geriatrics COPY Flashcards
Leading causes of death in geriatrics are
Heart disease Cancer Alzheimer's Cerebrovascular dz chronic LR dz
What are common problems in older adults (I’s)
Immobility, Instability
isolation, incontinence, infection, impaction, impaired senses, intellectual impairment, impotence, immunodeficiency, insomnia, iatrogenesis
What are atypical ways elderly present with common ailments
AMI: confusion CHF: confusion GI bleed: AMS URI: confusion UTI: confusion
Slide 7, list all drug families and classes
so annoying
What type of meds do most elderly use
OTC
Herbal and supplements
Sharing meds
What is polypharmacy*
concomitant use of multiple drugs OR administration of more meds than are clinically indicated
- Be concerned about adherence! If they have to take 10 pills per day, will they really take them all?
- Elderly in nursing homes typically take 7-9 different meds/day
How much is spent on side effects of drugs
In nursing homes, $1.33 is spent on ADE for every 1$ spent on meds
AKA, you spend more to fix it than you do to buy it
25% of ADE in elderly are preventable!
What are predictors of ADE
6+ chronic conditions 9+ meds 12+ doses of drugs/day prior ADE low body weight or BMI 85+ y/o CrCl <50
What are the meds MC involved in ADE
cardiovascular drugs diuretics NSAIDs hypoglycemics anticoags -AKA meds with a narrow margin of safety
What can you use to ensure the med you give an elderly pt is not inappropriate or unnecessary
Beer’s criteria for potentially inappropriate med use in older adults
Published in 1991, most recently revised in 2015, scheduled for 2018
Assesses risk vs benefit
Potentially inappropriate meds have
limited effectiveness in older adults and are associated with problems like delirium, GI bleeds, falls, anf fractures
Beers criteria overview
- PIM and classes to avoid in older adults
- PIM and classes to avoid in older adults due to drug-disease or drug-syndrome interactions
- PIM to be used with caution in older adults
(should be used as a guide for clinicians, but should not substitute professional judgement)
What are commonly used inappropriate drugs for elderly
antihistamines (2/2 anticholinergic ADE) anticholinergics GI/antispasmodics benzos TCA sedatives, hypnotics anticoags/antiplatelets
Why should you use caution with HF medications
may promote fluid retention/exacerbate HF
Do not use these drugs together in elderly
Benzos and non-benzo benzo receptor agonist hypnotics
-may increase risk of falls and fractures (2+ CNS active drugs)
What are challenges in geriatric pharmacotherapy
more drugs available each year FDA and off label indications expanding formularies change frequently prescription costs are rising knowledge of medication advances drugs change from Rx to OTC use of naturaceuticals is increasing effects of aging physiology on drug therapy
Remember pharmacokinetics vs pharmacodynamics
PK: what the body does to the drug as it moves thru
PD: what the drug does to the body
How are PD and aging associated
With age, alteration in receptor number, drug receptor affinity, and enhanced or diminished port-receptor response
What happens to balance and gait with age
Decreased: stride length (slower gait) and arm singing
Increased: body sway when standing
What happens to body composition with age
Decreased: total body water, LBM
Increased: body fat, alpha-acid glycoprotein
Same or decreased: serum albumin
What happens to cardiovascular system with age
Decreased: CO, resting max HR
Increased: SVR w/ loss of atrial elasticity and dysfunction of systems maintaining vascular tone
What happens to CNS with age
Decreased: number of receptors, short term memory and executive function
Increased sensitivity of remaining receptors
Altered sleep
What are other physiologic changes with age
Endocrine: altered insulin signaling, decreased E, T, TSH, and DHEA
GI: decreased motility, vitamin absorption, splanchnic blood flow, bowel surface area
GU: vaginal atrophy (low E), BPH, detrusor hyperactivity (incontinence)
Hepatic: decreased liver size, blood flow, and phase I metabolism (oxidation, reduction, hydrolysis)
Immune: decreased Ab production, increased autoimmunity
Oral: altered dentition, decreased ability to taste salt, bitter, sweet, and sour
Pulm: decreased resp. muslce strength, chest wall compliance, VC. increased residual volume
Renal: decreased GFR, renal blood flow, filtration, tubular secretory fxn, renal mass
