Geriatrics: Age-Related Changes Flashcards
Aging
is a pattern of life changes that occurs as one grows older
Cardio vascular changes in old patients are
Hypertrophy cause by increase build ups
Ischemic area cause by debris
Fibrosis is building of fiber that decrease elasticity
Cardiovascular Aging effects on heart rate can
Decreased maximum HR and resting heart rate is same ( but the ability of heart rate decrease to reach maximum threshold )
Decreased sensitivity to beta stimulation which can decrease sensitivity to beta-blockers
Cardiovascular Aging effects on Vasculature
Blunted baroreceptor reflex means the ability of heart rate decrease to compensate the volume when it is more
Cardiovascular Aging also cause
1) Orthostatic hypotension which cause low blood flow during movement
2) HFpEF (Heart failure with preserved ejection fraction)
3) Bradycardia and Exercise intolerance
Respiratory Aging cause an Increase in ____ and decreased in _______
an increase in Energy of breathing (means more energy needed to breathe) (especially in smokers)
Increase Airway resistance
Increase Dead space
and decrease in Respiratory muscle strength Chest wall compliance Total alveolar surface Vital capacity
Gastrointestinal Aging of stomach
Decreased gastric acid secretion ( it will be hard for pt to digest food and protect the stomach)
Decreased taste sensation
Dysphagia/aspiration (trouble swallowing)
GERD
Gastrointestinal Aging of small intestine leads to
Decreased absorption of calcium, folic acid, vitamin B12 Nutrient depletion Diverticulosis Constipation Incontinence (fecal/urine)
Gastrointestinal Aging of colon
Slow transit time
Increased water reabsorption
Renal Aging leads to
Decreased
Glomerular filtration rate –> has direct effect on drugs that excreted through urine
Aldosterone
Antidiuretic hormone (ADH)
Due to all these factor organ reserve increase and cause injury
Genitourinary Aging of Bladder/Urethra
Increased
Residual urine volume
Activity of detrusor muscle means even after emptying their is something in bladder
Pathophysiology of Genitourinary Aging of Bladder/Urethra cause
Urinary frequency (overactive bladder) Urinary retention/obstruction
Genitourinary Aging of women
Decreased estrogen Ovaries, uterus, vagina atrophy Decreased lubrication (due to decrease estrogen Urinary tract infections Dyspareunia ( pain during sex)
Genitourinary Aging of men leads to
BPH (Bening prostatic hyperplasia)
Erectile Dysfunction
Note: Older adults are sexually active!!
Skin and Aging leads to
Loss of interdigitations between epidermis and dermis leading to ease of tearing or breakdown
Sensory Aging: Vision effects on lens lead to
Increased Opacity ( lack of transparency)
Increased sensitivity to glare
Decreased elasticity
Because pupil shrink
Sensory Aging: Vision Pathophysiology cause
Light and dark adaptation
Accommodation/presbyopia ( focusing of near to far an eye )
Contrast sensitivity (what color we use to contrast)
Depth perception (edge of stairs)
Sensory Aging: Hearing Pathophysiology
Hearing loss High pitched sound Background noise Vertigo Cerumen impaction
Ototoxic drugs are
Aminoglycosides
High dose salicylates
Diuretics specifically FUROSEMIDE
Skeletal Aging causes are
Decrease in bone mass and density
Pathophysiology is:
Osteoporosis Arthritis Gait changes Loss of balance Falls Fractures
Pharmacokinetics of Geriatrics: Absorption
Potential for the delay in absorption, but no significant change in the extent of absorption for most drugs (means it will take longer but the whole drug will absorbe)
Increased gastric pH (means high ph)
Decreased absorption of acid-dependent drugs (calcium carbonate)
Early dissolution of enteric coating –> High pH so it dissolves early as it is suitable in an acidic environment
Pharmacokinetics: Absorption also leads to drug-induced changes MEANS drugs that change our gastric pH are
pH: PPI, antacids
Gastric motility/emptying: opioids and anticholinergics drugs change the extent of absorption
Absorption: Take-Home Message
Most drugs are well-absorbed in the presence of age-related changes only
Age-related changes, as well as concurrent diseases, result in increased variability in drug absorption
Effects of aging on absorption from other sites of administration is poorly understood
Body Composition of older adults
have decreased total body water
Decrease lean body mass
Increase body fat
Aging Pharmacokinetics and Distribution of hydrophilic drug
Decrease in Volume of distribution means
less water in the body and lower volume of distribution (not going all over the body)There’s going to be a higher concentration within the plasma, so you have higher plasma concentrations of hydrophilic drugs in older patients which will have a Greater swing within the dosing interval means if they drink more alcohol they will have more effects.
that’s why older people will have more effects of alcohol
extracellular water
Examples: ethanol, lithium, aminoglycosides
Aging Pharmacokinetics and Distribution of lipophilic drugs
Increase in Volume of distribution due to increase in body fat
Increase in Half-life
Increase Duration of therapeutic and toxic effects
Examples: diazepam, phenothiazine, phenytoin
Diuretics can have more effect especially if they consume alcohol (which will increase the effect of alcohol)
Benzodiazepines are not good for older patients.
