Elderly care Flashcards
What do NICE guidelines recommend for dealing with multimorbidity in elderly?
e.g. 78yo with 5 conditions who smokes minimum 11 drugs (+/- 10) minimum 9 self care/lifestyle activities *8-10 routine primary care appts *4-6 medical *8-30 psychosocial intervention *smoking cessation *pulmonary rehab
= seeing HCP probably every week!
what is polypharmacy and link to elderly?
prescribing >4 drugs.
common due to multiple comorbidities
no drugs strongly associated with age. increase
risk of DDI and ADRs increased
Pharmacokinetic factors: absorption. how is it different in elderly?
Reduced:
- saliva (solid oral formulations)
- GI motility- delayed gastric emptying
- GI and regional blood supply
Increased:
- GI pH
BUT little evidence to change dosage because of this. consider formulations still
what can even minor reductions in first pass metabolism lead to?
= significant increase in drug bioavailability.
explained:
first pass metab = extensive metabolism of lipid soluble drugs (90-95%)
reduced hepatic blood flow = reduced first pass metabolism and greater drug effect.
Give 3 examples of drugs that may accumulate (high bioavailability) as a result of reduced hepatic blood flow
Reduced hepatic blood flow = reduced first-pass metabolism in the liver = increased drug bioavailability. accumulate and can have ADRs.
- Nifedipine
- Nitrates
- Verapamil
PK factors: Distribution.
How is it altered in the elderly and what effect does it have?
elderly have altered distribution of body fat and water
more fat, less water
How does increased proportion of fat in eldely affect distribution of lipid soluble drugs e.g. diazepam?
more fat (14-35%) = higher Vd of lipid soluble drugs = accumulate.
How does decreased proportion of water in elderly affect the distribution of water soluble drugs e.g. digoxin?
Less water = decreased Vd for water soluble drugs = lower doses can be required.
e.g. loading doses of digoxin
PK factors: Distribution
affect of change in plasma protein conc in elderly? example of a drug affected
Reduced plasma protein conc/binding = increase in free drug e.g. phenytoin
= increased risk of toxicity!
PK factors- how is overall hepatic metabolism of many drugs changed with age?
and how does change in clearance affect on action of drugs e.g. morphine
overall hep metabolism of many drugs through CYP450 enzyme system decreases with age.
reduced metabolic clearance (30-40%) = higher levels/ duration of action of drugs extensively metabolised (morphine)
affect of reduced metabolic clearance on pro-drugs
= pro drugs may be less effective, as converted in active form by liver
PK factors: Elimination
how does GFR and renal tubular function change with age and which 4 drugs will need dose adjustment as a result?
both decrease (chronic liver disease- low GFR)
Renally excreted drugs need dose adjustment:
- Digoxin
- Gentamicin
- Lithium salts
- Opiates
higher dose: metab and elimination factors
what 5 physio and pathophysiological aspects are also affected by the ageing process?
- Heart
- Endocrine changes
- Skeletal muscle: atrophy
- Bones and joints: osteoporosis and osteoarthritis
- CNS: vision and hearing.
how is heart function changed with age? (4)
- cardiac architecture, less compliance
- loss of pacemaker cells
- calcification of conduction system
- less response to cetecholamines… Ca channel blockers
what endocrine changes are seen with increased age?
Reduced hormone production, target sensitivity
Oestrogen, testosterone, GH, IGF-1
How are receptors affected? (2)
and affect on drugs?
- changes in receptor sensitivity
- reduced numbers of receptors
= increased sensitivity to several drugs
e.g.
how does reduced baroceptor function lead to increased risk of falls?
reduced baroceptor function = increased hypotension with antihypertensive therapy = fall risk
Effect of decreased dopamine receptors
= increased risk of extra pyramidal side effects (EPSE)
- parkisonism
- rigid limbs
- tremor
what 2 things does the effect of age on drug sensitivity vary with however?
- drugs studied
- response measured
e.g. anticoagulation- elderly = greater response to same plasma conc of warfarin than younger patients. mechanism unknown
7 important drugs/classes in older adult patients
- analgesics (opioids, NSAIDs)
- digoxin
- diuretics
- warfarin and other anticoagulants
- ACEis
- beta blockers
- benzodiazepines
- phenothiazines
- antiparkinsonian drugs
affect of frailty on elderly
organ systems progressively declining = loss of function and physiological reserve, increased vulnerability to disease and death.
the primary users of healthcare resources
how is frailty assessed? i.e. quantified
frailty assessment:
1 –> 7
very fit–> severly frail. completely dependant
Five frailty syndromes (Geriatric Giants). any one of these = suspicion of frailty
- falls e.g collapse, found lying on floor
- immobility e.g. sudden change in mobility
- delirium: acute confusion
- incontinence- change/ new onset
- susceptible to side effects of meds e..g confusion w codeine, hypotension with antidepressants
4 ways to minimise risk of falls- major cause of disability and mortality in elderly
- identify drugs causing falls
- review meds-polypharmacy
- nutrition: Ca, Vit D to reduce risks of osteoporosis
- multidisciplinary falls service
what is the mechanism leading to fall caused by drug acting on brain/circulation? common
- sedation with slowing of reaction times and impaired balance
- hypotension/arrhythmias
2 types of meds that have a strong association of falls?
