Drugs and polypharmacy

Question 1

4th leading cause of death

Answer 1

ADRI’S

Question 2

Common iatrogenic drug problems (4)

Answer 2

Confusion, dry mouth, constipation, blurred vision, urinary retention

Question 3

What can anticholinergics cause?

Answer 3

orthostatic hypotension

Question 4

confusion and an unsteady gate can be caused by?

Answer 4

tricyclics and narcotics

Question 5

you can have digoxin toxicity with?

Answer 5

normal serum concentrations

Question 6

CNS toxicity can be caused by?

Answer 6

benzodiazepines

Question 7

Costly medication-related problems/ADRs in older patients?

Answer 7

• Falls
• Cognitive Loss /delirium
• Dehydration
• Incontinence
• Depression

Question 8

End result of ARDI’s (3)

Answer 8

Loss of functional capacity
Poor quality of life
Nursing home placement

Question 9

why do elders tend to have more prescriptions (some examples)

Answer 9

• More acute & chronic disease
• More doctors visits
• Drugs often given to counteract a side effect of another drug
• Several other factors arising from prescribers, patients and the system

Question 10

Adverse drug reactions look like “growing old” - wha side effects to ADRs can often be dismissed ?

Answer 10

Unsteadiness
Dizziness
Confusion
Nervousness
Fatigue
Insomnia
Drowsiness
Falls
Depression
Incontinence

Question 11

Prescribing Cascade

Answer 11

Drug 1
- ADE interpreted as new medical condition

Drug 2
- ADE interpreted as new medical condition

Drug 3

Question 12

how may an elder present with Hyperthyroidism

Answer 12

• Depression
• Cognitive impairment
• Muscle weakness
• Atrial fibrillation
• Heart failure
• Angina

Question 13

how may a younger patient present with Hyperthyroidism? (4)

Answer 13

Tremor
Anxiety
Weight loss
Diarrhoea

Question 14

Healthcare provider factors thatcontribute to polypharmacy? think of some examples

Answer 14

• Presumes that patient expects meds
• Prescribes without sufficiently investigating clinical situation
• No med review with patient on regular basis

-

Question 15

absorption is not affected by?

it is affected by? why is this

Answer 15

age

• rate of absorption is increased with age
• GI transit time slows

Question 16

a reduction in saliva production may result in?

Answer 16

a reduction in the rate of absorption of buccally administered drugs e.g. glyceryl trinitrate (GTN)

Question 17

distribution - what changes in the body as you get older (4)

Answer 17

• Reduced muscle mass
• Increased adipose tissue
• protein binding changes
• Increased permeability across the blood-brain barrier

Question 18

distribution - fat soluble drugs

Answer 18

↑ Vd, ↑ T1/2, ↑ duration of action e.g. diazepam

Question 19

distribution - water soluble drug?

Answer 19

↓Vd, ↑ serum levels e.g. digoxin, furosemide

Question 20

distribution -protein binding changes

Answer 20

Decreased albumin

↓ binding, ↑ serum levels acidic drugs e.g. furosemide

Question 21

what is hepatic metabolism affected by?

Answer 21

• Decreased liver mass

- Decreased liver blood flow

Question 22

consequences of hepatic metabolism

Answer 22

• Toxicity due to reduced metabolism/excretion
• Reduced first pass metabolism
  ↑ in bioavailability with some drugs e.g. propranolol
  Can cause ↓ bioavailability of pro-drugs e.g. enalapril

Question 23

what function decreases with age affecting excretion

Answer 23

Renal function

Question 24

excretion affect with age? - what does it ultimately lead to?

Answer 24

Reduces clearance and increases half-life of many drugs leading to toxicity

Question 25

increased sensitivity to particular medicines - why is this? (3)

Answer 25

change in receptor binding, decrease in receptor number, altered translation of a receptor initiated cellular response into a biochemical reaction.

Question 26

Give examples of drugs that have increased sensitivity (2)

Answer 26

diazepam (↑ sedation), warfarin (↑ anti-coagulation)

Question 27

what criteria/ prescribing tools can we use? (3)

Answer 27

Beers’ criteria List of ‘inappropriate’ drugs for older people Updated occasionally but many weaknesses - START-STOPP criteria (O’Mahony et al) Advice on medical optimisation A lot to remember, so mostly research tool NHS Scotland Polypharmacy Guidance

Question 28

why may you discontinue a drug? (many options)

Answer 28

- Adverse drug reaction - Drug-drug interaction - Drug-disease interaction - Better alternative - Not effective - Not indicated - Not evidence-based - Minimise polypharmacy

Question 29

Some evidence that it is safe and/or beneficial to stop ? (3)

Answer 29

antihypertensives, benzodiazepines, antipsychotics

Question 30

worst drugs for polypharmacy?

Answer 30

1. NSAIDs 2. Diuretics         3. Warfarin   4. ACEI 5. Antidepressants 6. Beta blockers                7. opiates 8. Digoxin 9. Prednisolone 10. Clopidogrel    

Question 31

most adverse events in polypharmacy is in what 2 drug groups?

Answer 31

Anticholinergics | Sedatives

Question 32

Common antimuscarinic effects - PERIPHERAL

Answer 32

- DRY EYES - DRY MOUTH - CONSTIPATION - REDUCED PERISTALSIS

Question 33

Common antimuscarinic effects - CENTRAL

Answer 33

- MEM IMPARIMENT - CONFUSION - DISORIENTATION - DELIRIUM - FALLS

Question 34

Sedatives are problematic | - WHY

Answer 34

Increased effects of benzodiazepines | Falls, confusion

Question 35

Anti-psychotics - effects

Answer 35

Increased adverse effects | Postural hypotension, stroke, confusion, movement disorders

Question 36

Analgesia - opioids are more ..?

Answer 36

More sensitive to effects, lower doses needed | Pethidine and tramadol may be less useful

Question 37

NSAIDs - effect (2)

Answer 37

Renal impairment | GI bleeding

Question 38

Digoxin - 2 things

Answer 38

Increased toxicity | Lower doses needed

Question 39

Diuretics - effect?

Answer 39

Decreased peak effect, but reduced clearance Abnormal urea and electrolytes Other issues around continence and mobility Often inappropriate indication (swollen legs)

Question 40

Anti-hypertensives effects? (4)

Answer 40

May have exaggerated effects on BP and HR - postural hypertension - ACEI = prodrugs = not metabolised to active form - Renal adverse effects

Question 41

Anti-coagulants are more sensitive to?

Answer 41

to warfarin | Greater risk from warfarin i.e. GI bleeding, falls

Question 42

side effects of antibiotics?

Answer 42

- Diarrhoea and c. diff infection - Blood dyscrasias (trimethoprim, co-trimoxazole) - Delirium (quinolones) - Seizures - Renal impairment (aminoglycosides)