Geriatrics 5 - polypharmacy

Question 1

Polypharmacy

Answer 1

many drugs, unnecessary medications

ADR increases

Question 2

ADR in elderly - how can they present?

Answer 2

cognitive loss/delirium 
incontinence 
dehydration 
dizziness 
immobility 
fatigue 
depression 
insomnia 
falls

Question 3

End result of ADR in the elderly

Answer 3

functional capacity loss
poor QOL
nursing home

Question 4

Average number of medications taken by 85 year old

Answer 4

8-9 prescribed and 2OTC

Question 5

Why do elderly take more medications?

Answer 5

more acute and chronic conditions
more doctor visits
drugs given to counteract side effects

Question 6

Prescribing cascade

Answer 6

drug 1 given

second drug given as ADR misinterpreted for new condition and so on

Question 7

Healthcare provider factors leading to polypharmacy

Answer 7

no medications review on a regular basis
patients expect meds?
unclear instructions given on taking medications
“best” drug for a problem
no effort to simplify regimen
order automatic refills

Question 8

What is affected in absorption of drugs in elderly?

Answer 8

RATE not the extent

Question 9

Example of absorption changes in elderly

Answer 9

less saliva produced

GTN reduced rate of absorption

Question 10

Drug exception in elderly absorption

Answer 10

levodopa - saliva enzyme metabolises this but there is less saliva

Question 11

3 main factors affecting distribution in elderly

Answer 11

body composition
protein binding
increased permeability across blood-brain barrier

Question 12

Body composition changes affecting absorption

Answer 12

reduced muscle mass
increased adipose tissue
reduced body water

Question 13

Fat soluble dugs in elderly and example

Answer 13

increased Vd, increased T1/2, increased duration of action

diazepam

Question 14

water soluble drugs in elderly and example

Answer 14

decreased Vd, increased serum levels

digoxin

Question 15

Protein binding - distribution and example

Answer 15

decreased albumin, less binding and increase serum levels of acidic drugs
furosemide

Question 16

2 things affecting hepatic metabolism with age

Answer 16

decreased liver mass and blood flow

Question 17

Consequences of metabolism changes in elderly

Answer 17

toxicity as reduced metabolism and excretion

reduced 1st pass metabolism

Question 18

which drugs bioavailability would decrease in elderly?

Answer 18

pro-drugs eg enalapril

Question 19

Excretion changes in elderly

Answer 19

renal function decreases with age

increased half life and toxicity

Question 20

Pharmacodynamics in elderly

Answer 20

change in receptor binding
decrease in receptor number
altered translation of a receptor initiated cellular response to a biochemical reaction

Question 21

2 drug examples of pharmacodynamics in elderly

Answer 21

warfarin - increased anti-coagulation

diazepam - increased sedation

Question 22

Drugs most associated with ADR’s

Answer 22

NSAIDS
diuretics 
warfarin 
ACEI 
anti depressants 
beta blockers
anticholinergic and sedatives

Question 23

Anticholinergic drugs

Answer 23

overactive bladder, TCA, anti emetics, anti-psychotics

Question 24

Main principles for prescribing in elderly

Answer 24

be clear about diagnosis to avoid ADR prescribing
lower doses
review new drug and check if achieving aim
review all prescriptions and stop if not working

Question 25

3 prescribing tools and guides

Answer 25

beers criteria
STOPP-START criteria
NHS Scotland polypharmacy guidance

Question 26

deprescribing

Answer 26

to reduce, substitute or discontinue a drug

Question 27

reasons for deprescribing

Answer 27

ADR - better alternative - not effective - drug drug interaction - drug disease interaction - minimise polypharmacy

Question 28

proactive deprescribing - what drugs?

Answer 28

antihypertensive
anti psychotics
benzodiazepines