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Fall 20' Pharm. III > Geriatric/Pediatric/extra drugs power points > Flashcards

Geriatric/Pediatric/extra drugs power points Flashcards

1
Q

The prudent way to administer drugs to the elderly would be?

A

start low and go slow since they normally require less

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2
Q

Describe what aging is and the ultimate outcome of aging?

A

as a progressive loss of those physiologic processes necessary to maintain homeostasis (homeostenosis), death being the ultimate failure of these mechanisms.

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3
Q

Is passive gastric absorption markedly altered in the elderly?

A

NO

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4
Q

Which has greater effect on motility, age or drugs when talking about the elderly?

A

drugs that inhibit intestinal motility have a greater effect than age.

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5
Q

True or False, IM or Subq injections are preferred over IV meds in the elderly?

A

Due to erratic absorption and a tendency to develop sterile infiltrates, intramuscular an subcutaneous injection are generally NOT recommended for elder patients.

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6
Q

TBW increases or decreases in the elderly and by how much?

A

decreases by 10-15% in the elderly

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7
Q

why do lipophilic drugs have a larger volume of distribution in the elderly?

A

body fat increases and muscle mass decreases by 20-40%

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8
Q

True or false.

elderly have a decreased central compartment volume? why?

A

True

due to a decrease in total body water, in combination with changes in the distribution of cardiac output

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9
Q

due to a loss in muscle mass, less body water total, more fat, and a decrease in central compartment volume what is a concern in relation to medicating the elderly?

A

Overmedication based on a failure to adjust for weight is a concern.

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10
Q

Does hepatic blood flow decrease in the elderly?

does liver mass increase in the elderly?

A

Hepatic blood flow declines by 20-53% in elderly subjects, while liver mass is reduced by 11-36%.

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11
Q

which enzyme may be decreased in the elderly which is responsible for phase 1 drug meabolism?

A

cytochrome P450 (CYP) may be decreased in the elderly. (even tho CYP enzyme activity is relatively preserved).

(function is preserved but amount may be reduced)

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12
Q

is phase II (conjugation) metabolism altered in the elderly?

A

No, does not appear to be

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13
Q

Renal function and aging - GFR changes and renal drug excretion?

A

GFR is reported to decrease by 1mL per year.

Overall, it appears that there is a small decrease in GFR with aging, but in the absence of disease it probably decreases less than previously thought.

Aging per se appears not to diminish renal drug excretion significantly.

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14
Q

Cardiac function in the elderly: does cardiac output change based on aging alone?

What should you change about your medication administration in the elderly related to cardiac circulation time?

A

cardiac output is generally maintained in the elderly, in absence of dz. However many patients have coexisting diseases and circulation times appears increased.

initial drug effect may be delayed, thus SLOWER bolus injection in the elderly is advised.

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15
Q

opioid elimination occurs mainly by?

A

hepatic metabolism, with renal excretion of metabolites and some parent drugs.

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16
Q

Important factors that influence opioid metabolism?

A

genetics, sex, age, and environmental factors including concurrent medications, diet and disease.

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17
Q

Which three opioids have active metabolites, accounting for both persistent analgesia and many side effects.

A

codeine
morphine
meperidine

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18
Q

what is the primary risk of opioids?

what does this mean in relation to the elderly?

A

respiratory depression is the primary risk of opioids, the incidence of which is markedly increased with age.

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19
Q

which opioid was more problematic for the elderly compared to meperidine?

A

morphine

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20
Q

which opioid when given to the elderly had almost no respiratory depression?

A

fentanyl

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21
Q

Aging has a greater effect on fentanyl pharmacodynamics or pharmacokinetics?

A

pharmacodynamics

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22
Q

which receptor is fentanyl highly selective for?

A

mu - receptor agonist

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23
Q

IV fentanyl and the elderly, what should you do to the dose?

A

reduce the dose

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24
Q

fentanyl patch application in elderly?

