Geriatric & Polypharmacy Flashcards
What does Part A of Medicard Cover?
Hospital, hospice, and short term nursing home afer hospitalization
How long will Medicare Part A pay for nuring home care after hospitalization?
90 Days
What does Medicare Part B cover?
Physician services, outpatient, durable medical and preventive
What does Medicare Part C cover?
MEdicare advantage( HMOs, PPOs, PFFs)
What does Medicare Part D cover?
PRescription drugs
What is MEDIGAP?
A supplementary plan to cover gaps between parts A and B
Who is ineligible for Medicare?
Persons who were never in the workforce or a non-working spouse of person who does work
***You can buy into it later on
Who does Medicaid cover?
- Poor- “Aiding your broke ass!”
- Disabled
- Covers extended nursing home stays
- Waiver for home health care
How man prescriptons does Tenncare, the medicaid on TN cover before out-of-pocket payment?
5
Drug coverage under Medicaid is a state benefit.
True/ False
True
Outside of Medicaid and Medicare, how do people pay for care?
VA(includes long term care)
Long term care insurance
Family Savings
Where do people receive care?
Patient’s home
Physician’s office or outpatient clinic
Hospital
Assisted living facilities
Nursing Homes
Hospice
Are assisted living facilities coverd by medicare/medicaid?
No
What are some scenerios that are a part of normal aging?
1/4-misuse problem(football leads to knee injury)
1/4 due disease
1/4-disuse(sedentary lifestyle)
1/4 due to
Normal Aging changes
General: ↑ Body fat; ↓ TBW (NOT OBESITY)
Eyes/Ears: ** Presbyopia, lens opacification, ↓ high frequency acuity. (NOT BLINDNESS)
Respiratory: ↓ cough reflex; ↓ lung elasticity; ↓ DLco; ↑ chest wall stiffness (NOT PNEUMONIA, DYSPNEA, HYPOXIA)
Cardiovascular: ↓ Arterial compliance; ↓ B-adrenergic responsiveness; ↓ baroreceptor sensitivity and SA node automaticity; ↑ BP (NOT SYNCOPE, HEART FAILURE OR HEART BLOCK)
GI: ↓ Hepatic function; ↓ acidity; ↓ colonic motility; ↓anorectal function (NOT CIRRHOSIS, FECAL IMPACTION OR INCONTINENCE)
Blood/Immune: ↓ Bone marrow reserve; ↓ T-cell function; ↑ autoantibodies (NOT ANEMIA, AUTOIMMUNE DISEASE)
Urogenital: Vaginal/urethral mucosal atrophy; prostate enlargement (NOT UTI, URINARY INCONTINENCE OR RETENTION)
Normal Aging Changes
Musculoskeletal: ↓ muscle; ↓bone density (NOT HIP FRACTURE)
- *Nervous system:** Brain atrophy; ↓Brain catechol & DA synthesis; ↓ righting reflexes; ↓Stage 4 sleep; ↓thermoregulation (NOT DEMENTIA, DELIRIUM, DEPRESSION, PARKINSONS, FALLS, SLEEP APNEA, HYPO- HYPERTHERMIA)
- *Endocrine:** See Dr. Clark’s lecture
What is considered a non-presentation in Hx taking?
When the patient is sick but the pathology(signs/symptoms) may not be present.
What is considered a nonspecific presentation?
When a patient comes in with vague symtoms.
i.e confusion, apathy, self-neglect, anorexia, falling, incontinence, fatigue, dyspnea)
What are some examples of an altered presentation?
- Depression without sadness
- Infection without fever, leukocytosis, tachycardia
- MI without chest pain
- Pulmonary edema without dyspnea
- Silent surgical abdomen
- Silent malignancy
Define Frailty.
“Feeble Fallers are Frail”
What are ADLs?
Activities of daily living; Things that you have to do everyday to maintain yourself
i.e Toilet, feeding, dressing, grooming, ambulation, bathing
How many daily functions must be lost before consideration into the nursing home?
2 of the following
i.e toilet, feeding, dressing, grooming, ambulatory, bathing
What are IADLs?
Instrumental activities of daily living
i.e
Paying bills; keeping records, shopping alone, playing games/hobbies; cooking & meal preparation; TV, books, radio & current events; traveling out of neighborhood.
What are some examples of Geriatric syndromes?
- Dementia, Delirium
- Urinary incontinence
- Falls & Gait Abnormalities
- Behavioral changes
- Weight loss
- Dizziness
- Poor nutrition or feeding impairment
- Sleep disorders
Approximately what percentage of the population are older adults consumers of prescription drugs?
25-30%
Approximately what percentage of the population are older adults consumers of OTC drugs?
40%
About how many prescription drugs are used by ambulatory adults?
2-4
How many prescription drugs do long-term residents use on a daily basis?
