IMM 23 and 29: Introduction to Geriatrics Flashcards
Categories of Older Adults
- middle-aged (45-64)
- young-old (65-74)
- old (75-84)
- old-old (85-99)
- oldest old (100+)
Generations of Older Adults
- octogenarian
- nonagenarian
- centenarian
Men vs. Women 65+
compared to men the same age, women are generally more likely to have various chronic medical conditions
List 10 of the common chronic diseases seen in older adults.
- hypertension
- periodontal disease
- osteoarthritis
- ischemic heart disease
- diabetes
- osteoporosis
- cancer
- COPD
- asthma
- mood and anxiety disorders
What is pharmacokinetics?
the science of how the body affects the drug
What is pharmacodynamics?
the science of how the drug interacts with the body
What PK parameters are impacted by aging? (4)
- absorption
- distribution
- hepatic metabolism
- renal excretion
What PD parameters are impacted by aging? (2)
- target organ changes
- homeostasis
What are the physiologic changes of aging? (11)
- ↓ brain size and synaptic activity
- ↓ levels of neurotransmitters
- ↑ permeability of blood brain barrier
- ↓ muscle mass and perfusion
- ↓ bone density
- ↑ adipose tissue
- ↓ skin integrity and perfusion
- ↓ gastric acid production and blood flow
- ↓ hepatic mass and blood flow
- ↓ function of some hepatic enzymes
- ↓ renal size, blood flow and function
Physiologic Factors Impacting Absorption
Describe the absorption of oral medications.
conflicting evidence of clinical relevance, but may impact rate and extent of absorption of oral medications
- ↓ gastric acid production (↑ gastric pH)
- ↓ gastrointestinal motility
- ↓ gastrointestinal tract blood flow
Physiologic Factors Impacting Absorption
Describe the absorption of IV administration.
no impact
Physiologic Factors Impacting Absorption
Describe the absorption of subcutaneous and intramuscular administration.
- DECREASED tissue perfusion in older adults can result in DECREASED RATE of absorption for subcutaneous and intramuscular injections
- may DECREASE maximum concentration (Cmax) and INCREASE time to maximal concentration (Tmax)
- no impact on EXTENT of absorption
Physiologic Factors Impacting Absorption
Describe the absorption of topical administration.
little evidence that age-related skin changes will impact transdermal absorption, but may contribute to increased skin irritation
- DECREASED epidermal and dermal thickness
- DECREASED elasticity
- DECREASED blood flow to the skin
- DECREASED water content of skin
Physiologic Factors Impacting Distribution
Describe how body composition affects distribution.
older adults have:
- ↓ total body water
- ↓ muscle mass/lean body weight
- ↑ adipose tissue
which can result in :
- hydrophilic drugs may have a decreased volume of distribution
- lipophilic drugs may have an increased volume of distribution
and because of the changes in Vd:
- half-life for hydrophilic drugs may decrease
- half-life for lipophilic drugs may increase
Physiologic Factors Impacting Distribution
Describe how plasma protein binding affects distribution.
- drugs highly bound to ALBUMIN most effected – albumin levels ~ 20% lower in older adults than younger adults, therefore may have HIGHER free fraction of drugs highly bound to albumin
- drugs highly bound to ⍺-1-acid glycoprotein levels NOT SIGNIFICANTLY effected – no significant changes to ⍺-1-acid glycoprotein levels in older adults
How does hepatic metabolism change?
- ↓ hepatic blood flow
- ↓ hepatic mass
↓ first pass metabolism
Physiologic Factors Impacting Clearance
How are hepatically-eliminated drugs affected?
action of Phase I Enzymes (ie. cytochrome P450 system) may be DECREASED
- reduced clearance of drugs metabolized by cytochrome P450 system
- because of the change in Cl, half-life of medications metabolized by CYP P450 may be increase
action of Phase II Enzymes (conjugation, glucuronidation) NOT SIGNIFICANTLY impacted by aging
Physiologic Factors Impacting Clearance
How is renal elimination affected?
drugs undergoing renal clearance may have DECREASED renal clearance in older adults due to:
- ↓ renal size
- ↓ renal blood flow
- ↓ glomerular filtration
- ↓ tubular secretion
because of the change in Cl, the half-life of medications cleared renally may be increased
Physiologic Factors Impacting Pharmacokinetics
What processes do most medication have a potential change in?
