Geriatric Pharmacotherapy Flashcards
1. Present the general implications and several specific examples of the physiologic changes of aging and pharmacotherapeutics. 2. Detail Beer’s criteria and the major classes of medications that should be cautiously used or avoided when treating elderly patients. 3. Define polypharmacy and its relevance to the geriatric patient.
Pharmacokinetic Changes in the Elderly in regards to Absorption
- Unchanged Passive Diffusion (most drugs)
- Decreased Active Transport
- Decreased Bioavailability (some drugs)
- Decreased First-Pass Metabolism
- Increased Bioavailabilty (some drugs)
Pharmacokinetic Changes in the Elderly in regards to Distribution
Water-soluble:
- Decreased Volume of Distribution(Vd)
- Increased Plasma Concentration
Lipid-soluble:
- Increased Vd
- Increased half-life
Pharmacokinetic Changes in the Elderly in regards to Metabolism
- Decreased Hepatic Metabolism
- Increased Half Life (Some drugs)
Pharmacokinetic Changes in the Elderly in regards to Elimination
- Decreased Clearance
- Increased Half-Life of Renally Eliminated Drugs
- Increased Half-Life of Active Metabolites
What is the most important thing to check in the elderly patients?
- Assess GFR!
In terms of pharmacodynamics, what should be known about elderly patients?
May be more sensitive to the effects of medications (therapeutic and side effects)
- Such as anticoagulants, antiplatelets, sedatives, antihypertensives, antidiabetics, etc.
In terms of pharmacodynamic properties with the elderly, how should we start medications.
Start at a lower dose and then titrate up slowly.
This is the use of multiple drugs or the administration of more medications than are indicated clinically.
Polypharmacy
Polypharmacy and the Elderly
- Occurs in approx. 50-60% of older outpatients
- May lead to drug/drug or drug/disease interactions (inc. risk of SE, multiple providers, OTCs)
- Avoid treating SE with another drug
- Dietary Supplements increase polypharmacy (and often not noted)
What types of medications are avoided because they are potentially inappropriate medications (PMI)
- First generation antihistamines
- Antispasmodics
- Digoxin
- Alpha 1 Blockers
- Central Alpha Blockers
- Tertiary TCA
- Antipsychotics
- Barbituates
- Benzodiazepine
- Non-benzzo hypnotics
- Insulin - Sliding Scale
- NSAIDs
- Sulonylureas
- Muscle Relaxants
What are the three categories of recommendations in Beer’s List?
- Meds to avoid regardless of indication
- Meds to avoid if certain disease(s) are present
- Meds to be used cautiously in older adults
What can anticholinergics cause that the elderly should avoid is possible
- Sedation
- Confusion
- Mental Clouding
- Delirium
- Memory Problems
- Difficulty Concentrating
- Dry mouth
- Tachycardia
- Falls
Medications with Dz Interactions:
Heart Failure
- NSAIDs
- Verapamil/diltiazem
- Pioglitazone/Rosiglitazone
- Dronedarone
Medications with Dz Interactions:
Syncope
- Alpha blockers
- Tertiary TCAs
- Chlorpromazine
- Olanzapine
Medications with Dz Interactions:
Delirium
- TCAs
- Anticholinergics
- Benzodiazepines
- H-2 Blockers
- Sedatives
Medications with Dz Interactions:
Dementia and Cognitive Impairment
- Anticholinergics
- Benzodiazepines
- H2 blockers
- Zolpidem
Medications with Dz Interactions:
Hx Fall or Fx
- Anticonvulsants
- Benzodiazepines
- Sedatives
- TCAs
- AntiHTN
- Hypoglycemic Agents
Advantages of Beers
- Lists Meds to Avoid
- Relatively evidence-based
- Only needs med review
Disadvantages of Beers
- Hasn’t prove to improve overall outcomes (mortality)
- Doesn’t discuss appropriate medications
Why do we avoid Anticoagulants?
- More sensitive; increasing age is risk factor for bleeding
- Risk increases when combined with other agents that increase risk for bleeding (NSAIDs, antiplatelets, etc.)
Why do we avoid meds in Pain Management?
- Sensitive to constipating and sedating effects of opioids; exacerbated by concomitant anticholinergic medications
- Many have active metabolites (morphine) which are renally cleared
- NSAIDs can worsen renal function, CHF, hypertension, increase risk for bleeding, and increase risk for cardiovascular events (almost all agents)
Why do we avoid meds in HTN?
- Risk for orthostatic hypotension higher with specific agents and/or classes
- More sensitive to blood-pressure lowering effects
- Diuretics may exacerbate incontinence issues or lead to dehydration
Why do we avoid meds in Depression/Anxiety?
- Certain agents have high anticholinergic burden
- Certain agents can be strongly sedating
Why do we avoid meds in Heart Failure?
- Metoprolol succinate may be better option vs. carvedilol
- Diuretics may cause hypotension and/or electrolyte abnormalities
Why do we avoid meds in Osteoporosis with fall risk?
- Proper treatment essential (bisphosphonate, calcium and vitamin D) to reduce future risk
- Minimize risks for additional falls/fracture by avoiding medications which increase risk for falls
Why do we avoid meds in DM?
- Sliding scale insulin and glyburide (Beers List); start at lower insulin doses
- Hypoglycemia increases risk for syncope, falls
- Metformin and SCr cutoffs
Why do we avoid meds in Allergies?
- Antihistamines: 1st generation vs. 2nd generation
