Elderly - Drugs and Polypharmacy Flashcards
How common are ADRs in nursing home patients?
350,000 p/a
What are the common iatrogenic problems associated with Anticholinergics?
Confusion Constipation Dry mouth Blurred vision Urinary retention Orthostatic hypotension
What are the common iatrogenic problems associated with Tricyclics?
Confusion
Unsteady gait
What are the common iatrogenic problems associated with long-acting benzodiazapines?
CNS toxicity
What are the most common ADRs seen in older patients?
Falls Delirium Dehydration Depression Incontinence Loss of capacity/QoL
What is the prescribing cascade?
Drug 1 has an adverse drug reaction, which is interpreted as a new condition for which
Drug 2 is give (+ new ADR)
Etc
What healthcare provider factors contribute to polypharmacy?
No med review Presuming patient expects drugs Insufficient investigation Assumes drug is best No effort to simplify medication regimen Lack of pharmacology knowledge
What are the 5 worst drugs in polypharmacy associated with ADR admission?
NSAIDS Diuretics Warfarin ACEI Antidepressants (Beta blockers, Opiates, Digoxin, Prednisolone, Clopridogrel)
What are the changes seen in absorption in old age?
Slowed rate of absorption, extent the same (delayed onset)
What are the changes seen in distribution in old age?
Changes in body composition
Changes in protein binding
Increased BB barrier permeability
How does protein binding change in old age?
Decreased serum albumin
How does body composition change in old age?
Reduced muscle mass
Increased fat mass
Reduced body water
How does Increased fat mass affect drug distribution?
Increased action duration of fat soluble drugs
How does reduced body water affect drug distribution?
Increased levels of water soluble drugs
How does metabolism of drugs change in old age?
Hepatic metabolism changes due to decreased liver mass/blood flow
Reduced first pass metabolism
How does excretion of drugs change in old age?
Renal function decreases
Increases half-life of many drugs
How do pharmacodynamics change in old age?
Increased sensitivity to drugs
Change in receptor binding
Lower receptor number
How does the effect of diazepam change in old age?
Increased sedative effect
How does the effect of warfarin change in old age?
Increased anticoagulation
What are the principles of prescribing for older people?
Be clear about diagnosis Consider whether drug therapy is best Lower doses/reduced frequency Consider ADR instead of new diagnosis Check if lower dose is recommended Review any prescriptions regularly Keep regimens simple
What are the guides for prescription?
Beers’ Criteria
START-STOPP criteria
NHS Scotland Polypharmacy Guidance
What is the role of the START-STOPP criteria?
Reduction in ADRs and LoS
What is the indications for deprescription?
Adverse drug reactions/interactions Better alternative Inaffective Not indicated Not evidence-based Minimise polypharmacy
What are the drugs that are most often deprescribed in the elderly (>65)?
Antihypertensives
Benzodiazapines
Antipsychotics
Statins?
What are the risks in psychiatric pharmacy of the elderly?
Care treating “agitation”
Sedatives increase falls/confusion
Antipsychotics have increased ADRs
Antidepressants less effective
What are the risks in analgesic pharmacy of the elderly?
Opioids (more sensitive, tramadol less useful)
NSAIDs have increased adverse effects
What are the “risky drugs” in cardiovascular pharmacy of the elderly?
Digoxin
Diuretics
Antihypertensives
Anticoagulants
What risks are associated with digoxin use in the elderly?
Increased toxicity (use lower dose)
What risks are associated with diuretic use in the elderly?
Decreased peak effect
Reduced clearance
Continence issues
Abnormal U+Es
What risks are associated with antihypertensives use in the elderly?
Exaggerated effects on BP + HR
Increased postural hypotension
ACEI may not be well metabolised
Renal ADRs
What risks are associated with anticoagulants use in the elderly?
Increased Warfarin sensitivity (so greater risk of ADRs)
What risks are associated with antibiotics use in the elderly?
Increased ADRs
What ADRs are seen with antibiotic use in the elderly?
Diarrhoea + c. diff Blood dyscrasias Delirium Seizures Renal impairment