- absorption
- distribution
Physiologic Factors Impacting Pharmacokinetics
Why do oral medications have a potential change in absorption?
- ↑ gastric pH
- ↓ motility
- ↓ blood flow
- ↓ first pass metabolism
Physiologic Factors Impacting Pharmacokinetics
Why do subcutaneous or intramuscular medications have a potential change in absorption?
↓ tissue perfusion
Physiologic Factors Impacting Pharmacokinetics
Why do medications have a potential change in distribution?
- change in body composition
- ↓ albumin levels, and therefore drugs bound to albumin
Pharmacodynamic Changes
What are the target organ physiologic changes? (3)
- ↑ permeability of blood brain barrier
- ↓ number and activity of receptors
- ↓ levels of hormones and neurotransmitters (epinephrine, dopamine, acetylcholine)
Pharmacodynamic Changes
What are the homeostatic changes? (1)
↓ ability of body to respond to physiologic challenges (ie. impaired baroreceptor reflex)
Physiologic Factors Impacting Pharmacodynamics
What are the changes to the central nervous system?
↑ permeability of BLOOD BRAIN BARRIER, resulting in:
- more medication crossing blood brain barrier/greater concentration of medication in brain in older adults compared to younger adults
- therapeutic effects potentially seen at LOWER doses
- INCREASED risk of CNS-related adverse effects (ie. confusion, sedation)
↓ number of neurons/receptors PLUS ↓ levels of neurotransmitters
- often an INCREASED susceptibility to effects of medications impacting neurotransmitter
- ie. older adults have ↓ dopaminergic neurons/dopamine receptors and ↓ dopamine levels in the brain – RESULT: increased susceptibility to adverse effects from dopamine antagonist (ie. antipsychotics)
- ie. older adults have ↓ GABA levels in the brain – RESULT: enhanced response to benzodiazepines (GABA agonist) at lower dose and HIGHER adverse effects
Physiologic Factors Impacting Pharmacodynamics
What are the changes to the cardiovascular system?
- ↓ number of β1 receptors PLUS ↓ post-receptor activation from β1 receptors
- DECREASED response to drugs that are agonists or antagonists of β1 receptors
- ie. older adults have decreased antihypertensive effects β1 blockers and as a result, this class of medications is not recommended for managing blood pressure in older adults
Physiologic Factors Impacting Pharmacodynamics
What does the baroreceptor reflex normally cause?
an increased heart rate in response to low blood pressure
- this prevents orthostatic hypotension (drop in blood pressure upon standing)
Physiologic Factors Impacting Pharmacodynamics
Describe the baroreceptor in older adults?
decreased baroreceptor, resulting in;
- increased response to anti-hypertensives
- increased risk of orthostatic hypotension
What is an adverse drug reaction (ADR)?
adverse effects of a drug that was properly administered in the correct dose, for therapeutic or prophylactic use
Describe the prevalence of ADRs in older adults.
