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Health.1 > Elderly care > Flashcards

Elderly care Flashcards

1
Q

What do NICE guidelines recommend for dealing with multimorbidity in elderly?

A 
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!

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2
Q

what is polypharmacy and link to elderly?

A

prescribing >4 drugs.
common due to multiple comorbidities

no drugs strongly associated with age. increase

risk of DDI and ADRs increased

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3
Q

Pharmacokinetic factors: absorption. how is it different in elderly?

A

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

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4
Q

what can even minor reductions in first pass metabolism lead to?

A

= 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.

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5
Q

Give 3 examples of drugs that may accumulate (high bioavailability) as a result of reduced hepatic blood flow

A

Reduced hepatic blood flow = reduced first-pass metabolism in the liver = increased drug bioavailability. accumulate and can have ADRs.

  • Nifedipine
  • Nitrates
  • Verapamil
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6
Q

PK factors: Distribution.

How is it altered in the elderly and what effect does it have?

A

elderly have altered distribution of body fat and water

more fat, less water

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7
Q

How does increased proportion of fat in eldely affect distribution of lipid soluble drugs e.g. diazepam?

A

more fat (14-35%) = higher Vd of lipid soluble drugs = accumulate.

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8
Q

How does decreased proportion of water in elderly affect the distribution of water soluble drugs e.g. digoxin?

A

Less water = decreased Vd for water soluble drugs = lower doses can be required.
e.g. loading doses of digoxin

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9
Q

PK factors: Distribution

affect of change in plasma protein conc in elderly? example of a drug affected

A

Reduced plasma protein conc/binding = increase in free drug e.g. phenytoin
= increased risk of toxicity!

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10
Q

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

A

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)

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11
Q

affect of reduced metabolic clearance on pro-drugs

A

= pro drugs may be less effective, as converted in active form by liver

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12
Q

PK factors: Elimination

how does GFR and renal tubular function change with age and which 4 drugs will need dose adjustment as a result?

A

both decrease (chronic liver disease- low GFR)
Renally excreted drugs need dose adjustment:
- Digoxin
- Gentamicin
- Lithium salts
- Opiates

higher dose: metab and elimination factors

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13
Q

what 5 physio and pathophysiological aspects are also affected by the ageing process?

A
  • Heart
  • Endocrine changes
  • Skeletal muscle: atrophy
  • Bones and joints: osteoporosis and osteoarthritis
  • CNS: vision and hearing.
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14
Q

how is heart function changed with age? (4)

A
  • cardiac architecture, less compliance
  • loss of pacemaker cells
  • calcification of conduction system
  • less response to cetecholamines… Ca channel blockers
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15
Q

what endocrine changes are seen with increased age?

A

Reduced hormone production, target sensitivity

Oestrogen, testosterone, GH, IGF-1

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16
Q

How are receptors affected? (2)

and affect on drugs?

A
  • changes in receptor sensitivity
  • reduced numbers of receptors

= increased sensitivity to several drugs

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17
Q

e.g.

how does reduced baroceptor function lead to increased risk of falls?

A

reduced baroceptor function = increased hypotension with antihypertensive therapy = fall risk

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18
Q

Effect of decreased dopamine receptors

A

= increased risk of extra pyramidal side effects (EPSE)

  • parkisonism
  • rigid limbs
  • tremor
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19
Q

what 2 things does the effect of age on drug sensitivity vary with however?

A
  • drugs studied
  • response measured

e.g. anticoagulation- elderly = greater response to same plasma conc of warfarin than younger patients. mechanism unknown

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20
Q

7 important drugs/classes in older adult patients

A
  • analgesics (opioids, NSAIDs)
  • digoxin
  • diuretics
  • warfarin and other anticoagulants
  • ACEis
  • beta blockers
  • benzodiazepines
  • phenothiazines
  • antiparkinsonian drugs
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21
Q

affect of frailty on elderly

A

organ systems progressively declining = loss of function and physiological reserve, increased vulnerability to disease and death.

the primary users of healthcare resources

22
Q

how is frailty assessed? i.e. quantified

A

frailty assessment:
1 –> 7
very fit–> severly frail. completely dependant

23
Q

Five frailty syndromes (Geriatric Giants). any one of these = suspicion of frailty