A

takes longer for plasma concentrations to rise compared to younger patients but it also releases back into their system from fat stores more slowly.

(delayed skin absorption but fat acts as a 2nd reservoir leading to prolonged release even after path removal)

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25
Q

which one of morphine’s metabolites is an effective analgesic?

A

M6G (not M3G)

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26
Q

Do the elderly have an increased or decreased GFR?

A

Decreased

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27
Q

If an elderly person (or anyone) has elevated creatinine concentrations what will occur with morphine administration?

A

accumulation of both morphine glucuronides

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28
Q

peak effect of morphine after bolus dose is how long?

A

90 min.

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29
Q

relatively weak µ - agonist with only approximately 10% effectiveness of morphine describes what drug?

A

meperidine

30
Q

what is the half life of meperidine?

A

3 hours

31
Q

meperidine is metabolized in the liver to what?

what is the half life and side effects of meperidine’s metabolite?

A

normeperidine

15-30 hours and in high concentrations can cause agitation and seizures

32
Q

explain some of Meperidine’s pharmacology?
What drug does it have activity like?
negative or positive inotropic effects?
what properties does it have that results in increased heart rate?

A

local anesthetic activity, negative inotropic effects, and intrinsic anticholinergic properties which can result in increased heart rate.

33
Q

Is meperidine a good drug choice for the elderly?

A

Meperidine has been associated with development of post-operative delirium in elderly patients. Aside from the treatment of postoperative shivering with single small doses, meperidine is not a good drug for use with the elderly.

34
Q

Meperidine is associated with severe serotonergic reactions when combined with ?

A

MAO A inhibitors

35
Q

why will repeat doses of meperidine in the elderly cause a build up of the active metabolite nomeperidine?

A

renal excretion is reduced in the elderly

36
Q

Remifentanil metabolism?

A

an ester which undergoes rapid hydrolysis by nonspecific tissue and plasma esterase.

37
Q

Does remifentanil accumulate?

What is it’s context sensitive half time after four hours of infusing?

A

Remifentanil accumulation does not occur, and its context –sensitive half-life (time taken for blood plasma concentration of a drug to decline by one half after an infusion designed to maintain a steady state has been stopped) remains at 4 min. after a 4 hour infusion.

38
Q

Remifentanil onset, offset, and blood concentration in the elderly?

A

The onset and offset are slower in elder individuals, although the blood concentrations are similar to young patients.

39
Q

peak effect of remifentanil bolus in the elderly takes longer (2-3 min. compared to 90 sec.), and they need half the bolus dose of a younger person, why is this?

A

As with fentanyl and alfentanil, this is because of increased pharmacodynamic sensitivity in the elderly rather than pharmacokinetics.

(pharmacodynamics = body’s biological response to the drug)

40
Q

difference between pharmacodynamics and pharmacokinetics?

A

The differences between pharmacokinetics and pharmacodynamics is that pharmacokinetics (PK) is defined as the movement of drugs through the body, whereas pharmacodynamics (PD) is defined as the body’s biological response to drugs.

41
Q

due to combined impact of increased sensitivity and decreased clearance of remifentanil in the elderly, what should be the infusion rate in the elderly?

A

1/3 the infusion rate of a younger person.

42
Q

Opioid doses in the elderly should be reduced by about how much and why?

A

50% primarily bc they are more sensitive

43
Q

Pharmacokinetic changes in the elderly are important only when?

A

long term infusions are contemplated

44
Q

How are propofol pharmacodynamics different as you age?

A

the amount of propofol needed to cause loss of consciousness decreases nearly 50% in the elderly.

45
Q

older patients and propofol, tell me everything you know?

A

older patients need less propofol for steady state maintenance

less needed to achieve specific EEG endpoints

and a 20% reduction in the amount of propofol needed as an induction bolus.

46
Q

propofol dose in the elderly that cause moderate sedation…clearance is considerably more altered by age in females or males?