Psychotropic meds
- benzodiazepines
- anxiolutics
- hypnotics
- sedatives
- antidepressants
- antipsychotics
cardiovascular meds
3 types of urinary incontinence
stress: urethral sphincter incontinence. weakened pelvic floor (women)
overflow: constant involuntary urine loss, prostatic hypertrophy (males), anticholinergic drugs
urge: strong desire to pass then involuntary loss
name 3 classes of drugs which may cause intellectual impairment: confusion, cognitive impairment may also = poor compliance/confusion over meds use
- anticholinergics
- hypnotics
- antidepressants
most important PK principles in older adults? what drugs are they therefore susceptible to?
reduced renal clearance = excrete drugs slowly, susceptible to nephrotoxic drugs
2 most important ppharmacodynamic changes?
increased sensitivity to given exposure of CNS depressant drugs
reduced baroceptor function = sedation and falls
where to find info for monitoring treatment and prescribing advice/support for elderly care?
NSF.
green page, meds and older people
also BNF dosing- elderly, SPC
conducting a meds review on elderly.
what to cover?
for each drug:
- why prescribed?
- appropriate?
- still required?
- any alternatives? with better effectiveness and tolerability?
- appropriate dose, frequency, formulation?
- ADRs experiences?
- still working?
- clinically significant interactions?
- can patient manage dosage form?
Structured medication review
holistic and personalised review.
considers ALL meds patient taking
‘meds rec + MUR on steroids’
how to improve dosage forms (and concordance)
what to consider?
- simplify dosing regimends- OD/BD
- blister packs and bottle tops
- sublingual tabs, dry mouths
- liquids, measuring
- functional capacity
- dexterity and deviced
how are potentially inappropraite meds in polypharmacy identified? (criteria)
STOPP/START
screening tools.
STOPP: potentially inapp prescriptions in patient >65y
START: unless end of life status, valid drug therapies to be considered where omitted for no valid clinical reasons
whats an example of a STOPP criteria?
-drug presc with no evidence based cinical indication
- duplicate drug class
e. g. 2 NSAIDs/SSRIs/ loop diuretics/ ACEi/ anticoagulants - verapamil/diltiazem with NYHA class III or IV heart failure
- loop diuretic for hypertension with concurrents urinary incontinence
whats an example of a START criteria?
- Vit K antagonists/NOACs where chronic AF present
- ACEi (donepezil) for mild-moderate Alz/dmentia
- Vit D supplement for housebound/risk of falls/with osteopenia
how to help older people with thier medicine programs
plan collaboratively: discuss with everyone involved. write requirements about managing meds on care plan: - purpose and info of meds - dosage and timing importance - implications of non-adherence - details of who to contact if concerns
support self management
-known SEs, reluctance to taking meds…
time dependant change in benefit-harm balance. as time increases…
with increasing time, benefit/harm balance decreases
Purpose of deprescribing
withdrawing inapp med supervised by HCP to manage polypharmacy and improve outcomes.
reduce dose, switch to safer meds
why must care be taken with deprescribing/withdrawing neuroactive drugs?
drug withdrawal syndromes.
dont stop suddenly
e.g.
Anti-psychotic: Risperidone- SE: Sedation
Anti-anxiety: Duloxetine- SE: Sexual dysfunction (eg: loss of libido, anorgasmia)Nausea
why may you be concerned if a patient has diabetes that you suspect is poorly controlled due to lower eGFR?
e.g. prescribed Metformin for T2DM. lower eGFR = decreased renal elimination
greater risk of LACTIC ACIDOSIS
Why is Lithium drug characteristic and why should it be monitored?
drug with a narrow therapeutic range!
if patient on it long term, develop renal toxicity. more info: purple book online
Possible reasonsn for lithium toxicity in a patient also with sodium? problems
kidneys not excreting it properly/ sodium from diet and lithium interaction.
Both have one positive charge and quite small.
Kidney gets confused, sometimes hangs on to Na instead.
Taking too much/ suddenly stopping salt intake: problem
possible reasons of increased urea and serum creatinine in a patient?
Urea may be raised due to muscle breakdown/ dehydration.
Serum creatinine: muscle breakdown. Removed only through kidneys. Used as marker for kidney function.
what must be checked before starting diuretics in patient?
Li levels must be checked before starting!
why are NSAIDs not advised with lithium?
Inhibits prostaglandin: change how much filtered. Renal efferent
what to do if Li not excreted properly and accumulating.
completely stop. safer than decreasing dose as levels alr too high
what to ideally prescribe with co-codamol (also iron tablets)?
cause constipation so
Stimulant/ softener laxative (not bulk forming- not drinking enough)
elderly should also require/consider as part of therapy:
- Covid booster.
- Flu jab
- Any pneumococcal vaccines due
