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Fall'20 Pharmacology III > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

In the absence of specific information, it is generally prudent to do what when administering drugs to aged patients?

A

“Start low and go slow”

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2
Q

Aging has been described as a progress I’ve loss of…

A

Physiologic processes necessary to maintain homeostasis

Death being the ultimate failure of these mechanisms

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3
Q

In the elderly passive gastric absorption is

A

Not markedly altered

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4
Q

Drugs that inhibit intestinal motility have greater effect than

A

Age

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5
Q

Due to erratic absorption and a tendency to develop sterile infiltrates, IM and SQ injections are generally recommended or not in the elder patients?

A

Not!

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6
Q

Total Body water is decreased by what % in elderly?

A

10-15%

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7
Q

Due to decreased thirst, elder patient may be

A

Dehydrated

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8
Q

A decrease in TBW, in combination w/changes in the distribution of CO, results in a

A

Decreased central compartment volume

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9
Q

Initial plasma concentrations following rapid IV admin may be increased b/c of the decreased size of the central compartment, yet the steady state distribution vol is?…. and why?

A

May be larger d/t increased body fat

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10
Q

Body fat increases and muscle mass decreases in the elderly by what%?

How does this impact lipophillic drugs?

A

20-40%

So lipophillic drugs will have a large vol of distribution

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11
Q

Even in healthy and exercising elderly, what is lost?

A

Muscle mass

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12
Q

Failure to adjust for weight raises concern for this?

A

Over medication

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13
Q

Are plasma protein levels a major concern in geriatric pharmacology?

A

No - not been identified

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14
Q

Hepatic blood flow declines how much?

Liver mass reduces?

A

20-53% while liver mass is reduced 11-36%

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15
Q

Tell me about hepatic function of the elderly in regards to:

Endoplasmic reticulum
Hepatic extracellular space
Bile flow

A

Endoplasmic reticulum is diminished
Hepatic extracellular space increased
Bile flow decreased

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16
Q

What phase of liver metabolism is effected in the elderly? Why?

A

Phase I - which is catalyzed mainly by microsomal CYP450 enzymes may be decreased.

Enzyme activity is relatively preserved.

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17
Q

Are phase II reactions affected in old age?

A

Appears to be unaltered

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18
Q

Generally, age reduces clearance of flow-limited drugs by what ___%? Similar to the decrease in hepatic BF, but there’s is no alteration for _______ drugs.

A

30-40%

Capacity limited

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19
Q

How much does GFR decrease per yr?

A

1ml/yr

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20
Q

What’s the overall consensus generally about renal function and aging?

In the absence of disease

A

Although there is a small decrease in GFR, it probably decreases less than once thought.

Aging doesn’t appear to diminish renal drug excretion significantly

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21
Q

In the elderly what happens to CO?

With coexisting disease, what happens to circulation time?

A

CO is maintained.

With coexisting dx - circulation times appear to increase

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22
Q

Due to increased circulation times and the delay of initial drug effects, what is a prudent action to reduce overdose and adverse CV impact?

A

Slower bonus injections

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23
Q

Opioid elimination occurs mainly by

A

Hepatic metabolism with renal excretion of metabolites and some parent drugs

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24
Q

What factors influence opioid metabolism?

A 
Genetics
Gender
Age
Environmental Factors
Current medications
Diet
Disease
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25
Q

Name three opioids with active metabolites:

A

Codeine, Morphine, Meperidine

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26
Q

The metabolites of some opioids that are active account many side effects as well as

A

Persistent analgesia

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27
Q

The primary risks of opioids with the elderly

A

Respiratory depression

The incidence is increased with age

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28
Q

Respiratory depression was more problematic with _____ vs meperidine.

What is seen in pts receiving fentanyl?

A

Morphine

And no resp depression in pts receiving fentanyl

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29
Q

Fentanyl is a highly selective:

A

Mu receptor agonist

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30
Q

Fentanyl is metabolized by

A

CYP3A4 to inactive and nontoxic metabolites

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31
Q

Early studies suggested what regarding fentanyl?

What was the conclusion?

A

Early - elimination 1/2 life was prolonged in the elderly as no change in vol of distribution was found.

Concluded that clearance was decreased and that fentanyl last longer in the elderly

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32
Q

Later studies found aging had minimal influence on fentanyl pharmacokinetics with what exception?

A

A transient concentration increase following the start of drug infusion

Attributed tod decreased rapid intercompartmental clearance

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33
Q

Aging effects pharmacodynamics or pharmacokinetics greater?

A

Pharmaco-Dynamics

“DEF”
“Dynamics effect fentanyl”

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34
Q

Elderly pts are more sensitive to fentanyl and should receive reduced doses. What should be similar to that of young pts?

A

The offset of drug effect (despite smaller doses)

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35
Q

With oral transmucosal fentanyl, what impact did aging have on the pharmacokinetics?

A

None.

However study in healthy older pts; so add co-morbidities and that could change

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36
Q

Fentanyl plasma concentrations depend on the rates of release and

A

Penetration through the skin layers

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37
Q

The mean half time (time for plasma concentrations to double after patch application) in younger (24-38yrs) and elderly (64-82) where?

