ic 1-3 geriatric syndrome Flashcards
What are the 5 types of Drug Related Problems?
1) Indication
Untreated indication
Improper selection
No indication
2) Dose-related
Overdose
Underdose
3) Interactions
With Drugs, Food, Labs
4) Adverse drug reactions
Look at timeline, onset of ADR with initiation of meds
5) Failure to receive drugs
Non adherence
Improper technique
What is the Pharmaceutical Care Framework
1) What matters most to patient and caregiver
Identify goals and DRPs that prevent patient from achieving goals
2) Explicit criteria eg. Beers, Stoppfall, High Alert Medications
Explicit criteria: medications that can cause more harm than good
HAM: high potential to cause great harm if not taken correctly
3) Implicit criteria (using Medication Appropriateness Index)
Clinical judgement
Missing from MAI
1) Adverse drug reactions
2) Untreated indications
4) Successful delivery of appropriate drugs
Educate on adherence, proper storage, proper administration
What are the questions in the Medications Appropriateness Index
What is missing?
Indication of drug
Efficacy for the condition
Dose, directions, practical
Drug interactions
Disease interactions
Any unnecessary duplication
Duration of therapy
Cost justified?
Missing:
1) Adverse drug reactions
2) Untreated indications
MAI only considers existing drugs, if they are suitable for current condition
NOT considering from the condition’s POV
Because MAI links current meds → condition, NOT condition → current meds
What is CFS? Score and the meaning
1 - 9 (1 - 3 are fit, 4 - 6 are frail, 7-8 are very frail)
CFS 1 (Very fit)
Very active, exercise regularly and among the fittest for their age
CFS 2 (Fit)
No active disease, exercise occasionally
CFS 3 (Managing well)
Medical problems well controlled, not regularly active
CFS 4: (Very mild frailty)
Symptoms limit activity but not dependent on others for daily help. Tired during the day
CFS 5 (Mild frailty)
Evident slowing, need help with IADL (instrumental) eg. finances, transportation
CFS 6 (Moderate frailty)
Need help with all outside activities, IADL and some of basic ADL (bathing, stairs)
CFS 7 (Severe frailty)
Completely dependent for personal care. Stable, not at risk of dying
CFS 8 (Very severe frailty)
Completely dependent, approaching end of life. Cannot recover from minor illness
CFS 9 (Terminally ill)
Life expectancy < 6 months, not living in severe frailty
What is CFS 6
(Moderate frailty)
Need help with all outside activities, IADL and some of basic ADL (bathing, stairs)
which CFS is completely dependent on basic ADL alr?
CFS 7
What does CGA stand for
Who is it for?
Comprehensive Geriatric assessment
CFS 4-7
5 parts of CGA
1) Functional status
2) Medical assessment
3) Mental
4) Medication /nutrition
5) Socioeconomic resources
How does absorption change in elderly (4 pts)
1) Decrease in gastric acid secretion due to PPI or mucosal atrophy
2) Gastric emptying time prolonged
Caused by Anticholinergics, Opioids
Need to space apart food > 30 mins for bisphosphonates
3) Concurrent medications
Inducer of CYP: Phenytoin
PGPi: Clarithromycin, Amiodarone
PGP is a efflux pump, other drugs eg. Digoxin can be absorbed and cause toxicity
4) Transdermal route
Eg. using Fentanyl patch, Nitroglycerin patch
Increase absorption: epidermis and dermis thinning, heat pack
Decrease absorption: reduced cutaneous blood supply
how does distribution change in elderly
1) Body composition: Fat ↑, total body water and muscle ↓
2) Decreased serum albumin, Increased a1-acid glycoprotein
May result in clinically significant interaction with drugs
Eg. Phenytoin
3) Distribution into brain increased
More leaky BBB
Make elderly more sensitive to anticholinergic SE
Pgp activity lower
2 types of metabolism and their changes in elderly
1) Phase 1 (CYP 450 enzymes)
Decreases with age
Due to reduced liver mass, hepatic blood flow, thickening of sinusoidal endothelium
2) Phase 2 conjugation eg. glucuronidation, acetylation, sulfation
Largely unchanged with age
PD changes in elderly
Elderly more sensitive to:
1) Postural hypotension
2) CNS depressants eg. Benzodiazepines
3) Neuroleptic / Antipsychotic Sensitivity Reaction
