Geriatrics Flashcards
Geriatric Population
The fastest growing segment in the US population is people 65 years of age and older; population older than 85 years of age is growing even faster
- By 2030 approximately 1/5 will be older than 65 years of age
- Older adults account for 1/3 of prescription drug use, whereas it is only 13% in the general population
- Polypharmacy common in older adult population
- Emergency visits for ADRs more common in older adults than in younger adults
- Functional status changes often make medication management difficult
Physical Changes Associated with Aging
Mental Changes
- Increased susceptibility to delirium and cognitive side effects of drugs
Sensory Changes
- Sight: 1/3 of older adults have visual impairment
- Hearing: 1/3 of older adults have hearing impairment
- Smell & Taste: diminished smell & taste may impair nutrition; compounded by medications
- Peripheral sensation contributes to fall risk: compounded by medication
Musculoskeletal changes
Geriatrics: Pharmacokinetic Changes
Absorption: not dramatically different in older adults compared with younger adults
Distribution: increased fat stores, decreased total body water & serum albumin
Metabolism: decreased hepatic blood flow, decreased cytochrome (CYP) 450 system function
Excretion: decreased renal mass & glomerular filtration rate & tubular secretion; serum creatinine an unreliable marker of renal function
Geriatrics: Pharmacodynamic Changes
- Reduced homeostatic mechanisms
- Altered receptor sensitivity
- Increased sensitivity to drugs
Geriatrics: Pharmacotherapeutics
High risk for ADRs
- Nonadherence: intentional and unintentional
- Unsafe practices
- High prevalence of use of OTC and herbal therapies
- Polypharmacy
- – Risk of drug-drug interactions
- – Prevalence of comobidities
- – Using one drug to treat side effects of another
General Principles for Prescribing for Older Adults
- Before prescribing, collect a “complete” drug history; revisit at least every 6 months
- Avoid a drug if benefit is only marginal
- Evaluate drug list for duplications
- Review drug list for ADRs, and query patient
- Prescribe nonpharmacological treatments, whenever possible
- Ensure patient symptom is not part of normal aging
- Make risk predictions
- Start low and go slow
Geriatrics: Self-Management Practices
- Need to maintain a medication list, including allergies and ADRs
- Brown bag to each visit
- Drug information sheet
- Use of pill box
- Reconciling medications with all care transitions
Geriatrics: Functional Assessment
- Ability to manage ADLs & cognitive status strong indictors of ability to manage medications
- Social support important to assess
- ADL assessment: Katz ADLs, Lawton instrumental ADL
- Assessment of vision and hearing
- Cognitive Status Assessments: Geriatric Depression Scale, Mini-Mental State Examination, or Mini-Cog
- Medication management ability assessment, medication-assisted treatment
Geriatrics: Improving Adherence
- Assess potential causes of unintentional nonadherence
- Ensure functional status allows for appropriate medication use
- Perform home assessment of frail older adults
- Collaborate with pharmacist to check for drug-drug/drug-food interactions or duplications
Geriatrics: Inappropriate Prescribing
Avoid drugs that:
- Have narrow therapeutic ranges
- Have slow elimination rates
- Totally depend on kidney excretion
- Have have drug-drug interactions
- Have high ADR profiles
Beer’s Criteria
Start/stop tools
Geriatrics: Beer’s Update
In 2019, Beer’s list dropped some medications that increase fall risk and issues in older adults
- these medications are still of concern, however
- there medications cause issues in ALL patients
- they are not geriatric-specific alerts
Geriatrics: Private Homes and Independent Living- Prescribing Considerations
Social Support Communication with caregiver Caregiving limitations Home care for homebound patients - Skilled - Unskilled ---Reasonable caregiver expectations
Geriatrics: Assisted Living- Prescribing Considerations
- Home-like, not medical environment
- Variable regulatory standards
- Variable nursing support
- Medication administration issues
- Cognitive impairment common
- Caregiver knowledge limited
- Written medication orders for OTC, prescription, and herbal products required
Geriatrics: SNF- Prescribing Considerations
Oversight by pharmacist and RN in facility
All medications must be linked with diagnosis
Queries by pharmacists common
Numerous quality improvement opportunities related to medication use