A

females

47
Q

Doses of propofol as low as what can be appropriate?

A

0.8-1.2 mg/kg

48
Q

Midazolam changes (renal and hepatic) in the elderly?

A

Clearance is reduced in the elderly by as much as 30% from that of a young adult due to a loss of functional hepatic tissue and a decrease in hepatic perfusion.

Midazolam undergoes significant metabolism, primarily to hydroxymidazolam, which is pharmacologically active, renally excreted, and may accumulate in patents with diminished renal function.

49
Q

midazolam dose should be reduced by how much in a 90 year old patient?

A

75%

50
Q

Paradoxical reactions to midazolam occur in which patients become agitated rather than sedated what medication can reverse this?

A

Flumazenil may reverse the episodes.

51
Q

The neuromuscular blocking drugs inhibit transmission at the neuromuscular junction and exert their effect pre or post synaptically?

A

postsynaptically

52
Q

what is the average decrease in muscle mass in the elderly?

A

25-35%

53
Q

what is a weird thing that elderly people have in relation to the neuromuscular junction?

A

the presence of extrajuctional acetylcholine receptors in elderly muscle, although these have no known impact on neuromuscular function.

54
Q

ED95 for neuromuscular blockade and the elderly?

A

The ED95 for neuromuscular blockade is essentially the same for young and old patients for all currently used neuromuscular blockers.

55
Q

What are the two hepatically metabolized NMB that have prolonged recovery in the elderly?

A

Vec

Roc

56
Q

which NMB do you give if someone has liver or kidney issues?

A

cisatracurium

57
Q

The clearance of WHAT drugs may be prolonged in the elderly, but this is actually beneficial, given their clinical applications.

A

Anticholinesterases (neostigmine and pyridostigmine)

58
Q

Geriatric patients appear more susceptible to WHAT associated with the reversal of neuromuscular blockade.

A

cardiac arrhythmias

59
Q

Should you decrease the dose of NMB and anticholinesterase drugs in the elderly?

A

No, the effects take longer to see full effect, but the dosage can stay the same as if for younger patients.

60
Q

what are the two mechanisms involved in the uptake and distribution of volatile anesthetics?

A

MV

CO

61
Q

As a person ages does their need for volatile anesthetics increase or decrease?

A

you can decrease the dose ( this is pharmacodynamic)

62
Q

MAC for volatile anesthetic gas decreases by how much for each decade of life?

A

6.7%

63
Q

MAC for nitrous oxide decreases about ?per YEAR.

A

7.7%

64
Q

What in relation to volatile anesthetics were significant independent predicators of increased mortality according to Monk et al report?

A

cumulative deep hypnotic time and intraoperative hypotension

65
Q

Increase in body fat and decrease in muscle mass also mean that lipophilic drugs will have a ?

A

larger volume of distribution

66
Q

Aging as a single factor does or does not diminish renal drug excretion significantly?

A

DOES NOT

67
Q

Is the dose of naloxone significantly altered with age?

A

No

68
Q

Is propofols dose decrease in the elderly due to pharmacokinetic or pharmacodynamics?

A

BOTH

69
Q

One might expect decreased absorption of drugs administered by intramuscular injection in neonates, because of their reduced muscle bulk, skeletal muscle blood flow, and muscular contractions. This is not necessarily the case, why?

A

because neonates also have a high density of skeletal muscle capillaries.

70
Q

If a neonate has a right to left shunt will this slow or speed up induction of anesthesia?

A

slow

71
Q

intubating dose of Sch in infants compared to children compared to adults?

A

succinylcholine 3-4 mg kg in infants, 2 mg kg in children, and 1 mg/kg in adolescents and adults.

72
Q

Which CPY is the last to appear in the neonate and thus may have important effects on the risk of drug toxicity in these patients?

A

CYP1A2

Fall 20' Pharm. III (5 decks)

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