- account for 57.6% of all ADR-related hospitalizations
- 48% of older adults ADR-related hospitalizations occur in aged ≥ 80 years
- ADR’s account for 2.7% of all hospitalizations in older adults (vs. 1% for younger individuals)
What are the risk factors for adverse drug reactions? (9)
- older age
- male
- polypharmacy
- ↑ number comorbidities
- ↑ number of prescribers
- ↑ number of pharmacies
- previous hospitalizations in past year
- newly started medications
- poor kidney function
Physiologic Changes of aging and ADRs
Pharmacokinetic Factors
- plasma protein binding: ↑ free fraction (↓ albumin)
- volume of distribution: ↓Vd (hydrophilic drugs) = ↑ concentration
- volume of distribution: ↑ Vd (lipophilic drugs) = ↑ duration of action
- ↓ phase 1 enzymatic reactions = ↓ hepatic metabolism and ↑ drug accumulation
- ↓ Renal Elimination = ↑ Drug accumulation
Physiologic Changes of aging and ADRs
Pharmacodynamic Factors
- ↑ permeability of blood brain barrier = ↑ risk of CNS ADRs
- ↓ receptors and neurotransmitters = ↑ susceptibility of ADRs
What is a common cause of ADRs in elderly?
anticholinergic medications
- allergy medications
- anti-nauseants
- antidepressants
- antipsychotics
- incontinence medications
- sleeping pills
- muscle relaxants
- cough and cold medications
What are some common side effects from anticholinergic medications?
- eyes: blurred vision, dry eyes
- mouth: dry mouth
- bowel: constipation
- skin: skin-flushing, unable to sweat, overheating
- bladder: urine retention (unable to empty bladder)
- heart: rapid heart rate
- brain: drowsiness, dizziness, confusion, hallucinations
What are some common ADRs in older adults?
- mental status changes
- orthostatic hypotension
- gastrointestinal/genitourinary disturbances
What is polypharmacy?
broadly defined as the use of multiple medications
How is polypharmacy categorized? (2)
traditionally defined numerically:
- polypharmacy: ≥ 5 medications
- hyper-polypharmacy: ≥ 10 medications
may also be categorized based on chronicity of use or appropriateness of therapy
What is the most common definition of polypharmacy?
taking at least 5 or more prescription medications concurrently
What are the consequences of polypharmacy?
↑ risk of:
- mortality
- emergency department visits and hospitalizations
- adverse drug events
- drug interactions
- cognitive and functional impairment
- falls
- frailty
- admission to long term care facility
- medication non-adherence
- prescribing cascades
↓ quality of life
What are the patient risk factors for polypharmacy?
- older age
- ale
- ↑ number comorbidities
- ↑ number of pharmacies
- ↑ number of prescribers
- mental health conditions
- residing in long-term care facility
What are the health care system risk factors for polypharmacy?
- lack of primary care physician
- poor medical record keeping
- poor transitions of care
- prescribing to meet disease-specific quality metrics
- use of automated refill systems
What is a prescribing cascade?
- adverse effect from one medication is misinterpreted as a new condition, and a new treatment (drug or medical device) is used to treat the adverse effect
- adverse effect from a drug is anticipated and a new drug prophylactically prescribed
Describe the approach to prescribing cascades.
- is one of the patient’s current medications causing the signs/symptoms that new medication is being prescribed to treat
- is the medication causing the reaction necessary, can it be stopped or substituted for something else
- what are the risks and benefits of continuing the medication that led to the cascade
What are the 3 types of potentially inappropriate prescribing (PIP)?
- mis-prescribing
- over-prescribing
- under-prescribing
What is mis-prescribing?
use of medication where there is increased risk of adverse drug events
What is over-prescribing?
use of medication when no clear indication exists
What is under-prescribing?
lack of prescription of indicated, potentially useful medications
What is potentially inappropriate medication (PIM)?
medications that should generally be avoided in older persons
- ineffective
- pose unnecessarily high risk while safer alternatives are available
What are potentially inappropriate medications (PIM) associated with?
- falls
- cognitive impairment
- adverse drug events
- hospitalizations
- emergency department visits
- ↑ prescription costs
- ↑ health care costs
What are the risk factors for potentially inappropriate medications (PIM)?
- older age
- female
- polypharmacy
- ↑ number of prescribers
- ↑ number of comorbidities
- mental health conditions
What is the Beer’s Criteria designed to do?