For patients with Dementia with Lewy Body (DLB) or Parkinson’s Disease with Dementia (PDD)
Schizo: Use Quetiapine (Dont use antipsychotics with long half life eg. 1st gen)
Antiemetics: use Domperidone (Dont use antiemetics with high antidopaminergic effect eg. Prochlorperazine, Metoclopramide)
Interventions for frailty (3 points)
Can be reversed in early stage, dont let it deteriorate
1) Physical exercise / Occupational therapy
To maintain muscle mass
Factors that prevent physical exercise
Poor motivation
Poor cardiopulmonary function
2) Nutritional intake with Milk Feeds
Factors that affect food intake
Medication side effects eg. taste, appetite, anticholinergics (affect saliva production)
Depression
Access to food (financial, physical disability)
Cannot chew / swallow
3) Medication review
Vit D supplementation
Low Vit D can affect immune system, muscle mass
What are the 4 Fall risk increasing drugs
1) Sedation
2) Orthostatic hypotension
When sitting up or standing, blood pool in lower limbs and abdominal areas
Good baroreflex → activate sympathetic NS to increase BP and restore cardiac output
OH will affect perfusion to brain (dizziness), eye (vision issues), and leg (weakness)
3) Anticholinergic
Mechanism to increase risk of fall is uncertain
Possibly slows reaction time
4) Hypoglycemia
Classes of FRIDs in STOPPFALL (5 points)
1) Orthostatic Hypotension
Alpha blockers
Central antihypertensive eg. methyldopa
Vasodilators eg. nitrate
Diuretics (Dehydration)
2) Opioids
Cause sedation
3) Psychotropics
Antidepressants eg. TCA
Can cause OH, anticholinergic, sedation
Antipsychotics
Benzodiazepines
Z hypnotics
4) Anticonvulsants
Older gen cause more drowsiness, ataxia (poor muscle control, cause clumsy movements)
5) Anticholinergics
1st gen antihistamines
Muscle relaxants
4 types of dizziness
1) Vertigo
2) Pre-syncopal dizziness
Due to postural hypotension
3) Dysequilibrium
4) Unspecified dizziness
Why dont oral meds work in dizziness
Experience dizziness that last several mins
Thus oral meds wont work cos usually take 30 mins to take effect
Should stop meds if suspect that they cause dizziness cos there are not many pharm options available to treat dizziness
What is used for dizziness? When should it be used?
Vestibular suppressants
Symptomatic relief for prolonged Vestibular symptoms (> 30 mins)
5 types of Vestibular suppressants
1) Strong Anticholinergic Effects
2) Benzodiazepines
3) Antidopaminergics (For nausea, vomiting due to dizziness)
4) Calcium Channel Antagonists eg. Cinnarizine
5) Betahistine
What are the drugs for dizziness with strong anticholinergic side effects that can help with dizziness (3 points)
1) First gen antihistamine (Diphenhydramine, Dimenhydrinate (Novomin), Meclizine)
2) Anticholinergic (Scopolamine (Hyoscine Hydrobromide))
3) Phenothiazine antiemetics (Prochlorperazine, Promethazine)
Considerations for use of benzodiazepine in elderly
Use Lorazepam
Use short acting BZD and short course eg. a few days
Very sedating, increase fall risk in elderly
Increases risk of cognitive impairment, depression
What vestibular depressants cannot be used for patients with PD, PDD, DLB
Use what instead
1) Central dopamine antagonists eg. Metoclopramide
2) Phenothiazine (have antidopaminergic effects) eg. Prochlorperazine, Promethazine
Use Domperidone, Ondansetron
Betahistine
Type 3 Histamine Receptor antagonist, negligible agonism at H2 receptor
Commonly used in elderly
Caution
Use with caution with Asthma, COPD
Contraindicated with history or active PUD
May be due to (negligible) agonism at H2 receptor
Causes of delirium acronym
I WATCH DEATH
Infection (UTI, pneumonia etc.)
Withdrawal
Alcohol, Barbiturates, Benzodiazepines
Acute metabolic disorders
Electrolyte imbalance, hepatic, renal failure
Trauma
CNS pathology
Stroke, haemorrhage, Parkinsons
Hypoxia
Conditions that affect O2 supply to brain or affect cardiac output
Anaemia, cardiac failure, pulmonary embolus
Deficiency
Vit B1, B12, Folic acid
Endocrinopathy
Hypoglycemia, thyroid, parathyroid, adrenal
Acute vascular conditions
Shock
Toxins to drugs or medications
Anticholinergics, narcotics (opioids), alcohol
Heavy metals
