Geriatrics Info Flashcards
4 areas of Cardiovascular Aging
Electrical Conduction
Hypertrophy
Ischemic Area
Fibrosis
Cardiovascular Aging: Vasculature
Blunted Baroreceptor Reflex
Cardiovascular Aging: Heart Rate
Decreased maximum HR, resting HR stays the same
Decreased sensitivity to Beta Stimulation (ie Beta blockers)
Cardiovascular Aging: Orthostatic Hypotension
More susceptible to it occurring
Diuretics and Alpha Blockers can increase chances
Cardiovascular Aging: HFpEF
Want to be careful treating, don’t want to drop blood pressure too much
Systolic hypertension
Cardiovascular Aging: Bradycardia
Exercise Intolerance
Respiratory Aging: Increased….
Energy of breathing
Airway Resistance
Dead Space
Respiratory Aging: Decreased….
Respiratory muscle strength
Total alveolar surface
Vital capacity
Gastrointestinal Aging: Esophagus & Stomach
Decreased Taste sensation
Dysphagia (discomfort swallowing)/Aspiration
GERD
Decreased gastric acid secretion
Gastrointestinal Aging: Small intestine & Colon
Decreased absorption of calcium, folic acid, vitamin B12
Nutrient depletion
diverticulosis
Constipation
Incontinence
Slow transit time & increased water reabsorption
Renal Aging: Functional Changes
Decreased Glomerular filtration rate
Renal Aging: Hormone Effects
Decreased response to Aldosterone and ADH
Genitourinary Aging: Bladder/Urethra Increased….
Residual urine volume
Activity of detrusor muscle
Genitourinary Aging: Bladder/Urethra Pathophysiology…
Urinary frequency (overactive bladder) Urinary retention/obstruction
Genitourinary Aging: Women
Menopause:
Decreased estrogen
Ovaries, uterus, vagina atrphy
Vaginal Changes:
Decreased Lubrication
Pathophysiology:
UTI & Dsypareunia (pain during sexy time)
Genitourinary Aging: Men
Pathophysiology:
BPH and ED
Genitourinary Aging: Sex
Old people be fuckin
Risk for STDs and HIV/AIDS
Cause of aging of skin?
Loss of interdigitations between epidermis and dermis leading to ease of tearing or breakdown
Sensory Aging: Vision (Lens)
Increased Opacity, Sensitivity to glare
Decrease Elasticity
Sensory Aging: Vision (Pathophysiology)
Light/Dark adaptation
Accommodation/presbyopia
Contrast sensitivity
Depth perception
Sensory Aging: Hearing (Pathophysiology)
Hearing loss (high pitch and background noise)
Vertigo
Cerumen (earwax) impaction
Ototoxic drugs….
Amino-glycosides
High dose salicylates (Super high aspirin dose)
Diuretics (Furosemide)
Skeletal Aging: Changes
Decreased bone mass and density
Skeletal Aging: Pathophysiology
Osteoporosis Arthritis Gait Changes Loss of Balance Falls Fractures
Pharmacokinetics: Absorption info
Potential for DELAY in absorption, but no significant change in EXTENT of absorption for most drugs
Pharmacokinetics: Absorption Exceptions
Increased Gastric pH:
decreased absorption of acid-dependent drugs (calcium carbonate)
Drug-Induced changes:
pH (PPI, Antacids)
Gastric motility/emptying (opioids/anticholinergics)
Aging effect on body composition
decrease total body water and lean body mass
increase body fat
(Geriatrics) Pharmacokinetics: Distribution of Hydrophilic drugs
Decreased Vd
Increase plasma conc
greater swing within the dosing interval
examples: ethanol, lithium, aminoglycosides
Pharmacokinetics: Distribution of Lipophilic drugs
Increased Vd
Half-life increase
Duration of therapeutic and toxic effects increase
Examples: diazepam, phenothiazine, phenytoin, benzos
Decreased Vd can be further impacted by drugs that…..
affect extracellular water
Pharmacokinetics: Distribution (protein-binding)
decrease albumin
increase % of unbound or free drug
Age-related decrease is modest but important in chronically ill or malnurished
Pharmacokinetics: Distribution (protein-binding) Clinically significant interactions
Highly protein bound drugs
Example: Warfarin, phenytoin, benzos
Which CYP inducers/inhibitors do you have to be careful with?
CYP450
(Geriatrics) Pharmacokinetics: Metabolism
1st pass metabolism decreased due to decreased hepatic blood flow and mass
decrease dose of drugs with high hepatic extraction and consider efficacy of prodrugs
Pharmacokinetics: Metabolism (Phase I metabolism)
decrease clearance and increase half life
should decrease dose and adjust based on patient
Drugs metabolized by Phase II preferred
Drugs undergoing first pass have….
higher bioavailability
(Geriatrics) Prodrugs will have…..
lower bioavailability
Pharmacokinetics: Excretion (reduction in GFR)
CrCL may not be accurate
Check product labeling to determine use of CrCL or eGFR
(Geriatrics) Pharmacokinetics: Excretion (Drugs & Excretion)
decreased clearance and increased 1/2 life for drugs with renal elimination and active metabolites
Most significant age-related change in Pharmacokinetics?