- minimize adverse effects
- improve medication selection
- educate health care practitioners
- help evaluate quality of medication use
Who can the Beer’s Criteria be applied to?
all individuals 65 years and older in ambulatory, acute, or long-term care
- not applicable in hospice or palliative care
What medications does the Beer’s Criteria contain?
medications that:
- should generally be avoided in most older people
- avoided in older people with specific health conditions
- avoided in combination with other treatments (high interaction risk)
- should be used with caution
- should be dosed differently or avoided in older people with renal dysfunction
- are highly anticholinergic
What are the considerations for using the beers criteria?
- medications are POTENTIALLY inappropriate, not definitely inappropriate
- always read the rationale and recommendations to determine if it is applicable to your patient
- optimal care involves not only identifying PIMs, but also offering safer alternatives
- remember that it is an American resources and there are differences in drug availability between the US and Canada
What is the STOPP/START Criteria?
dual set of criteria outlining:
- Screening Tool of Older Person’s Prescriptions (STOPP) criteria: potentially inappropriate medications
- Screening Tool to Alert doctors to Right Treatment (START) criteria: commonly encountered errors of omission
What approach does the STOPP/START Criteria use?
systems-based approach (cardiovascular, central nervous system, gastrointestinal system)
What is deprescribing?
stopping medications or adjusting dosages down to the minimum effective dosage
What are the goals of deprescribing?
- improving patient outcomes
- minimizing polypharmacy
When should you consider deprescribing?
- medications are unnecessary
- medications are causing adverse effects/putting patient at risk of adverse effects
- shortened life expectancy
- increased frailty
- treatments no longer align with patient goals and preferences
What are the steps in deprescribing?
- identify medication to deprescribe (often start with 1 at a time)
- engage patient and prescriber in deprescribing
- identify if medication can be stopped abruptly
- create a tapering schedule (if needed)
- if a taper algorithm is not available – consider the pharmacokinetics, pharmacodynamics, patient stability and monitoring to create your own plan
- support patients through medication discontinuation
- monitor for discontinuation symptoms or need to restart medications
- document outcomes
What are the patient barriers to deprescribing?
- favourable perception of medication
- fear of medication discontinuation
- discouragement from healthcare professionals
- complexity of healthcare system
What are the patient enablers to deprescribing?
- clear benefits of deprescribing
- safety concerns
- deprescribing education
- follow up
- relationship with prescriber
- deprescribing strategies – ‘trial’ of deprescribing, tapering, one medication at a time
Describe the continuum of care for older adults.
- independent living
- assisted living
- nursing home/residential care facility
What is independent living?
living in their own home, primarily independent
- may receive informal care from family/friends, or formal care from homecare services
What is assisted living?
living in a facility that provides some supports (meals, cleaning, managing medications), but clients are mostly independent
What is a nursing home/residential care facility?
living in a facility that provides 24H nursing care, clients are mostly dependent for their personal care
What are basic activities of daily living (bADL)?
- bathing
- grooming
- dressing
- toileting
- feeding
What are instrumental activities of daily living (iADL)?
- cooking
- cleaning
- taking medications
- laundry
- shopping
- finances
- transportation
What is frailty?
decline in multiple systems, resulting in increased vulnerability to stressors and increased functional impairment/loss of functional reserves
- multifactorial, including changes in physical, psychological and/or social health
- chronic, progressive, dynamic spectrum – can be delayed or in some patients improved
What might frailty present as?
- reduced muscle mass and strength
- reduced energy and exercise tolerance
- cognitive impairment
Is frailty an inevitable part of aging?
no
What are the consequences of frailty?
increased risk for:
- hospitalization
- loss of activities of daily living
- premature mortality
- physical limitation
- falls and fractures
What are the risk factors for frailty?
sociodemographic:
- advanced age
- female
- low educational achievement
- low socioeconomic status
- living alone/social isolation
lifestyle:
- physical inactivity
- poor nutrition/low protein intake
- smoking
- increased alcohol intake
clinical:
- multi-morbidity
- polypharmacy
- cognitive decline
- functional decline
- muscle weakness
- reduced gait speed
- weight loss
- depression
- geriatric syndromes
What are some ways to avoid frailty?
