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Pharmacology > Geriatric Pharmacology > Flashcards

Geriatric Pharmacology Flashcards

1
Q

What is the Beers list (Beers Criteria)? What categories does it have?

A

List of medications likely to cause adverse effects in elderly

Categories:
- high risk (problematic to most older patients)

  • moderate risk (problematic for certain disease conditions)
  • some risk (use with caution)
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2
Q

Name age-related changes in body composition

A

Decrease total body water

Decrease lean body mass

Increased body fat

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3
Q

Name age-related changes in liver function

A

Decreased hepatic size

Decreased hepatic blood flow

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4
Q

Name age-related changes in cardiac function

A

Decreased myocardial sensitivity to beta-adrenergic stimulation (beta-blockers may have less effect)

Decreased baroreceptor activity

Decreased cardiac output

Increased total peripheral resistance

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5
Q

Name age-related changes in kidney function

A

GFR tends to decrease

Decrease in RBF

Decrease in filtration fraction

Decrease in tubular secretory function

Decrease in renal mass

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6
Q

Name age-related changes in pharmacokinetics. (absorption, distribution, metabolism, clearance/elimination)

A

Absorption: least affected, can change secondary to reduced stomach acidity

First-pass metabolism: reduced

Distribution: affected because of different body composition (less body water, lower lean body mass %)

Metabolism/clearance: decreased d/t changes to kidney and liver function and blood flow

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7
Q

How does aging affect the Vd of lipophilic and hydrophilic drugs?

A

Aging increases Vd for lipophilic drugs

Decreases Vd for hydrophilic drugs

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8
Q

How does aging affect the loading dose of highly water soluble drugs?

A

Aging leads to decreased loading dose for highly water soluble drugs

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9
Q

Given constant clearance, which will have a longer half-life in an elderly patient: a lipophilic drug or a hydrophilic drug?

A

Lipophilic drug

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10
Q

What is the effect of aging on 1/2 life and maintenance dose of flow-limited phase I drugs (metabolized by liver)? flow-limited Phase II drugs?

A

increased half life for both, thus maintenance dose should be decreased.

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11
Q

What is the effect of aging on 1/2 life and maintenance dose of capacity limited liver metabolized phase 1 drugs? Phase 2 drugs?

A

increased half life for phase I drugs; no change for phase II

increased maintenance dose for phase I capacity-limited drugs.

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12
Q

Why would you use creatinine clearance estimates to guide dosing?

A

Creatinine clearance gives estimate of GFR. Serum creatinine used to estimate

(Rate of creatinine clearance used because creatinine is filtered, not actively absorbed or secreted)

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13
Q

What is the Cockcroft-Gault equation? Why do we use it?

A

Accounts for decreased muscle mass (thus decreased serum creatinine) in elderly patients

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14
Q

What are the adverse effects of NSAIDS? How are they changed in the elderly

A

Renal damage (blocked formation of prostaglandins which maintain renal blood flow), GI bleeding and irritation (protective mucus secretion/negative acid secretion feedback is blocked)

Both effects worsened in the elderly d/t decreased renal clearance

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15
Q

Which classes of drugs have high anti-cholinergic activity?

A

Anticonvulsants
Antidepressants TCAs > SSRI (Paroxetine > other SSRIs)
Antihistamines (use second generation antihistamines to avoid)
Muscle relaxants
Parkinson disease
Urinary antispasmodics Vertigo

Anti-psychotics
Cardiovascular
GI antispasmodics
H2 antagonists not specifically discussed in class, but on chart

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16
Q

What are the adverse effects of anticholinergic drugs? Which effects are more pronounced in the elderly?

A

Dry mouth, decreased GI motility, urinary retention, orthostatic hypotension, blurry vision

Increased fall risk in elderly!

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17
Q

How many drugs/wk is considered polypharmacy? What do you need to watch out for?

A

> or = 5 drugs/wk

Concern for drug-drug interactions

Ex. impaired excretion due to competition for tubular drug transporters

(Not in objectives)

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18
Q

How can you prevent a “prescribing cascade”?

A
  • start with low dose and titrate
  • avoid prescribing before confirming diagnosis
  • don’t change multiple drugs at once
  • reach therapeutic dose before switching or adding agents.

(Not in objectives)

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19
Q

What is the risk with inadequate monitoring the elderly?