A

Young: 4.2 and elderly 11.1 hours

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38
Q

In the elderly, integumentary system factors increased absorption of fentanyl overa. Longer period of time.

Despite this absorption delay, what is significant about the subcutaneous fat in elderly?

A

It acts as a secondary reservoir — prolonging release even after removal of patch

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39
Q

Morphine is metabolized by what?

It’s metabolites are?

A

Glucuronidation to morphine-3-glucoronide and to Morphine-6-glucuronide (M6G)

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40
Q

Tell me about M6G

Can it pass BBB?
Is it effective as an analgesic?
Eliminated by?

A

BBB crosses extremely slowly
It is an effective analgesic
Eliminated by the kidney

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41
Q

What is seen in pts with elevated creatinine concentrations with morphine administration?

Peak?

A

Accumulation of both morphine glucuronides

Peak effect approx. 90min after a bolus dose

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42
Q

Meperidine is a relatively weak mu-agonist. It has approx ___% effectiveness of morphine

A

10%

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43
Q

Half life of meperidine is

A

~3hrs

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44
Q

Meperidine is metabolized in the liver to normeperidine.

It’s half life is?
What can it cause in high concnetrations?

A

15-30hours

Causes agitation and seizures at high conc.

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45
Q

Meperidine has complex pharmacology… explain some of it

A

Local anesthetic activity
negative inotropic effects
Intrinsic anticholinergic props — may increase HR

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46
Q

When combined with MAOI’s, meperidine is associated with

A

Severe serotonergic reactions

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47
Q

Normeperidine likely accumulates in elderly due to reduced renal excretion with ..

A

Repeated doses

48
Q

Aside from tax for post op shivering, meperidine is not a good drug in the elderly.

It’s associated with this post op complication

A

Post op delirium

49
Q

Why do we want to stop shivering?

A

Increased myocardial o2 demand

50
Q

Remifentanil undergoes rapid hydrolysis by

A

Nonspecific tissue and plasma esterase

51
Q

Due to its rapid hydrolysis, after a 4 hour infusion, context sensitive half life of remifentanil remains at

A

4 mins

52
Q

Is remifentanil good in elderly populations?

A

Yes.

Onset and offset are slower in elders but blood concentrations are similar to younger pts

53
Q

After bolus injection; Peak drug effect of remifentanil

Young vs old

A

90s vs 2-3 mins in elder

54
Q

It’s recommended that elder subjects need about half the bolus dose of remifentanil than younger pts. How does this impact the effect of the drug?

A

Same drug effect

55
Q

Remifentanil has an increased pharmacokinetic or pharmacodynamic impact?

A

Pharmacodynamic

56
Q

Remi gtts need to be reduced about what of younger pts?

A

1/3 of younger pts

57
Q

Remi infusion rates are about one-third that of younger patients because of:

A

Combined impact of
INCREASED sensitivity and
DECREASED clearance

58
Q

Primarily b/c the elderly are more sensitive, opioid doses should be

A

Reduced by 50%

59
Q

Propofol pharamacodynamics are significantly altered with aging.

Loss of consciousness EC 50 values for 25, 50, and 75 yrs were?

A

25: 2.35 mcg mL-1
50: 1.8
75: 1.25

Nearly a 50% decrease

60
Q

Age related changes were found in both induction and infusion doses of propofol.

Pts older than 70 reached deeper EEG stages than younger pts.

They needed more time to reach the deepest EEG stage and….

A

Needed more time until a lighter EEG stage was regained

61
Q

In general - elderly need less propofol. Current literature suggests what % of reduction for induction bolus?

A

20%

62
Q

Tell me the dose range for propofol that may be appropriate for elderly?

A

0.8-1.2 mg/kg

63
Q

Propofol infusion rates to achieve a persistent level of moderate sedation are ______ in the elderly

A

Lower

64
Q

Recent data indicates that propofol clearance is altered more by what in females than in males.

A

Age

65
Q

This factor has not effect on BIS rate with increasing propofol concentration

A

Age

66
Q

Goal BIS monitoring number

A

50 (40-60);

Less than 40 = stage 4

67
Q

With increasing age what is known to decrease to a greater degree than BIS - but more slowly?

A

Systolic blood pressure

68
Q

Midazolam has been found to have significantly different _____ in elderly

A

Kinetic

69
Q

Midazolam Clearance is reduced in the elderly by what % from that of young adults.

A

As much as 30%

70
Q

Midazolam clearance reduction in the elderly is due to what two reasons:

A
  1. Loss of functional hepatic tissue

2. Decrease in hepatic perfusion

71
Q

Midazolam undergoes significant metabolism, primarily to:

A

Hydroxymidazolam

72
Q

Hydroxymidazolam is the primary metabolite of?

Is it active or inactive?

A

Midazolam

Active

73
Q

Hydroxymidazolam (pharmacologically active) is excreted:

May accumulate in patients with?

A

Renally excreted

Accumulate in patients with diminished renal function

74
Q

Why are elderly patients significantly more sensitive to Midazolam than younger patients?