Aging Pharmacokinetics and Distribution of Protein-binding
Decrease in Albumin means increased % of unbound or free drug
The age-related decrease is modest but important in chronically ill or malnourished
Aging Pharmacokinetics and Distribution of Clinically significant interactions are
Highly protein-bound drugs
Examples: warfarin, phenytoin, benzodiazepines
Distribution: Take-Home Message
Distribution may be altered due to age-related physiologic changes and concurrent diseases
Lipid-soluble drugs may show an increased volume of distribution while water-soluble drugs may show a decreased volume of distribution
Age-related changes in protein binding do not generally result in clinically significant changes in drug therapy
Pharmacodynamics and Pharmacologic Effects are
Centrally-acting drugs demonstrate increased sensitivity and side effects Benzodiazepines Opioids Alcohol Neuroleptics Anticholinergics H1-antihistamines (1st generation)
Aging Pharmacokinetics Excretion and Reduction in glomerular filtration leads to
Cockroft-Gault (CrCl) may not be accurate
Check product labeling to determine the use of CrCl or eGFR
Decrease clearance and increase t½ for drugs with renal elimination and active metabolites
AGS Beers Criteria: Cardiovascular for Digoxin
Digoxin
Conditions
▪ When used first-line for rate control for afib
▪ When used first-line for heart failure
▪ Doses >125mcg/day
Potential harm
▪ Higher doses have no added benefit;
toxicity
▪ Other agents have evidence of mortality and hospitalization benefits in HFrEF
AGS Beers Criteria: Cardiovascular Alpha Blockers
Alpha-Blockers
Examples
▪ Doxazosin
▪ Prazosin
▪ Terazosin
Conditions
▪ When used for the treatment of hypertension
Potential harm
▪ Orthostatic hypotension (high risk)
Excretion: Take-Home Message
Decreased renal clearance of drugs is the most significant age-related change in PK, accounting for the majority of necessary dose adjustments
Serum creatinine may be a poor predictor of renal function, especially in frail older adults
Renal Aging and MDRD will
Estimates GFR Stages CKD (chronic kidney disease) Drug dosing (new drugs)
Metformin neeed eGFR rate
Rivaroxaban and Zoledronic acid Reclast (actual BW)
AGS Beers Criteria: Sedating Antihistamines
Examples ▪Brompheniramine ▪Chlorpheniramine ▪Dimenhydrinate ▪Diphenhydramine ▪Doxylamine
Potential harm
▪Highly anticholinergic
▪Clearance reduced in older patients
Exceptions
▪Diphenhydramine may be used
for acute allergic reactions
Notes
▪ Tolerance develops when used as a hypnotic
Renal Aging of CrCl vs GFR with Cockroft-gault are
Estimates the CrCl
Estimate Drug dosing (most drugs)
Overestimates the Frail and Reduced muscle mass
Pharmacodynamics and other Pharmacologic Effects are
Beta-blockers: decrease response
Warfarin: increase risk of bleeding
Cardiac drugs: increased risk of orthostatic hypotension
Diuretics: decrease the effectiveness
Functional loss of aging: Activities of Daily Living (ADLs)
Bathing Ambulation Toileting Transfers Eating Dressing
Functional loss of aging: Instrumental ADLs
Shopping
Cooking/ Cleaning
Using Telephone or transportation
Managing Money and Medications
AGS Beers Criteria: Proton Pump Inhibitor
Examples
▪Omeprazole
▪ Esomeprazole
▪ Lansoprazole
Conditions
▪ Avoid use >8 weeks
Potential harm
▪C difficile infection
▪Bone loss and fractures
Exceptions
▪Chronic NSAID or corticosteroid use
▪ Erosive esophagitis
▪ Failure of drug discontinuation or H2 blocker trial
Metabolism
First pass metabolism (decreased) which means drugs that are undergoing the first pass have higher bioavailability
Prodrugs have lower bioavailability
Decrease drug clearance due to changes in kidney
Increase t½
Hepatic enzymes (CYP450) appear unchanged **Caution with CYP450 inhibitors/inducers**
AGS Beers Criteria: Central Nervous System CNS for Benzodiazepines
Benzodiazepines
Rationale
▪ Increased sensitivity and decreased metabolism
Potential harm
▪ Cognitive impairment
▪ Delirium
▪ Falls/fractures
Exceptions
▪ Seizure disorders, REM sleep behavior disorder, ethanol withdrawal, severe anxiety
AGS Beers Criteria: Central Nervous System CNS for Tricyclic Antidepressants
Tricyclic antidepressants
Examples
▪ Amitriptyline
▪ Nortriptyline
▪ Protriptyline
Potential harm
