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308: Pharmacology > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What problems in medication can you identify in this patient?

85 yr old frail female admitted after a fall

Meds include

Warfarin, Perindopril, Diazepam, Ibuprofen, Furosemide, Sertraline, Amlodipine, Prochorperazine, Betahistine

A
  • Warfarin/Ibuprofen>>bleeding
  • Ibuprofen/Diuretic/Perindopril>>ARF
  • Sertraline>>Low sodium/GI bleeds
  • Diazepam>> sedation
  • Antihypertensives (Amlodipine) in those who fall
  • Prochlorperazine (anti-emetic) >> Parkinsonism
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2
Q

How is drug absorption different in the elderly and how does this apply clinically?

A

reduced rate of absorption and decrease the time of steady-state of the drug in circulation

  • Levodopa- competes with nutrients
    • plan dosing to avoid meal times
  • Bisphosphonates
    • advise to take on empty stomach sitting up 30 minutes before food
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3
Q

How is drug absorption different in the elderly and how does this apply clinically?

A

reduced rate of absorption and decrease the time of steady-state of the drug in circulation

  • Levodopa- competes with nutrients
    • plan dosing to avoid meal times
  • Bisphosphonates
    • advise to take on empty stomach sitting up 30 minutes before food
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4
Q

how is volume of distribution measured

A

amount of drug in the body/ concentration in plasma

Vd affects the half-life and duration of effect of the drug

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5
Q

How does muscle mass in elderly people affect the volume of distribution?

Give a clinically significant drug

A
  • as you get older you lose more lean muscle mass
  • therefore drugs that distribute into the muscle have less muscle to go to →
  • increased plasma concentration of that drug
  • Digoxin distributes well into the muscle however can result in digoxin toxicity in the elderly due to reduced lean muscle mass
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6
Q

What are the side effects of Digoxin toxicity?

A

Cardiac

  • heart block, bradycardia, junctional tachycardia

Psychiatric

  • delirium, fatigue, malaise, confusion, dizziness

Visual

  • blurred or yellow-green vision, halos, double vision, photophobia

Gastrointestinal

  • nausea, vomiting, anorexia, diarrhoea, abdominal pain
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7
Q

How do you safeguard for Digoxin toxicity?

How would you treat it?

A

A patient with normal digoxin levels (1-2 ng/mL), 6 hours post-dose but renal insufficiency or severe hypokalemia may have more serious cardiotoxicity than a patient with high digoxin levels and no renal or electrolyte disturbances.

Treat by withdrawing drug/correcting electrolytes

Severe- digoxin specific antibody fragments (Digibind)

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8
Q

How does body fat in elderly people affect the volume of distribution?

Give a clinically significant drug

A
  • increased body fat → increased Vd for fat-soluble drugs e.g BZD, Haloperidol
  • this increases the half-life of the drug
  • the Vd of Diazepam is double in elderly
    • the half-life also increases from 24 hours to 90 hours in the elderly
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9
Q

What are symptoms of Benzodiazepines?

A

Drowsiness

Confusion

Ataxia

Dependence

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10
Q

How can Benzodizapine overdose be treated/ reversed?

A

Flumazenil 200mcg

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11
Q

How does Body water in elderly people affect the volume of distribution?

Give a clinically significant drug

A
  • decreased body fat → decreased Vd for water-soluble drugs e.g Gentamicin
  • resulting in increased plasma concentration
  • therefore a lower loading dose should be prescribed
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12
Q

How does serum albumin in elderly people affect the volume of distribution?

Give a clinically significant drug

A
  • ↓Albumin 12-25% - further depressed by heart failure, renal disease, rheumatoid arthritis, hepatic cirrhosis some malignancies
  • Drug binding capacity ↓ 12-25%
  • ↑ free drug e.g
    • Phenytoin, warfarin, propranolol, diazepam, levothyroxine, digoxin, furosemide
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13
Q

What are signs and symptoms of Phenytoin toxicity?

A
  • Nausea, vomiting
  • Tremor
  • Ataxia
  • Nystagmus
  • Coarse facies
  • Hepatitis
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14
Q

What is the interaction between warfarin and Aspirin?

A
  • Warfarin is highly bound to plasma albumin (99%)
  • Warfarin has narrow therapeutic index
  • Warfarin has a small volume of distribution
  • Aspirin can displace warfarin from plasma albumin
  • Displacement of 1-2% of bound warfarin doubles or triples concentration of free warfarin
  • ↑ bleeding
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15
Q

What are the adverse effects of antiplatelet agents?