A

Primarily b/c of a pharmacodynamic difference

75
Q

The recommended Midazolam dose reduction from the 20 yr old to the 90 yr old?

A

75%

76
Q

Paradoxical reactions are

A

When pts become agitated rather than sedated

77
Q

How do you tx paradoxical reaction to midazolam ?

A

Flumazenil may reverse the episode

78
Q

NMBD’s inhibit transmission at the NMJ and exert their effect

A

Postsynaptically

79
Q

In the elderly, the average muscle mass decrease is

A

25-35%

80
Q

Beyond the avg muscle loss, some elderly pts have significant muscle loss and weakness. This resulting state is defined as

A

Frail

81
Q

Aging is associated with structural changes at the NMJ. What is one of the intriguing alterations in elderly muscle?

A

The presence of extrajunctional acetylcholine receptors

…. have no known impact on NM function

82
Q

Young vs old patient; ED95 for NMBD?

A

Essentially the same

83
Q

With age, The pharmacokinetics of muscle relaxants are

A

Significantly altered

84
Q

Onset of NMBD’s is dependent on a number of factors including

A

Muscle mass
CO
— that may be altered in elderly

85
Q

Hepatically metabolized drugs

A

Vec and Roc

86
Q

Vec & Roc (hepatic metabolized) manifest

A

Prolonged recovery

87
Q

With Vec, in elderly vs younger pts; what is seen in regards to E 1/2t, clearance and recovery time?

A

Spontaneous recovery time was longer

  • E1/2 t was prolonged
  • plasma clearance was reduced
88
Q

Are their differences b/w young and old with the pharmacokinetics of atracurium and cisatracurium?

A

Minor

89
Q

Clearance of anticholinestearse in the elderly

A

May be prolonged.

…. may be beneficial given clinical applications

90
Q

Geriatric pts appear more susceptible to what SE associated w/the reversal of NMBlockade?

A

Cardiac arrhythmias

91
Q

NMBD doses in elderly?

A

Are not altered. But the clinician must wait longer for the full effect (pump is slower)

92
Q

Is the dose of anicholinesterase reversal drugs altered by aging?

A

No

93
Q

The principal physiologic mechanisms involved in the uptake and distribution of volatile anesthetics are

A

Minute ventilation and CO

94
Q

MV, CO and the blood/gas partition coefficient of the drug determine the rate of equilibration b/w

A
  1. The alveolar partial pressure and

2. The inspired anesthetic partial pressure

95
Q

Senescence is associated with majors changes to what functions?

However in healthy elderly pts, their baseline CO is maintained

A

both CV and pulmonary

96
Q

MV is typically controlled during anesthesia. So what is the cause for the decreased volatile dose concentration in elderly?

A

Pharmacodynamic

97
Q

In volatiles; this is a majore modifier of anesthetic action

A

Age

98
Q

Two analyses found a MAC reduction of

A

6% per decade of life (after 1 yr age)

Also seen in MAC-awake

99
Q

Is the MAC reduction found with aging consistent in all, some, or none of the gases?

Name them?

A

Consistent across all.

Halothane, enflurane, isoflurane, sevo, des and N2O

100
Q

On avg. volatile anesthetic MAC decreases what % per decade?

A

6.7% per decade

101
Q

MAC for Nitrous decreases what % (and over what time period?)

A

7.7% per YEAR

102
Q

MAC awake decreases with age

A

Proportionate to MAC

103
Q

Monk et al study reported that what two factors were significant independent predictors of increased mortality:

A
  1. Cumulative deep hypnotic time

2. Intraoperative hypotension

104
Q

Should we avoid volatiles in elderly patients?

A

There is no compelling evidence

105
Q

Increase in body fat and decrease in muscle mass means for lipophillic drugs:

A

They’ll have a large vol of distribution

106
Q

A decrease in total body water, in combo w/changes in the distribution of CO =

A

A decreased central compartment volume

107
Q

Does aging diminish renal drug excretion?

A

Not significantly

108
Q

Opioid doses in elderly should be reduced by

A

About 50%

109
Q

Pharmacokinetic changes are important only when

A

Long term infusions are contemplated (opioids?)

110
Q

Do you adjust the dose of Narcan with the elderly? If so, how

A

No alteration

111
Q

The primary risk with increased incidence in the elderly of opioids is:

A

Respiratory depression

112
Q

Sedative hypnotics should be SIGNIFICANTLY decreased in elderly.

To minimize hemodynamics consequences, Induction doses should be

A

Infused more slowly

113
Q

What’s one anesthetic that appears to have both pharmacokinetic and pharmacodynamic differences b/w young and old recipients?

A

Propofol

114
Q

Elderly patients may be most sensitive to what drug?

What kind of reactions may occur?

A

Midazolam

-may have paradoxical reactions

115
Q

Biggest take aways regarding NMBDs with the elderly?

A

Doses don’t need to be altered

But the clinician must wait longer for full effect

116
Q

MAC of volatiles in the elderly

A

Significantly reduced

Fall'20 Pharmacology III (14 decks)

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