Sensory: presbyopia, presbycusis. decreased night vision, sensation of smell and taste
Skeletal: decreased bone mass, joint stiffening
Skin/hair: thin stratum corneum. decreased melanocytes, depth of fat layer. more hair in resting phase= thin grey hair
What PK changes are associated with aging
GI absorption: decreased active transport and first pass metabolism. unchanged passive diffusion and bioavailability of most drugs
Distrib: decreased volume of distrib. increased plasma concetration of water soluble, Vd and increased deposition of lipid soluble
Hepatic metabolism: decreased clearance
Renal excretion: decreased clearance
What is the phase I metabolic pathway
oxidation, reduction, and hydrolysis converts drugs to metabolites
MOST affected pathway with age
CYP3A4 is involved in >50% of drugs on the market
What is the phase II metabolic pathway
conjugate drugs to inactive metabolites that do not accumulate
Less affected with age
Usually, phase I path drugs are preferred for elderly
Key concepts in drug elimination
Half life: time for serum concentration to decline by 50%
Clearance: volume of serum from which drug is removed per unit of time
Pearl she gave us
In an elderly patient, always consider serum creatinine 1 if they are just slightly below it (0.7, 0.8, etc)
What is CrCl
used to make dosing adjustments in patients with renal dysfunction
decreased LBM = lower Cr production and lower GFR
This means in older people, SrCr does NOT reflect CrCl
What are the PD changes of aging
In CNS:
reduced dopamine (increased EPS Sx)
reduced serotonin receptor fxn (more sensitive to antidepressants)
altered GABA-benzo receptor fxn (more sensitive to benzos, alcohol, and barbituates)
reduced ACh (enhanced anticholinergic ADE, sedation, confusion, psychosis, delirium, urinary retention, constipation. decline in cognitive fxn)
What happens to skin in elderly
epidermis thins and subQ fat decreases
Topical absorption increases!
What are commonly overRx and inappropriately used drugs
antiinfectives anticholinergics antispasmodice antipsychotics benzos digoxin dipyridamole H2 antagonisrs laxatives and fecal softeners NSAIDs PPI sedating antihistamines TCA vitamins, minerals
What is STOPP
screening tool of older persons potentially inappropriate prescriptions criteria
Focuses on avoiding use of meds that are potentially inappropriate in elderly
Examples of STOPP criteria
Theophylline ad monotherapy for COPD NSAIDs with HF NSAIDs with warfarin Vasodilators with postural hypotension Bladder antimuscarinics with dementia
What are commonly underprescribed drugs
ACE with DM and proteinuria
ARB
Anticoags
antiHTN and diuretics for uncontrolled HTN
BB after MI or w/ HF
Bronchodilators
PPI or misoprostol to protect tummy from NSAIDs
statins
vitamin D and calcium for high risk osteoporosis
What is START
screening tool to alert docs to right treatment
focuses on ID undertreatment of Rx omissions in elderly
criteria is organized by organ!
What is dangerous that elderly dont realize about taking different meds
Duplicate meds contain the same active ingredient! Ex: vicodin and tylenol PM
Aleve and ibuprofen (same drug class)
How do you effectively dose an elderly patient
based on age, functional status, renal and hepatic function, comorbid conditions, concurrent drug regimen, goal of care
Start LOW go SLOW
Explain a prescribing cascade
You give metoclopramide
Pt develops parkinsonism ADE that is mistaken for a new condition
You give CCB and anti-parkinsons Rx
Pt gets peripheral edema from new drugs, and is thought to be a new condition
You give the patient diuretics
etc. etc. etc.
What can drug-drug interactions lead to
decreased efficacy, unexpected ADE, increased activity of a drug
May lead to ADE: confusion, delirium, cognitive impairment, hypotension, acute renal failure
Likelihood increases as number of meds increases
List drugs and their common risks
Benzos, TCA, antipsychotics: falls and fractures
TCA, anticholinergics: cognitive impairment
NSAIDs: AKI
NSAIDs or ASA: GI bleeding
non-DHP CCB: pulmonary edema, worsening CHF
TCA: urinary frequency
Opioids: worsening constipation
What are common food interactions
dairy coffee, tea grapefruit juice alcohol charcoal broiled foods green leafy veggies licorice ginseng
In summary…
Rational prescribing means choosing correct dose of correct drug for condition and individual pt
Age alters PK (ADME)
ADE are common and can be minimized with attention to RF, drug-drug, and drug-disease interactions