Decreased renal clearance, accounts for majority of necessary dose adjustments
Renal Aging: CrCL
Estimated using Cockroft-Gault
Used for Drug dosing most drugs
Overestimate due to frail, reduced muscle mass patients
Renal Aging: GFR
estimated using MDRD
Stages CKD
Drug dosing of new drugs
Underestimates heathy patients
Which drugs show increased sensitivity and side effects?
Centrally-acting drugs
Benzo Opioids Alcohol Neuroleptics Anticholinergics H1-antihistamine 1st gen
Pharmacologic effects: Beta Blocker
Decreased response
Pharmacologic effects: Warfarin
Increased risk of bleeding
Pharmacologic effects: Cardiac Drugs
increased risk of orthostatic hypertension
Pharmacologic effects: Diuretics
Decreased effectiveness
ADLs
Activities of Daily Living
Bathing Transfers Eating Dressing Toileting Ambulation
IADLs
Instrumental ADLs
Shopping
Cooking/Cleaning
Using phone or transportation
Managing money and medications
Prescribing Cascade
Treating side effects of the previously prescribed drug
“Research shows that any symptoms in an elderly person should be considered an adverse effect until proven otherwise”
STOPP vs START
STOPP: Potentially inappropriate/duplication of therapy
Drugs you want to stop due to poly pharmacy
START: Omission of therapy
Drugs that you want to consider to start prescribing/using
AGS Beers Criteria: Sedating Antihistamines
1st Gen antihistamines
Potential harm (highly anticholingeric and reduced clearance in older patients)
Exceptions: Benadryl used for allergic reactions
Extra: Tolerance develops when used as a hypnotic
AGS Beers Criteria: PPIs
Conditions: Avoid use > 8 weeks
Potential Harm: C.Dif infection, bone loss/fractures
Exceptions:
Chronic NSAID or corticosteroid use
Erosive esophagitis
Failure of drug discontinuation or H2 blocker trial
AGS Beers Criteria: Cardiovascular Drug (Digoxin)
conditions:
used 1st line for HF or rate control fib
want doses <125mcg/day
Potential Harm:
higher doses have no added benefit, just toxicity
other agents have evidence of mortality and hospitalization benefits in HFrEF
AGS Beers Criteria: Cardiovascular Drug (Alpha blockers)
Conditions: when used for treatment of hypertension
Potential Harm: Orthostatic hypotension = high risk
AGS Beers Criteria: Benzos
Rationale:
Increased sensitivity and decreased metabolism
Potential Harm:
Cognitive impairment, delirium, falls/fractures
Exceptions:
Seizes disorders, REM sleep behavior disorder, ethanol withdrawal and severe anxiety
AGS Beers Criteria: Tricyclic Antidepressants
Potential Harm:
Highly Anticholinergic
Sedating
Orthostatic Hypertension
AGS Beers Criteria: HF
Med: All NSAIDs
Harm: Fluid retention may exacerbate HF
AGS Beers Criteria: Chronic Kidney Disease
Med: All NSAIDs
Harm: May cause acute kidney injury or worsen renal function
Med: H2 Blockers
Harm: May need to reduce dose if CrCl < 50ml/min
AGS Beers Criteria: Delirium
Med: H2 Blockers
Harm: May cause or increase confusion
AGS Beers Criteria: Dementia
Med: Anticholinergics
Harm: Adverse CNS effects
Medication Appropriateness Index
Bunch of questions about the medication
Ranging from safety, to correct dosage/instructions/to cost compared to other options
Medication Review
Dosing: Start Slow, Go Slow, But go
Monitoring: Meds that are no longer needed
Consider medications individually and within the big picture
Elder Abuse Characteristics
more common females
often family member
not just physical
Physical Elder abuse
Intentional use of physical force that results in acute or chronic illness, bodily injury, physical pain, functional impairment, distress, or death
Sexual Elder abuse
Forced and/or unwanted sexual interaction (touching and non-touching acts) of any kind with an older adult
Psychological or Emotional Elder Abuse
Verbal or nonverbal behavior that results in the infliction of anguish, mental pain, fear, or distress
Financial or Exploitation Elder Abuse
Illegal, unauthorized, or improper use of an older individual’s resources, for the benefit of someone other than the older individual
Intentional Elder Neglect
Failure to protect an elder from harm or to meet needs for essential necessities of life which results in a serious risk to health and/or safety
Unintentional Elder Neglect
Failure to meet needs due to ignorance or infirmity
Self Elder 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
