Geriatric & Polypharmacy

Question 1

What does Part A of Medicard Cover?

Answer 1

Hospital, hospice, and short term nursing home afer hospitalization

Question 2

How long will Medicare Part A pay for nuring home care after hospitalization?

Answer 2

90 Days

Question 3

What does Medicare Part B cover?

Answer 3

Physician services, outpatient, durable medical and preventive

Question 4

What does Medicare Part C cover?

Answer 4

MEdicare advantage( HMOs, PPOs, PFFs)

Question 5

What does Medicare Part D cover?

Answer 5

PRescription drugs

Question 6

What is MEDIGAP?

Answer 6

A supplementary plan to cover gaps between parts A and B

Question 7

Who is ineligible for Medicare?

Answer 7

Persons who were never in the workforce or a non-working spouse of person who does work

***You can buy into it later on

Question 8

Who does Medicaid cover?

Answer 8

1. Poor- “Aiding your broke ass!”
2. Disabled
3. Covers extended nursing home stays
4. Waiver for home health care

Question 9

How man prescriptons does Tenncare, the medicaid on TN cover before out-of-pocket payment?

Answer 9

5

Question 10

Drug coverage under Medicaid is a state benefit.

True/ False

Answer 10

True

Question 11

Outside of Medicaid and Medicare, how do people pay for care?

Answer 11

VA(includes long term care)

Long term care insurance

Family Savings

Question 12

Where do people receive care?

Answer 12

Patient’s home
Physician’s office or outpatient clinic
Hospital
Assisted living facilities
Nursing Homes
Hospice

Question 13

Are assisted living facilities coverd by medicare/medicaid?

Answer 13

No

Question 14

What are some scenerios that are a part of normal aging?

Answer 14

1/4-misuse problem(football leads to knee injury)

1/4 due disease

1/4-disuse(sedentary lifestyle)

1/4 due to

Question 15

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)

Answer 15

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)

Question 16

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

Question 17

What is considered a non-presentation in Hx taking?

Answer 17

When the patient is sick but the pathology(signs/symptoms) may not be present.

Question 18

What is considered a nonspecific presentation?

Answer 18

When a patient comes in with vague symtoms.

i.e confusion, apathy, self-neglect, anorexia, falling, incontinence, fatigue, dyspnea)

Question 19

What are some examples of an altered presentation?

Answer 19

• Depression without sadness
• Infection without fever, leukocytosis, tachycardia
• MI without chest pain
• Pulmonary edema without dyspnea
• Silent surgical abdomen
• Silent malignancy

Question 20

Define Frailty.

Answer 20

“Feeble Fallers are Frail”

Question 21

What are ADLs?

Answer 21

Activities of daily living; Things that you have to do everyday to maintain yourself

i.e Toilet, feeding, dressing, grooming, ambulation, bathing

Question 22

How many daily functions must be lost before consideration into the nursing home?

Answer 22

2 of the following

i.e toilet, feeding, dressing, grooming, ambulatory, bathing

Question 23

What are IADLs?

Answer 23

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.

Question 24

What are some examples of Geriatric syndromes?

Answer 24

• Dementia, Delirium
• Urinary incontinence
• Falls & Gait Abnormalities
• Behavioral changes
• Weight loss
• Dizziness
• Poor nutrition or feeding impairment
• Sleep disorders

Question 25

Approximately what percentage of the population are older adults consumers of prescription drugs?

Answer 25

25-30%

Question 26

Approximately what percentage of the population are older adults consumers of OTC drugs?

Answer 26

40%

Question 27

About how many prescription drugs are used by ambulatory adults?

Answer 27

2-4

Question 28

How many prescription drugs do long-term residents use on a daily basis?

Answer 28

2-10

Question 29

About how many people over \>60 are hospitalized from the use of prescription drugs?

Answer 29

1/3

Question 30

How many people over the age of 60 die due to prescription drugs?

Answer 30

1/2

Question 31

Misuse is the 5th leading cause of death. True/False

Answer 31

True

Question 32

What percentage of people over 60 yrs do not take meds as directed?

Answer 32

~40%

Question 33

What are some things that should be considered when prescribing meds to people over 60?

Answer 33

•Polypharmacy (& associated risks) * Age and disease-related changes in pharmacokinetics and pharmacodynamics * Adverse drug reactions •Compliance issues

Question 34

What is polypharmacy?

Answer 34

Use of more than 1 chemcial agent to effect a therapeutic endpoint(TD)

Question 35

Why is there a greater prevalence of polypharmacy in older adults?

Answer 35

* 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..)

Question 36

Polypharmacy predisposes the patient to taking medication incorrectly. True/ False

Answer 36

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!!

Question 37

What increases the probablity of taking medications incorrectly?

Answer 37

•Overlapping (“additive”) or antagonistic pharmacologic effects •Adverse drug reactions: ----drug-disease, drug-drug •Patient non-compliance

Question 38

Define an adverse drug reaction.

Answer 38

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!

Question 39

Adverse drug reactions may be undetected in older adults b/c they can mimic the characterisitics of problems, diseases, or symptoms. True/False

Answer 39

True

Question 40

Name some common adverse drug reactions in the Elderly.

Answer 40

* Cognitive status- \*\*Confusion is the most common * Accidents and Falls(especially with anticholinergic effects) * Renal toxicity * Hepatic toxicity

Question 41

What is the Beers Criteria?

Answer 41

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

Question 42

Which are of pharmacokinetics is the least affected by normal aging? Absorption Distribution Metabolism Excretion

Answer 42

Absorption

Question 43

What are some age-realted chagnes to the GI tract that may affect absorption?

Answer 43

* Decrease in # of absorptive cells * Decrease gastric acidity( inc. gastric pH) * Decrease GI blood flow and motility

Question 44

What are some age-realted chagnes to the GI tract that may affect distribution?

Answer 44

* 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

Question 45

What are some age-realted chagnes to the GI tract that may affect metabolism?

Answer 45

* Dec. in liver mass & blood flow + concomitant diseases, nutritional status, genetics = potential for dec. in hepatic function

Question 46

What are the results of a decreased metabolism?

Answer 46

* 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

Question 47

Liver function tests do not entirely represent the extent of changes in the drug metabolism? true/false

Answer 47

True

Question 48

What are some age-realted chagnes to the GI tract that may affect elimination?

Answer 48

* Dec renal funtion( dec GFR) * Drug interactions * Presence of multiple diseases

Question 49

Recall that serum creatinine is NOT a reliable measurement of renal function

Answer 49

Use clearance ## Footnote _140 - age in yrs x weight in kg_ 72 x serum creatinine (% mg/100mL) for women, multiply result by 0.85

Question 50

WATCH for Drugs requiring low dosing due to decreased renal function!!

Answer 50

Ex. * Allopurinol * Digoxin * Many cephalosporins * Ciprofloxacin * Histamine receptor antagonists (e.g., cimetidine, ranitidine, famotidine) * Venlafaxine * Morphine

Question 51

**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

Question 52

What are some drugs where the toxicity for drugs with age-related decrease effects?

Answer 52

Beta-blockers and tolbutamide

Question 53

What are some potential barriers of non-adherence?

Answer 53

Physiological factors Behavioral/attitudes Tx-related factors Prescriber/pt interactions

Question 54

What are some assessments of adherence?

Answer 54

* 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