- activity
- vaccination
- optimize medications
- interact
- diet and nutrition
What are geriatric syndromes?
conditions occurring predominantly in the elderly
What are the causes of geriatric syndromes?
multifactorial
- multiple organ systems
- age-related risk factors
- situation specific stressors
What are the consequences of geriatric syndromes?
- ↑ frailty
- ↓ quality of life
- significant disability
- ↓ independence +/- institutionalization
In what populations can frailty and geriatric syndromes occur?
in both older and younger individuals
What are the geriatric 5M’s?
mobility, mind, medications, multicomplexity, matters most
- framework to identify areas of care for all older adults
- provides broader context than focusing only on individual health conditions
- promotes alignment of care with patient’s health and life goals
Mobility
What is a fall?
sudden and unintentional change in position resulting in an individual landing at a lower level such as on an object, the floor, or the ground, with or without injury
Mobility
What is the leading cause of injury among older Canadians?
falls
Mobility
Falls as a Geriatric Syndrome
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Mobility
Falls Prevention
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Mobility
What are pharmacists’ role in falls prevention?
look for drugs that cause:
- dizziness, sedation, confusion, gait abnormalities, weakness
- hypotension, bradycardia
- orthostatic hypotension
- hypoglycemia
- bowel/bladder urgency or incontinence
Mind
What is cognition?
mental processes of thinking, attention, language, learning, memory and perception
- certain declines in cognition are expected
Mind
What is dementia?
occurs when changes in cognition impact daily functioning (ADL’s and iADLs)
- Alzheimer’s disease is the most common type of dementia
- many patients with dementia are community-dwelling
- dementia diagnosis does not automatically indicate treatment de-escalation
Mind
What are some cognition cues in pharmacy practice?
- patient is a ‘poor historian’ – having trouble remembering or answering questions
- provides vague answers
- unable to answer questions on own/often deferring to family member/caregiver
- not filling medications on schedule
- mixing up appointment times
- difficulty following instructions
- getting lost
- decreased self-care (more disheveled or decreased hygiene than previous)
- unexplained weight los
Mind
What drugs should you look for?
drugs that cause dizziness, sedation, confusion, cognitive impairment, impaired judgement, delirium, depression
Mind
What should you assess in terms of adherence?
- keeping track of medications
- taking medications at the right time
- missing doses of medications
Medications
- identify potentially inappropriate medications/prescribing, prescribing cascades and adverse effects
- deprescribe
- modify complex regimens to improve adherence
- check dexterity (ability to open vials, use inhalers, inject medications, etc) and ability to swallow medications
- ensure medications are meeting client-specific goals
- look for drugs that are worsening other geriatric syndromes/5M’s
Multicomplexity
- consider the impacts of physiologic changes of aging on medical conditions and medications
- avoid thinking about a medication/medical condition in isolation
- be aware that some medical conditions present atypically in older adults
- thoroughly assess and manage geriatric syndromes and frailty
- considering modifying targets (i.e. BP, A1c) depending on life expectancy and time-to-benefit
- individualize recommendations
Describe atypical presentation of disease in older adults.
due to age-related physiological changes, multiple comorbidities and unrecognized/reported symptoms, older adults with common medical conditions may present atypically
Matters Most
- what’s most important with your health
- what are your healthcare goals
- what concerns do you have about your health
- what are the most important parts of your day
- how do medications help/hinder
What is adherence?
extent to which a person’s behaviour agrees with the medication regimen from a health care provide
What is the prevalence of non-adherence in seniors?
up to 50%
What is the importance of non-adherence?
- ↓ therapeutic benefits
- ↑ adverse effects
- ↑ hospitalizations
- over-treatment of medical conditions
- ↑ health care utilization and cost
What are patient risk factors for poor adherence?
