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Summer 1 > geriatrics COPY COPY > Flashcards

geriatrics COPY COPY Flashcards

1
Q

Leading causes of death in geriatrics are

A 
Heart disease 
Cancer 
Alzheimer's 
Cerebrovascular dz 
chronic LR dz
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2
Q

What are common problems in older adults (I’s)

A

Immobility, Instability
isolation, incontinence, infection, impaction, impaired senses, intellectual impairment, impotence, immunodeficiency, insomnia, iatrogenesis

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3
Q

What are atypical ways elderly present with common ailments

A 
AMI: confusion 
CHF: confusion 
GI bleed: AMS 
URI: confusion 
UTI: confusion
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4
Q

Slide 7, list all drug families and classes

A

so annoying

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5
Q

What type of meds do most elderly use

A

OTC
Herbal and supplements
Sharing meds

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6
Q

What is polypharmacy*

A

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
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7
Q

How much is spent on side effects of drugs

A

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!

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8
Q

What are predictors of ADE

A 
6+ chronic conditions 
9+ meds 
12+ doses of drugs/day 
prior ADE 
low body weight or BMI 
85+ y/o 
CrCl <50
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9
Q

What are the meds MC involved in ADE

A 
cardiovascular drugs 
diuretics 
NSAIDs 
hypoglycemics 
anticoags 
-AKA meds with a narrow margin of safety
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10
Q

What can you use to ensure the med you give an elderly pt is not inappropriate or unnecessary

A

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

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11
Q

Potentially inappropriate meds have

A

limited effectiveness in older adults and are associated with problems like delirium, GI bleeds, falls, anf fractures

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12
Q

Beers criteria overview

A
  1. PIM and classes to avoid in older adults
  2. PIM and classes to avoid in older adults due to drug-disease or drug-syndrome interactions
  3. PIM to be used with caution in older adults
    (should be used as a guide for clinicians, but should not substitute professional judgement)
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13
Q

What are commonly used inappropriate drugs for elderly

A 
antihistamines (2/2 anticholinergic ADE) 
anticholinergics 
GI/antispasmodics 
benzos 
TCA
sedatives, hypnotics 
anticoags/antiplatelets
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14
Q

Why should you use caution with HF medications

A

may promote fluid retention/exacerbate HF

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15
Q

Do not use these drugs together in elderly

A

Benzos and non-benzo benzo receptor agonist hypnotics

-may increase risk of falls and fractures (2+ CNS active drugs)

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16
Q

What are challenges in geriatric pharmacotherapy

A 
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
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17
Q

Remember pharmacokinetics vs pharmacodynamics

A

PK: what the body does to the drug as it moves thru
PD: what the drug does to the body

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18
Q

How are PD and aging associated

A

With age, alteration in receptor number, drug receptor affinity, and enhanced or diminished port-receptor response

19
Q

What happens to balance and gait with age

A

Decreased: stride length (slower gait) and arm singing
Increased: body sway when standing

20
Q

What happens to body composition with age

A

Decreased: total body water, LBM
Increased: body fat, alpha-acid glycoprotein
Same or decreased: serum albumin

21
Q

What happens to cardiovascular system with age

A

Decreased: CO, resting max HR
Increased: SVR w/ loss of atrial elasticity and dysfunction of systems maintaining vascular tone

22
Q

What happens to CNS with age

A

Decreased: number of receptors, short term memory and executive function
Increased sensitivity of remaining receptors
Altered sleep

23
Q

What are other physiologic changes with age

A

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

24
Q

What PK changes are associated with aging

A

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

25
Q

What is the phase I metabolic pathway

A

oxidation, reduction, and hydrolysis converts drugs to metabolites
MOST affected pathway with age
CYP3A4 is involved in >50% of drugs on the market

26
Q

What is the phase II metabolic pathway

A

conjugate drugs to inactive metabolites that do not accumulate
Less affected with age
Usually, phase I path drugs are preferred for elderly

27
Q

Key concepts in drug elimination

A

Half life: time for serum concentration to decline by 50%

Clearance: volume of serum from which drug is removed per unit of time

28
Q

Pearl she gave us

A

In an elderly patient, always consider serum creatinine 1 if they are just slightly below it (0.7, 0.8, etc)

29
Q

What is CrCl

A

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

30
Q

What are the PD changes of aging

A

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)

31
Q

What happens to skin in elderly

A

epidermis thins and subQ fat decreases

Topical absorption increases!

32
Q

What are commonly overRx and inappropriately used drugs

A 
antiinfectives 
anticholinergics 
antispasmodice 
antipsychotics 
benzos
digoxin 
dipyridamole 
H2 antagonisrs 
laxatives and fecal softeners 
NSAIDs
PPI 
sedating antihistamines 
TCA 
vitamins, minerals
33
Q

What is STOPP

A

screening tool of older persons potentially inappropriate prescriptions criteria
Focuses on avoiding use of meds that are potentially inappropriate in elderly

34
Q

Examples of STOPP criteria

A 
Theophylline ad monotherapy for COPD 
NSAIDs with HF 
NSAIDs with warfarin 
Vasodilators with postural hypotension 
Bladder antimuscarinics with dementia
35
Q

What are commonly underprescribed drugs

A

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

36
Q

What is START

A

screening tool to alert docs to right treatment
focuses on ID undertreatment of Rx omissions in elderly
criteria is organized by organ!

37
Q

What is dangerous that elderly dont realize about taking different meds

A

Duplicate meds contain the same active ingredient! Ex: vicodin and tylenol PM
Aleve and ibuprofen (same drug class)

38
Q

How do you effectively dose an elderly patient

A

based on age, functional status, renal and hepatic function, comorbid conditions, concurrent drug regimen, goal of care
Start LOW go SLOW

39
Q

Explain a prescribing cascade

A

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.

40
Q

What can drug-drug interactions lead to

A

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

41
Q

List drugs and their common risks

A

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

42
Q

What are common food interactions

A 
dairy 
coffee, tea 
grapefruit juice 
alcohol 
charcoal broiled foods 
green leafy veggies 
licorice 
ginseng
43
Q

In summary…

A

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

Summer 1 (16 decks)

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