A
  • 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
24
Q

4 ways to minimise risk of falls- major cause of disability and mortality in elderly

A
  • identify drugs causing falls
  • review meds-polypharmacy
  • nutrition: Ca, Vit D to reduce risks of osteoporosis
  • multidisciplinary falls service
25
Q

what is the mechanism leading to fall caused by drug acting on brain/circulation? common

A
  • sedation with slowing of reaction times and impaired balance
  • hypotension/arrhythmias
26
Q

2 types of meds that have a strong association of falls?

A

Psychotropic meds

  • benzodiazepines
  • anxiolutics
  • hypnotics
  • sedatives
  • antidepressants
  • antipsychotics

cardiovascular meds

27
Q

3 types of urinary incontinence

A

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

28
Q

name 3 classes of drugs which may cause intellectual impairment: confusion, cognitive impairment may also = poor compliance/confusion over meds use

A
  • anticholinergics
  • hypnotics
  • antidepressants
29
Q

most important PK principles in older adults? what drugs are they therefore susceptible to?

A

reduced renal clearance = excrete drugs slowly, susceptible to nephrotoxic drugs

30
Q

2 most important ppharmacodynamic changes?

A

increased sensitivity to given exposure of CNS depressant drugs

reduced baroceptor function = sedation and falls

31
Q

where to find info for monitoring treatment and prescribing advice/support for elderly care?

A

NSF.
green page, meds and older people

also BNF dosing- elderly, SPC

32
Q

conducting a meds review on elderly.

what to cover?

A

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?
33
Q

Structured medication review

A

holistic and personalised review.
considers ALL meds patient taking

‘meds rec + MUR on steroids’

34
Q

how to improve dosage forms (and concordance)

what to consider?

A
  • simplify dosing regimends- OD/BD
  • blister packs and bottle tops
  • sublingual tabs, dry mouths
  • liquids, measuring
  • functional capacity
  • dexterity and deviced
35
Q

how are potentially inappropraite meds in polypharmacy identified? (criteria)

A

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

36
Q

whats an example of a STOPP criteria?

A

-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
37
Q

whats an example of a START criteria?

A
  • 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
38
Q

how to help older people with thier medicine programs

A 
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…

39
Q

time dependant change in benefit-harm balance. as time increases…

A

with increasing time, benefit/harm balance decreases

40
Q

Purpose of deprescribing

A

withdrawing inapp med supervised by HCP to manage polypharmacy and improve outcomes.

reduce dose, switch to safer meds

41
Q

why must care be taken with deprescribing/withdrawing neuroactive drugs?

A

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

42
Q

why may you be concerned if a patient has diabetes that you suspect is poorly controlled due to lower eGFR?

A

e.g. prescribed Metformin for T2DM. lower eGFR = decreased renal elimination

greater risk of LACTIC ACIDOSIS

43
Q

Why is Lithium drug characteristic and why should it be monitored?

A

drug with a narrow therapeutic range!

if patient on it long term, develop renal toxicity. more info: purple book online

44
Q

Possible reasonsn for lithium toxicity in a patient also with sodium? problems

A

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

45
Q

possible reasons of increased urea and serum creatinine in a patient?

A

Urea may be raised due to muscle breakdown/ dehydration.

Serum creatinine: muscle breakdown. Removed only through kidneys. Used as marker for kidney function.

46
Q

what must be checked before starting diuretics in patient?

A

Li levels must be checked before starting!

47
Q

why are NSAIDs not advised with lithium?

A

Inhibits prostaglandin: change how much filtered. Renal efferent

48
Q

what to do if Li not excreted properly and accumulating.

A

completely stop. safer than decreasing dose as levels alr too high

49
Q

what to ideally prescribe with co-codamol (also iron tablets)?

A

cause constipation so

Stimulant/ softener laxative (not bulk forming- not drinking enough)

50
Q

elderly should also require/consider as part of therapy:

A
  • Covid booster.
  • Flu jab
  • Any pneumococcal vaccines due

Health.1 (12 decks)

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