▪ Highly anticholinergic
▪ Sedating
▪ Orthostatic hypotension
AGS Beers Criteria: Disease-specific
Condition Medication Potential Harm
Heart failure NSAIDs (all) Fluid retention may exacerbate heart failure
Chronic kidney disease NSAIDs (all) May cause acute kidney injury or worsen renal function
Delirium H2-receptor blockers May cause or increase confusion
Chronic kidney disease H2-receptor blockers May need to reduce dose if CrCl<50 ml/min
Dementia Anticholinergics Adverse CNS effects
Medication Appropriateness Index (MAI)
This is ( implicit criteria tool) Indication Are directions practical or correct Efficacy with minimal toxicity Ease of administration are there drug-drug interaction Medications that are no longer needed
The things that are different are
Cost So it’s not going to be effective again if the patient can’t take it, they have administration issues or if they can’t afford it.
Physical Elder Abuse
Intentional use of physical force that results in acute or chronic
illness, bodily injury, physical pain, functional impairment, distress,
or death
-Hitting, beating, slapping
-Shoving, pushing
-Choking, suffocation
-Unlawful confinement (lock them in the room)
-Restraints (limit their physical movement)
Sexual Elder Abuse
Sexual Abuse
Forced and/or unwanted sexual interaction (touching and non-
touching acts) of any kind with an older adult
-Contact between the penis and the vulva or the penis and the anus
involving penetration, however slight
-Contact between the mouth and the penis, vulva, or anus
-Penetration of the anal or genital opening of another person by a hand,
finger, or another object
-Touching, either directly or through the clothing, of the genitalia, anus,
groin, breast, inner thigh, or buttocks
Psychological or Emotional Abuse (Elder)
Verbal or nonverbal behavior that results in the infliction of
anguish, mental pain, fear, or distress
-Humiliation ( why did u wet your pants or cannot hold pee)
-Threats of abandonment ( if u not gonna do this I will not come to you)
-Isolation
-Intimidation (frightening)
-Control
Financial Elder Abuse
Illegal, unauthorized, or improper use of an older individual’s
resources, for the benefit of someone other than the older
individual
-Misuse or theft of money or possessions
-Use of coercion/deception to surrender money/property
-Withholding pension
-Misusing power of attorney
-Forging signatures
Neglect Elder Abuse: Intentional
Failure to protect an elder from harm or to meet needs for essential necessities of life results in a serious risk to health and/or safety Withholding -Food or water -Medical treatment -Medications (or over-medicating) Failure to provide -Personal hygiene -Clothing -Shelter -Protection from unsafe activities/environments
unintentional neglect
Failure to meet needs due to ignorance or infirmity
- Caregiver who is ill
- Caregiver who lacks knowledge or skills
- Caregiver who is unaware of community resources
- Unwilling caregiver
Self Neglect
Older adult fails or refuses to address their own basic physical,
emotional, or social needs in a way that threatens his/her own
health and safety
- Poor nutrition
- Inadequate housekeeping
- Over/under-medicating
- Not meeting healthcare needs
Identifying Abuse and Neglect
Identify physical cues -Repeated or unexplained injuries -Repeated falls -Medication levels -Malnutrition -Poor hygiene -Lack or delay in obtaining durable medical equipment (DME)
What to do in case of elder abuse
Document all data
Learn how to recognize signs
Adult Protective Services
Check in often
MRP: Prescribing cascade
Cascade is a doctor prescribes one medication and that medication effect other parts then the doctor prescribes the side effect of the first drug and the cascade keeps going.
STOP Criteria
Potentially inappropriate/ duplication of therapy
means we have to consider stopping this polypharmacy in older adults.
Start Criteria
Omission of therapy
Medication we need to consider based on a certain disease state,
Inappropriate prescribing : AGS beer criteria
potentially inappropriate medications in older adults;
potentially inappropriate medications to avoid in older adults with certain conditions;
medications to be used with considerable caution in older adults;
