Geriatrics Flashcards
Define opportunities for pharmacists in the care of older adults in various settings.
inpatient medical/surgical unit (wards) - consultant based
retail pharmacy - vaccines, medication regimen review
ambulatory care pharmacy - anti-coagulation management, cardiovascular risk reduction, medication review management; retail pharmacy roles stems from this
long term care
What are the key roles of the pharmacist when caring for older adult patients in LTC?
support providers to answer questions about meds
consult on medication regimens, recommned initiation or adjustments of medications based on clinical data
serve as a provider with prescriptive authority
Pharmacy services in LTC
supply, distribute, secure medications for short-stay (rehab), assisted living, and long-stay/permanent residents
Consultant pharmacy services
review medication administration, patient charts, medication storage at monthly or 3-month intervals
Sample communication
often multiple copies (chart, provider, pharmacist records)
identify, explain drug therapy problem
recommend action
physician/provider response
Identify medications that may result in more adverse events than benefits in older adults.
sedative/hypnotics
neuroleptics/antipsychotics
antidepressants
opioids
loop diuretics
alpha-blockers
medications with anticholinergic properties - focuse on risk of cognitive impairment
sedatives, medications with CNS effects (falls, dizziness)
diabetic agents: sliding scale insulin, long-acting sulfonlyureas
medications that may exacerbate chronic conditions (heart failure)
Medication problems in the older adult
age-related increase in chronic conditions = higher medication use
polypharmacy
nonadherence
altered pharmacokinetics
Polypharmacy
medications without indication
medications treating ADR
60% understand medications well, leaving 40% that need our attention
Nonadherence
over 200 barriers to adherence
aging NOT one
Beers criteria
criteria for potentially inappropriate medication use in older adults (age 65 yrs and older)
evaluates risks of medications against benefits with specific considerations for older people
Identify safer alternative medications for older adults.
Beers criteria alternatives:
anticholinergies: several, indication specific
sedatives: non-pharmacologic, other treatments for anxiety
sulfonylureas: shorter acting agents, relaxed treatment targets
Goals of care for older adults
maintain independence (daily activities, finances, transportation)
avoid need for institutionalization
maintain QOL
maintain functional ability
Functional abilities in older adults
activities of daily living (ADLs): dressing, bathing, transferring, feeding, toileting, walking/ambulation
instrumental activities of daily living (IADLs): handling finances, shopping for groceries, meal prep, using a phone, housekeeping/laundry, handling medications, using transportation
Risk factors for functional decline
age
immobility/exercise intolerance
poor muscle strength
poor balance
malnutrition, weight loss
hospitalizations
morbidity from chronic disease
cognitive impairment
depression
Physiologic changes associated with aging
decreased total body water
decreased lean body mass
increased body fat
decreased baroreceptor response/activity
reduced heart rate variability
decreased hepatic blood flow
decreased renal blood flow
decreased neurotransmitter volume (sensitivity to CNS adverse effects)
Pharmacokinetic changes with aging
generally no change in bioavailability of most drugs (but slower Tmax)
Water soluble drugs
ex. atenolol
decrease Vd and increase concentration of water-soluble drugs
Lipid-soluble drugs
ex. rifampin
increase Vd and increase T1/2 of lipid-soluble drugs
Hepatically-cleared drugs
ex. propranolol
decrease clearance and increase T1/2 of most hepatically-cleared drugs
Renally-cleared drugs
ex. atenolol
decrease clearance and increase T1/2 of most renally-cleared drugs
Rate of change is
unique to each person
Describe the roll of palliativce care and advance care directives supporting end of life care in older adults.
palliative care: after diagnosis of terminal illness, disease not responsive to curative treatment or treatment doesn’t exist
hospice care: provided at home, in LTC, or independent facility
Palliative care treatment
medical, psychological, social, spiritual care for patient and family
optimize QOL, focus on symptoms only, not life-prolonging
stop meds not improving QOL
Hospice care treatment
life expectancy of 6 months or less, certified by MD
home or institution-based, interdisciplinary
diagnostic tests, hospitalizations, labs no longer covered
Beers criteria does not apply to
hospice/palliative care
What are the key roles of the pharmacist when caring for older adults pts in palliative or hospice care?
align meds with goals
ensure effective control of bothersome symptoms
educate family and providers of medication regimen
activate non-standard dosage forms if needed
support financial concerns
ensure safe and legal disposal of medications
Common conditions and symptons that may be managed
pain
anxiety
insomnia
difficulty swallowing
fatigue
constipation/diarrhea
bowel obstruction
delirium
dyspnea
nausea/vomiting
edema
dry mouth
restlessness
respiratory congestion
Paths to death
varied, unpredictable
contradicts what many perceive
planning ahead can mean better QOL
Evidence shows that palliative care:
reduces burden of treatment
reduces transitions, time in acute care settings
optimizes comfort measures - better pain management
greater family satisfaction with care
Advanced care directives
verbal and written instructions about future medical care & treatment
elective, do not take away your right to make current care decisions
include: health care representative - names someone to make decisions if you are unable (or prevents someone from making decisions for you); psychiatric advance directive - sets preferences re: mental illness during periods of incapacity; power of attorney - financial or health care grants power to others you choose
Physician orders for scope of treatment
legal document declaring: preferences for resuscitation, medical interventions, antibiotics, artificial nutrition
agreement between pt (or legal guardian) and physician
must be signed and dated to be valid
How do we define older adult?
disparities in aging
sub-populations -
age strata: 60-70, 71-80, 81-90, >90
health & functional status: frail vs. non-frail older adults (# of comorbidities or functional status)
living or caregiving environment: community-dwelling, assisted living, comprehensive care, dependent vs independent
Healthy aging
process of developing and maintaining the functional ability that enables wellbeing in older age
functional ability is about having the capabilities to engage in activities one values
Healthy aging - mental health
prevent or treat mood disorders & cognitive impairment
Healthy aging - nutritional health
prevent or treat deficiencies, diabetes
Healthy aging - cognitive health
education, cognitively stimulating exercises, social activity
More healthy aging
stable housing
physical health
access to health care (preventive)
Recommendations for rational prescribing
recognize new symptoms as potential adverse reactions
optimize non-pharmacologic treatment options
make single changes at a time
align medication use with patient values
minimize regimen and promote adherence
avoid medications with high risk of adverse events and modest benefit
review dose and frequency against renal and hepatic function
define reasonable targets for chronic disease
Considerations in choosing medications
life expectancy
goals of care
treatment targets
time required to benefit
Deprescribing
supervised process of tapering or stopping drugs, aimed at minimizing polypharmacy and improving patient outcomes
Deprescribing considerations
align medication use with priorities
multiple stakeholders to support changes
incorporate safer alternatives
maintain symptom/management
