adverse drug reactions
What are the risk factors of drug-related problems in the elderly?
1) Polypharmacy
2) Inappropriate Prescribing
3) Underuse
4) Medication non-adherence
Polypharmacy has been strongly associated with:
1) Adverse drug reactions
2) Risk of geriatric syndromes (falls, cognitive impairment)
3) Non-adherence
4) Diminished functional status
5) Increased health care costs
Polypharmacy includes:
1) Prescription drugs
2) Nonprescription drugs
3) Herbal medicines
4) Supplements
5) Unnecessary drugs
Inappropriate prescribing includes:
1) Wrong dose and duration
2) Duplication
3) Drug interaction problem
4) Prescription of drugs that should be avoided in the elderly
What is underuse?
Removal/omission of drug therapy that is indicated in prevention or treatment of disease.
Causes of medication non-adherence?
1) Adverse effects
2) Complex regimens
3) Misunderstanding of information about prescribed medications
4) Cost
5) Dysmobility (arthritis, etc.)
6) Social factors (living alone)
7) Dementia
A drug may be considered unnecessary if:
1) It does NOT have indication per the problem list.
2) Is NOT effective.
3) The risk outweighs the benefits.
4) There is therapeutic duplication.
How do you assess and monitor drug therapy in the elderly?
1) Compare the patient’s problem list with drug
list.
2) Determine if the patient has a chronic condition but is NOT receiving an evidence based medication to improve outcome.
3) Monitor effectiveness and toxicity of drugs by clinical assessment and lab tests.
4) Documenting problems and formulating a therapeutic Plan
5) Implement a team-based management approach and develop strategies to avoid prescribing errors.
6) Take measures to enhance adherence to medications
7) Assess the presence of drug-disease interaction
What lab test should be done with Amiodarone?
Hepatic function tests
What lab test should be done with Antiepileptics?
Drug level
What lab test should be done with ACEi & ARBs?
Serum K+ level
What should we look for when using antipsychotics?
Extrapyramidal adverse drug reactions
What lab test should be done with diuretics?
Serum K+ level
What lab test should be done for hypoglycemics?
1) Glucose
2) Glycated Hb
What lab test should be done with Lithium?
Drug level
What lab test should be done with Warfarin?
PT or INR
What should you take into account when documenting problems and formulating a
therapeutic plan for the elderly?
1) Remaining life expectancy
2) Time until therapeutic benefit
3) Treatment target
4) Medication regimen complexity
5) Goals of care
What measures could you take to enhance adherence to
medications?
1) Modify medication schedule to fit patient’s lifestyle
2) Prescribe generic agents to reduce cost
3) Offer easy-to-open bottles
4) Offer easy-to-swallow dosage forms
5) Provide both written and oral drug information
6) Involve caregivers stressing the importance of adherence
What are some side effects or diseases caused by anticholinergics?
1) Benign prostatic hyperplasia
2) Dementia or cognitive impairment
What are some side effects or diseases caused by antipsychotics?
1) History of falls
2) Parkinson’s disease
What are some side effects or diseases caused by aspirin?
Peptic ulcer disease
What are some side effects or diseases caused by Calcium channel blockers?
Heart failure
What are some side effects or diseases caused by Metoclopramide?
Parkinson’s disease
What are some side effects or diseases caused by NSAIDs?
1) Peptic ulcer disease
2) Heart failure
3) Renal failure
Why shouldn’t you give Anticholinergics with other drugs with anticholinergic activity such as antihistamines?
Elimination reduced in older adults
What are the risks of using Anticholinergics with other drugs with anticholinergic activity such as antihistamines?
1) Confusion
2) Dry mouth
3) Constipation
4) Urine retention
Which drugs are potentially inappropriate for elderly?
1) Anticholinergics + H1 blockers
2) Nitrofurantoin
3) Peripheral and central α-blockers
4) Immediate-release nifedipine
5) Amiodarone
6) Antidepressants
7) Antipsychotics
8) Barbiturates & benzodiazepines
9) Long-acting sulfonylureas
10) Metoclopramide
11) Proton pump inhibitors
12) Meperidine (Pethidine)
13) NSAIDs
14) Central muscle relaxants
Why shouldn’t you give Nitrofurantoin to the elderly?
1) Pulmonary toxicity
2) Hepatotoxicity
3) Peripheral neuropathy
Why shouldn’t you give peripheral and central α-blockers to the elderly?
1) High risk of adverse effects
2) Orthostatic hypotension
3) CNS adverse effects
Why shouldn’t you give immediate-release nifedipine to the elderly?
1) Hypotension
2) Myocardial ischemia
Why shouldn’t you give Amiodarone to the elderly?
High risk of many adverse effects
Why shouldn’t you give antidepressants to the elderly?
1) Highly anticholinergic
2) Sedating
3) Orthostatic hypotension
4) Myocardial ischemia
Why shouldn’t you give antipsychotics to the elderly?
1) Increased risk of CVA
2) Cognitive decline
3) Dementia
4) Mortality
Why shouldn’t you give barbiturates & benzodiazepines to the elderly?
1) High rate of dependence
2) Tolerance
3) Sedation
4) Cognitive impairment
5) Delirium
6) Falls
7) Fractures
What is the insulin sliding scale?
The progressive increase in the pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges
Why shouldn’t you use the insulin sliding scale in the elderly?
Increased risk of hypoglycemia
Why shouldn’t you use the long-acting sulfonylureas in the elderly?
Increased risk of hypoglycemia
Why shouldn’t you use Metoclopramide in the elderly?
Increased risk of extrapyramidal adverse effects, dyskinesia
Why shouldn’t you use the proton pump inhibitors in the elderly?
Risk of Clostridium difficile infection
Why shouldn’t you use Meperidine (pethidine) in the elderly?
High risk of neurotoxicity, including delirium
Why shouldn’t you use the NSAIDS in the elderly?
1) Peptic ulcer disease
2) Cardiovascular disease
3) Renal failure
What are some central muscle relaxants?
1) Chlorzoxazone
2) Cyclobenzaprine
3) Orphenadrine
Why shouldn’t you use central muscle relaxants in the elderly?
1) Poorly tolerated because of anticholinergic effects
2) Sedation
3) Increased risk of falls and fractures