2-10
About how many people over >60 are hospitalized from the use of prescription drugs?
1/3
How many people over the age of 60 die due to prescription drugs?
1/2
Misuse is the 5th leading cause of death.
True/False
True
What percentage of people over 60 yrs do not take meds as directed?
~40%
What are some things that should be considered when prescribing meds to people over 60?
•Polypharmacy (& associated risks)
- Age and disease-related changes in pharmacokinetics and pharmacodynamics
- Adverse drug reactions
•Compliance issues
What is polypharmacy?
Use of more than 1 chemcial agent to effect a therapeutic endpoint(TD)
Why is there a greater prevalence of polypharmacy in older adults?
- Inc. symptoms resulting from Inc. prevalence of disease
- Drugs prescribed to treat side effects of other drugs
- Prescribers
- Drug advertising (…pills to cure all…stay young..)
Polypharmacy predisposes the patient to taking medication incorrectly.
True/ False
True: Pt may take wrong dose, wrong time, wrong purpose.
***IT is imperative to explain to your patient the purpose of the drug before they leave the office!!
What increases the probablity of taking medications incorrectly?
•Overlapping (“additive”) or antagonistic pharmacologic effects
•Adverse drug reactions:
—-drug-disease, drug-drug
•Patient non-compliance
Define an adverse drug reaction.
An undesired SE or toxicity casued by the administration of drugs
***Onset may be sudden or take days
In older patients: this may present as confusion!
Adverse drug reactions may be undetected in older adults b/c they can mimic the characterisitics of problems, diseases, or symptoms.
True/False
True
Name some common adverse drug reactions in the Elderly.
- Cognitive status- **Confusion is the most common
- Accidents and Falls(especially with anticholinergic effects)
- Renal toxicity
- Hepatic toxicity
What is the Beers Criteria?
A guidline for healthcare professionals to help improve the safety of prescribing medications for older adults.
It emphasizes deprescribing meds that are unnecessary to reduce problems of high risk-benefit ration, polypharmacy, drug interactions, and adverse drug reactions
Which are of pharmacokinetics is the least affected by normal aging?
Absorption
Distribution
Metabolism
Excretion
Absorption
What are some age-realted chagnes to the GI tract that may affect absorption?
- Decrease in # of absorptive cells
- Decrease gastric acidity( inc. gastric pH)
- Decrease GI blood flow and motility
What are some age-realted chagnes to the GI tract that may affect distribution?
- Inc in fat %
–fat soluble drugs will be asborbed faster and maintain longer
–in water soluble drugs they will not be absorbed quickly
- Dec in TBW
- Dec[plama protein]-may be more sensitive to drugs; need to drop dose
- Dec lean muscle mass
- Dec blood flow to organs
What are some age-realted chagnes to the GI tract that may affect metabolism?
- Dec. in liver mass & blood flow + concomitant diseases, nutritional status, genetics = potential for dec. in hepatic function
What are the results of a decreased metabolism?
- Inc concentrations of
1. benzos
2. tricyclic antidepressants
3. B-blockers
4. narcotic analgesics - Inc for potential for adverse events
- Lower doses may be therapeutic
Liver function tests do not entirely represent the extent of changes in the drug metabolism?
true/false
True
What are some age-realted chagnes to the GI tract that may affect elimination?
- Dec renal funtion( dec GFR)
- Drug interactions
- Presence of multiple diseases
Recall that serum creatinine is NOT a reliable measurement of renal function
Use clearance
140 - age in yrs x weight in kg
72 x serum creatinine (% mg/100mL)
for women, multiply result by 0.85
WATCH for Drugs requiring low dosing due to decreased renal function!!
Ex.
- Allopurinol
- Digoxin
- Many cephalosporins
- Ciprofloxacin
- Histamine receptor antagonists (e.g., cimetidine, ranitidine, famotidine)
- Venlafaxine
- Morphine
Morphine: Prolonged pain relief at lower doses
Benzodiazepines: Inc. sedation & postural instability (extended effect r/t long ½ life)
Warfarin: Inc sensitivity to anticoagulant effect
What are some drugs where the toxicity for drugs with age-related decrease effects?
Beta-blockers and tolbutamide
What are some potential barriers of non-adherence?
Physiological factors
Behavioral/attitudes
Tx-related factors
Prescriber/pt interactions
What are some assessments of adherence?
- Observation of home environment
- Ask client to gather all medications (Brown Bag Review)
- –Open ended questions regarding each medication (time consuming)
- -what drugs are they taking? how are they taking?
- Direct questions:
•“do you ever forget to take your medicines?” “how many times in the last week have you missed a dose?”
•“when you feel better do you stop taking your medicines”
•“sometimes if you feel worse do you stop taking your medicines?”
•
- Pharmacy refill patterns
