Falls and medication use in the elderly

Question 1

Describe the consequences and costs of falls in the elderly

Answer 1

• Serious injury
• Leading cause of death due to unintentional injury in the elderly
• Major cause of attendance to A&E by the elderly
• Half never return to former level of independence

Question 2

Tool for assessing the probability of fracture

Answer 2

FRAX

Fracture Risk Assessment Tool

Question 3

Intrinsic/patient-based risk factors for falls

Answer 3

Medication/polypharmacy
Frailty
Failure to use walking aids
Posture
Incontinence 
Existing medical conditions

Question 4

Extrinsic/environment-based risk factors for falls

Answer 4

In the home: Rugs, poor lighting, stairs/steps, furniture/obstacles
Seasonal:
Winter –> Cold, winter fuel costs
Summer –> Dehydration, sun stroke

Question 5

Describe and explain the assessment of falls risk

Answer 5

Falls clinic for performance of a MULTIFACTORIAL falls risk

• *Thorough history INCLUDING systems analysis
• *Thorough examination: Look, feel, move, test (timed up and go test)

Question 6

Describe and explain the preventative measures which can reduce the risk of falls

Answer 6

1. Exercise based interventions: Balance retraining and muscle strengthening
2. Medication management
3. Educational and behavioural counselling: Educate on falls risk and modify extrinsic factors
4. Vision correction
5. Vitamin D and Calcium supplementation

Question 7

State the factors contributing to adverse drug reactions

Answer 7

• *Age-related body changes: Decreased perfusion, increased MAP, decreased muscle and KIDNEY mass
• **Polypharmacy
• **Adherence and concordance issues

Question 8

State changes that occur in the aging body and how they affect pharmacokinetic, pharmacodynamics and drug therapy

Answer 8

SEE SEPARATE CARDS

Question 9

Name the framework used to assess whether a medication is suitable for use in the elderly

Answer 9

BEERs criteria

Question 10

Changes in pharmacokinetics seen in the elderly

Answer 10

Absorption:
Decreased absorption leading to a lower and decreased peak concentration

Distribution:
CO decreased, decreasing distribution.
Decreased muscle mass, decreased water content and increased fat content-affects distribution of lipid and water soluble drugs.
Decreased levels of serum albumin decrease binding capacity

Metabolism:
Decreased hepatic mass plus decreased perfusion to the liver leads to decreased clearance.
Bioavailability may increase due to decreased first pass metabolism

Excretion:
Decreased renal mass leads to reduced elimination, drug accumulation and toxicity.
**Assume some level of renal impairment in the elderly

Question 11

Changes in pharmacodynamics seen in the elderly

Answer 11

Changes in receptor sensitivity, number and hormone levels.

Question 12

Changes in homeostatic functions seen in the elderly

Answer 12

Decreased: Baroreceptor reflex, postural control, thermoregulation, cognitive function, immune response
**Reduced ability to respond to changes in the environment

Question 13

Key issues in geriatric pharmacotherapy

Answer 13

Multiple diseases leads to polypharmacy and therefore increased risk of drug interactions.
MUR indicated for those > 4 medications or using high risk medications.

Question 14

Identify potential reasons for and issues in adherence of the elderly

Answer 14

Reasons: Poor vision, reduced dexterity, impaired cognition, financial status, beliefs/understanding about medication
Issues: Leads to increased doses and addition of medications when they’re not needed!

Question 15

Considerations for pharmacotherapy

Answer 15

• Correct drug and dose
• Consider non-pharmacological therapy
• Start with a low dose
• Avoid starting 2 agents at the same time

Question 16

General overview for pharmacotherapy in the elderly

Answer 16

PD and PK changes result in decreased clearance and increased sensitivity to the elderly.
Lower doses and slow titration rates.
Careful monitoring required for successful outcomes.