A

Aspirin

  • Peptic ulcer disease
  • Bleeding tendency
  • Fluid retention
  • Renal failure
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16
Q

What are the adverse effects of anticoagulant agents?

A

Warfarin or DOAC

  • Bleeding tendency
  • Interaction
17
Q

Explain how Liver metabolism is affected in the elderly

A
  • ↓ liver volume – up to 30% reduction
  • ↓ liver blood flow 12-40% (extremely variable)
  • ↓ first-pass metabolism due to ↓ blood flow
  • ↓ enzyme activity CP450 (frail elderly)-
  • ↓ clearance of drugs = ↑ t1/2
  • Eg. antidepressants, antipsychotics, beta blockers, opiates, benzodiazepines, calcium channel blockers, theophylline, warfarin, phenytoin, NSAIDS, paracetamol, erythromycin
18
Q

How is Excretion affected in the Elderly?

what are its therapeutic implications?

A
  • Renal blood flow
  • ↓ Renal mass (20%)
  • ↓ Renal function (nephrons 30%)
  • GFR declines by 1% per year from age 40

therefore reduced clearance of drugs that are more than 60% excreted by kidneys

  • reduce dose in once-daily preps
  • increase dosage in more frequently administered drugs

Lithium (may need dialysis) and Morphine (conjugated product are more potent not indicated in renal failure)

19
Q

What are signs of Morphine toxicity?

treatment?

A
  • Nausea, vomiting
  • Constipation
  • Drowsiness
  • Respiratory depression
  • Hypotension

treat with Naloxone IV 400mcg

20
Q

What are some drugs that are pharmacodynamically increased in the elderly?

A
  • Alcohol causes increase is drowsiness and lateral sway in older people than younger people at same serum levels
  • Benzodiazepines (↑) – enhanced sedation
  • Warfarin (↑)
  • Hypotensives (↑) – postural hypotension
  • GI effects of NSAIDs (↑)
  • Central effects of anticholinergics (↑)
21
Q

What are some drugs that there effects are pharmacodynamically decreased in the elderly?

A
  • ß1 modulators in cardiac tissue (↓)- down regulated by 1/3
  • Reduced & delayed bronchodilatory response to β-agonists
  • Calcium channel blocking effect on PR interval (↓)
22
Q

What are side effects of ACE inhibitors

A
  • Hypotension
  • Potassium increase
  • Renal failure
  • Cough
23
Q

What are side effects of Calcium channel blockers?

A
  • Hypotension
  • Fluid retention
  • Negatively Inotropic
24
Q

What are side effects of Diuretics?

A
  • Hypotension
  • Hypokalemia
  • Hyponatraemia
  • Confusion
  • Dehydration
25
Q

What are side effects of Antipsychotics - Haloperidol?

A
  • Confusion
  • Sedation
  • Parkinsonism
  • Tardive Dyskinesia
  • Neuroleptic malignant syndrome
26
Q

What are side effects of Tricylic antidepressants

A
  • Cardiac arrhythmias
  • Drowsiness
  • Dry mouth
  • Constipation
  • Urinary retention
27
Q

What is the STOPP/START criteria?

A

evidenced-based criteria used to review mediation regimens in elderly people

Screening Tool of Older person potentially inappropriate Prescriptions

Screening Tol to Alert to Right treatment

28
Q

What are examples of the START criteria

A
29
Q

What are examples of STOPP criteria?

A
30
Q

What are risk factors for Adverse drug effects in elderly people with polypharmacy?

A
  • ≥ 6 chronic diseases
  • ≥ 12 doses/day
  • ≥ 9 medications
  • Low BMI (<22 kg/m2) - Likely
  • Age > 85 years
  • Creatinine Clearance <50mL/min - Likely
  • History of prior ADE - Likely
  • Nursing Home resident
31
Q

What physiological changes in pharmacodynamics and kinetics are associated with Neurological diseases?

A
  • Reduced neurotransmitter levels
  • Impaired cerebral blood flow
  • Greater sensitivity to neurological effects
32
Q

What drugs have increased pharmacodynamic response in the elderly?

A
  • Warfarin
  • Benzodiazepines
  • Diltiazem (calcium channel blocker)
33
Q

What drugs have a decreased pharmacodynamic response in the elderly?

A
  • Beta-blockers
  • Beta 2- agonists
  • Furosemide

308: Pharmacology (11 decks)

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