Elderly - polypharmacy Flashcards
What are common iatrogenic problems associated with anticholinergics?
Confusion Dry mouth Constipation Blurred vision Urinary retention Orthostatic hypotension
What are common iatrogenic problems associated with tricyclics?
Confusion
Unsteady gait
What are common iatrogenic problems associated with long acting benzodiazepines?
CNS toxicity
What are common iatrogenic problems associated with narcotics?
Confusion
What are common general adverse drug reactions in older patients?
Falls Cognitive loss/delirium Dehydration Incontinence Depression
What are reasons older people get more prescriptions?
More acute and chronic diseases
More doctors visits
Drugs are often given to counteract side effects of another drug
What healthcare provider factors contribute to polypharmacy?
No med review with patient on regular basis
Presumes patient expects meds
Prescribes without sufficient clinical investigation
Evidence that drug is ‘best’ drug for problem
Providing unclear instructions about how to take meds
Ordering automatic refills
Lack of geriatric pharmacology knowledge
What are the 3 worst drugs for admissions related to adverse drug reactions in the elderly?
NSAIDS
Diuretics
Warfarin
What happens to drug absorption in older people?
Decreased rate but overall the same
May see a delayed onset of action of drug
How does drug distribution change within elderly patients?
Body composition changes - increased fat, decreased muscle - Increased distribution of fat soluble drugs
Protein binding decreases due to decreased albumin
Increased blood brain barrier permeability
How does drug metabolism change in the elderly?
First pass metabolism decreases due to decreased liver mass and decreased hepatic blood flow
How does excretion change in the elderly?
Renal function decreases with age leading to decreased excretion
What happens as a result of decreased excretion?
Increased drug half-life leading to toxicity
What happens regarding pharmacodynamics in elderly people?
Increased sensitivity of some medicines
What causes increased drug sensitivity in older patients?
Change in receptor binding
Decrease in receptor number
Altered translation of receptor cell response
What are principles of prescribing for older people?
Clear diagnosis to avoid prescribing drug to manage adverse effect
Consider whether drug therapy is best therapeutic action
Lower doses or reduced frequency of administration are generally needed
Think of whether drug causes problems in elderly patients
Check whether lower dose is recommended in elderly
Review new drug and see if it’s achieving its aim
Review all prescriptions regularly
Try to keep regimens simple
Consider compliance issues elderly patient may experience
What are tools for prescribing in older people?
Beers’ criteria
START-STOPP criteria
NHS Scotland Polypharmacy Guidance
What is Beers’ criteria used for?
List of inappropriate drugs for older people
Occassionally updated but many weakness
What is START-STOPP criteria used for?
Advice on medical optimisation
Mostly used as a research tool
What are the 7 steps of the NHS Scotland Polypharmacy Guidance?
Identify objectives of therapy
Identify essential drug therapy
Does the patient take unecessary drug therapy
Are therapeutic objectives being achieved
Does the patient have ARDs or at risk of ARDs
Is drug therapy cost effective
Is patient willing and able to take drug therapy as intended
When would you deprescribe a drug?
ADR Drug-drug interaction Better alternative drug Not effective Not indicated Not evidence-based Minimise polypharmacy
What are risks of psychiatric medication in older people?
Sedatives - falls, confusion
Anti-psychotics - Postural hypotension, stroke, confusion, movement disorders
Anti-depressants - less effectove
What are risks of opioids in older people?
More sensitive to the effects so may need lower doses
What are risks of NSAIDs in older people?
Increased adverse effects - renal impairment, GI bleeding
What is the main risk of digoxin in older people?
Increased toxicity - lower dose needed
What are risk factors of anti-hypertensives in elderly patients?
May have exaggerated effects on BP and heart rate
More likely to see issues with postural hypotension
ACE inhibitors pro drugs which may not be metabolised to active form
Renal adverse effects
What are risks of warfarin in elderly patients?
More sensitive to effects
Greater risk - GI bleeding, falls
What are adverse effects of antibiotics in older people?
Diarrhoea and c. diff infection Blood abnormalities Delirium Seizures Renal impairment