A

Pts may not associate adverse effect with drug. Set up follow-up appointment beforehand.

20
Q

Why is overdosage of specific concern in the elderly?

A

Decreased clearance of drugs leads to increased circulating concentrations.

21
Q

What is STOPP

A

Screening Tool of Older Persons’ potentially inappropriate prescriptions

  • assess use of drug with specific patient conditions
22
Q

What is START?

A

Screening Tool to Alert doctors to Right Treatment

  • identify underuse of beneficial medications in older adults
23
Q

What is bio-availability (F)?

A

Fraction of drug reaching systemic circulation (is 1 for IV dose)

24
Q

Change in first-pass metabolism in elderly patients?

A

Reduced first pass metabolism; can lead to decreased INACTIVATION of drug, or decreased ACTIVATION of prodrug

25
Q

What drugs might need a higher dose d/t decreased first-pass metabolism in the elderly?

A

Codeine, propanolol, enalapril, perindopril, simvastatin

26
Q

What is volume of distribution?

A

Volume of fluid in which drug must be dissolved to Achieve desired plasma concentration

amt of drug in body/plasma drug concentration

27
Q

Does a lipophilic drug have a high volume of distribution or low volume of distribution?

A

High Vd

28
Q

Would a muscle binding drug (eg Digoxin) have increased Vd or decreased Vd in elderly?

A

Decreased Vd in elderly

Less bound to muscle, more bound to systemic circulation

29
Q

Would a highly water soluble drug (eg Gentamicin) have increased or decreased Vd in elderly?

A

Decreased Vd in elderly d/t decreased body water

30
Q

What is the effect of increased Vd on half-life?

A

Depends on clearance.
t(1/2) = 0.693*Vd/CL

Lipid soluble drug would have increased Vd. Increased half-life???

Water soluble drug would have decreased Vd. However, clearance is also reduced, so there would be less of an increase than with lipid solubles.

31
Q

What is the effect of decreased Vd on loading dose?

A

If Vd is decreased, loading dose will be smaller (assuming bio availability is constant!

32
Q

What is clearance?

A

Rate of elimination of drug from body relative to drug concentration

CL=Q (flow rate to organ) x E (extraction ratio)

33
Q

What factors affect hepatic drug clearance?

A

Q: hepatic blood flow (via portal vein, hepatic artery)

E: liver metabolism
Phase I enzymes = cytochrome p450s
Phase II enzymes = polar group conjugation (eg. glucoronidation) to facilitate excretion

34
Q

How does aging affect hepatic drug clearance?

A

Q: hepatic blood flow decreases

E: Phase I enzyme activity reduced
Phase II enzymes activities UNCHANGED

35
Q

Capacity limited drugs have a clearance rate limited by:
a) hepatic blood flow
or
b) liver enzyme function?

A

Rate-limiting step is b) liver enzyme function

36
Q

True or False?

A capacity limited drug will have decreased clearance in the elderly if metabolized by phase I enzymes

A

True!

If phase II enzymes, clearance is unchanged

37
Q

How is clearance of flow-limited drugs changed in the elderly?

A

Hepatic clearance is decreased secondary to decreased hepatic blood flow

38
Q

What maintenance rate is required to maintain a steady state drug concentration?

A

Maintenance rate must be equal to clearance.

39
Q

Reduction of hepatic clearance requires more or less frequent maintenance doses?

A

Less frequent or lower doses.

40
Q

Change in maintenance dose in elderly for capacity limited phase II enzyme metabolized drugs?

A

No change in maintenance dose, d/t no change in clearance

41
Q

Change in maintenance dose in elderly for capacity limited phase I enzyme metabolized drugs?

A

Decreased maintenance dose

42
Q

Change in maintenance dose in elderly for flow-rate limited drugs?

A

Decreased maintenance dose

43
Q

In elderly patients, will GFR estimated from serum creatinine be an overestimate or underestimate?

A

Less muscle mass, means lower serum creatinine means falsely OVERestimated GFR

44
Q

Responsiveness of elderly to hypotensive beta-blocking effects is increased or decreased?

A

Decreased

45
Q

BP response to calcium channel blockers in elder is increased or decreased?

A

Increased (exaggerated acute response d/t reduced baroreflex activation)

46
Q

Sensitivity to anesthetic agents increases or decreases with age?

A

Increased sensitivity

Pharmacology (6 decks)

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