Geriatric Assessment

Question 1

Older Adults Age Categories

Answer 1

Divided into three age categories
◦Young old: 65-74
◦Middle old: 75-84
◦Oldest old: >85
Often clinical trials will use these terms to define the patients enrolled
Term older adult typically begins at age 65
Difficult to categorize based solely on age
◦Co-morbid conditions
◦Frail adults may respond differently
◦“optimal ageing” vs. “usual ageing”

Question 2

Changes in Older Adult Vital Signs

Answer 2

Blood pressure
◦Systolic hypertension
◦Orthostatic hypotension
Decreased arterial compliance and baroreceptor reflex response
Heart rate and rhythm
◦Pacemaker cells and maximal heart rate decline
◦More likely to have abnormal heart rate
Temperature
◦More susceptible to hypothermia

Question 3

Changes in the Older Adult Skin

Answer 3

• Vascularity of the dermis decreases
  Skin may appear thin, fragile, loose, and transparent
  Actinic purpura
  ◦from blood that has leaked through poorly supported capillaries

Question 4

Changes in the Older Adult Head and Neck

Answer 4

Eyes produce fewer lacrimal secretions
◦Dry eyes
Visual acuity
◦Gradually diminishes between 50 and 70
◦Near vision blurs for virtually all older adults
Affects lenses
◦Increase risk for cataracts, glaucoma, macular degeneration

Question 5

Head and Neck

Answer 5

◦Decreased salivary secretions and decreased sense of taste
Often medication or disease state related
◦Teeth
Periodontal disease
Malnutrition

Question 6

Lungs and Thorax

Answer 6

◦Chest wall becomes stiffer and harder to move
◦Respiratory muscle may weaken
◦Lungs lose some elastic recoil
◦Cough becomes less effective

Question 7

Changes in Older Adult Cardiovascular System

Answer 7

Neck and Vessels
◦Systolic bruits heard in middle to upper portion of carotid arteries suggest partial arterial obstruction from atherosclerosis

Extra heart sounds (S3 and S4)
◦S3 (3rd heart sound) strongly suggests congestive heart failure from volume overload
◦ S4 (4th heart sound) could suggest decreased ventricular compliance

Question 8

Cardiac Murmurs

Answer 8

◦Systolic aortic murmur common
◦Mitral regurgitation-mitral valve does not close, leading to leaking of blood and backup into the left atrium

Question 9

Memory

Answer 9

Memory is the most common complaint of older adults
◦Normal aging process
Older adults need more time to learn the same material
Reduced word retrieval (recalling names)
◦Rating scales are often inconsistent with actual level of impairment

Question 10

Mini-Mental State Exam

Answer 10

The Mini-Mental State Exam (MMSE) is a used test cognitive function among older adults
Orientation
Attention
Memory
Language
Visual-spatial skills
Scores range from 0-30. Scores > 25 are normal. Patients with Alzheimer’s typically score between 19-24.

Question 11

Pharmacokinetic Changes Absorption

Answer 11

Gastrointestinal tract
◦Decreased gastric acid secretion
◦Delayed gastric emptying
◦Slowed intestinal transit time
◦Reduced gastrointestinal blood flow
Decreased stomach acid leads to decreased absorption of some medications
◦Example: Calcium Citrate is recommended in older adults “ better absorption” gastric acid not necessary to breakdown medication.

Question 12

Pharmacokinetics Changes Distribution

Answer 12

↑Percentage of body fat and ↓ of muscle mass
Medications that distribute into fat have a significantly increased volume of distribution
◦Prolonged half-life
Caution with lipophilic medications
Diazepam and chlordiazepoxide
Medications that distribute into muscle or body water have a significantly decreased volume of distribution
◦Decreased volume of distribution
Smaller doses to avoid toxicity
Lithium

Question 13

Pharmacokinetic Changes Protein Binding

Answer 13

Serum albumin usually unchanged in healthy older adults but significantly lower in frail or malnourished elderly patients
◦Serum drug concentration (total drug concentration)
Bound drug + free drug
◦Free drug concentration
Drug not bound to protein
Able to exert therapeutic effect
◦Common medications: phenytoin, warfarin, diazepam
◦Serum albumin level: 3.2-5g/dl (normal levels)

Question 14

Pharmacokinetic Changes Metabolism

Answer 14

Metabolism primarily occurs in the liver
◦Liver mass can be 20% to 40% smaller and accompanied by a 35% decrease in hepatic blood flow
Medications with a high first pass rate will show higher bioavailability
Lower doses
Metoprolol, verapamil, morphine, diazepam

Question 15

Pharmacokinetic Changes Excretion

Answer 15

Reduction in renal mass, renal blood flow, glomerular rate (GFR), filtration fraction, and tubular secretion
Scr: derived from muscle and assess kidney function. Not accurate in older adults due to ↓muscle mass.

Question 16

Cockcroft- Gault Equation

Answer 16

(140-age) X weight(kg) x (.85*)
Serum creatinine X 72
*for females

Controversy over increasing Scr to 1.0 in older adults over 60 years.

Question 17

Adverse Drug Reactions (ADRs)

Answer 17

 About 1 in 3 older adults taking at least 5
medications will experience an adverse drug
event each year
◦ About 2/3 of these patients will require medical
attention
 95% are predictable and 28% are preventable

Question 18

ADRs Avoiding Overuse of Medications

Answer 18

 Polypharmacy: overutilization or
inappropriate use of multiple medications
 Reviews of a patient’s medications should be
done at initial assessment, every 3 to 6
months thereafter, and with any medication
change

Question 19

Prevent ADRs

Answer 19

 Identifying risk factors
◦ Adverse Drug Reactions (ADRs) are often
exaggerated in older adults due to pharmacokinetic
and dynamic changes
◦ Misuse, overuse and underuse of medications are
also increased in older adults
 Medication Regimen Review
◦ Indentifying medications at increased risk for ADRs

Question 20

What is Medication Regimen Review (MRR)

Answer 20

 Evaluation of medication regimen
 Promoting positive outcomes
 Minimizing adverse events

Question 21

Role of a Consulting Pharmacist

Answer 21

 Perform Medication Regimen Reviews (MRR)
 Ensure safe drug use and monitoring
 Recommend cost effective regimens

Question 22

Medication Regimen Review Indicators

Answer 22

 Indication/reason for medication
 Effectiveness
 Dose
 Presence of monitoring
 Presence of duplicative therapy
 Food and or drug interactions
 Presence of potential adverse drug reactions
(ADR)

Question 23

Identifying Inapropriate prescribing:

The Beers Criteria

Answer 23

Updated in 2012
For patients > 65 years of age
Based on expert consensus developed through an extensive literature review evaluated by experts in geriatric care, clinical pharmacology, and psychopharmacology
Adopted by the Centers for Medicare and Medicaid Services in July 1999 for nursing home regulation

Question 24

Beers Criteria

Avoid Use

Answer 24

Question 25

Beers Criteria

Avoid Use 2

Answer 25

Question 26

Beers Criteria

Caution

Answer 26

Question 27

Geriatric Assessment

Answer 27

Obtain an accurate medical history
◦Review all medications
Multiple co-morbidities
Multiple doctors prescribing medications
Frequent users of acute hospitals
Drug Related Problems
Often inaccurate
History from multiple sources is often required
Cognitive issues
Utilize family members for information

Question 28

Eliciting Symptoms in Older Adult

Answer 28

Purposely underreport symptoms
◦Afraid or embarrassed
◦Financial issues
◦Discomfort of procedures and treatments
◦Overlook or attribute to ageing