- treatment understanding, knowledge and beliefs
- lack of support and interpersonal relationships
- older age
- lower education level
- poor physical, cognitive or mental health
What are medication risk factors for poor adherence?
- drug regimen
- drug formulation and packaging issues
- lack of immediate consequences of missed doses
- cost/coverage
- adverse drug reactions
What are healthcare provider risk factors for poor adherence?
- poor communication
- lack of confidence in health care providers
- lack of patient involvement in decision making
What are some methods for improving adherence?
- multi-modal, individualized education
- patient empowerment in management of their medical conditions
- individualizing medication regimens
- active participation in decision making
- offer patients choices in treatment
- consider economic barriers
- building trusting relationships
- inquire about non-adherence
- adherence devices – pill boxes/dosettes, blisterpacking
- administration of medication by family/caregiver or home care/care aide
- automatic pill dispensers
What are some communication barriers with seniors?
- hearing impairment
- visual impairment
- speech impairment
- cognitive impairment
- technological barriers
What are some ways to overcoming hearing impairment communication barriers?
- eliminate background noise/distractions
- speak loudly and clearly, check for volume and tone
- allow face and mouth to be visible if lip-reading
- portable amplifier systems
What are some ways to overcoming visual impairment communication barriers?
- explain what you are doing
- ask what might help (increasing light, reading document, etc)
- write instructions in large font with dark marker
What are some ways to overcoming speech impairment communication barriers?
- allow more time for response
- eliminate background noises/distractions
- allow them to write down answers
- open ended vs. close ended questions
What are some ways to overcoming cognitive impairment communication barriers?
- introduce yourself and your role each time
- use short simple sentences or questions
- redirection
- maintain calm demeanor
- open ended vs. close ended questions
What are some communication strategies for older adults?
- allow extra time
- minimize distractions
- sit face to face
- make eye contact
- listen without interrupting
- check to ensure your volume, tone and enunciation is clear
- avoid medical jargon
- stick to one topic at a time
- simplify and write down instructions (check font size)
- frequently summarize most important points
- check for understanding
- give opportunities to ask questions
- ensure comfortable, accessible seating
- be prepared to assist patient to sit/stand
- be prepared to escort patients
What are some communication strategies for dementia?
- make sure to have the person’s attention before speaking
- keep voice at normal level unless the person indicates otherwise
- reduce communication complexity but be adult – simplify sentence structure and reduce rate of speech, don’t talk down
- minimize background noise
- give them time to speak – resist urge to finish sentences or offer words
- confirm that you are communicating successfully by using ‘yes’ and ‘no’ questions – use facial expressions and/or pictures
What is ageism?
stereotyping, prejudice and discrimination against people on the basis of age
What is ageism at the individual level?
- negative attitudes and opinions of elderly by health care providers
- different treatments and diagnostics offered based on age
- ↓involvement in patient in clinical decision making
- less respectful, use of demeaning or patronizing tone
What is ageism at the systems level?
- ↓ access to medical care
- limited financial resources to pay for medical care/medications
- ↓ participation in clinical trials
- inadequate health care professional training
What is self-ageism?
ie. beliefs that pain and suffering are normal parts of aging
What are the consequences of ageism?
- enhances intergenerational conflict
- creates negative stereotypes of aging
- impacts availability and quality of services for elderly
Those who self-report ageism are associated with…
- self-reported fair or poor health status and deterioration in self-reported health status over time
- more likely to have chronic health conditions: coronary heart disease, chronic lung disease, arthritis, life-limiting illness
- more likely to have depressive symptoms
Why are older adults under-represented in clinical trials?
- multiple comorbidities and polypharmacy
- communication issues
- difficulty obtaining consent
- physical mobility and transportation challenges
- adherence concerns
- ageism
- lack of policy requirements for data in older adults
Under-representation of older adults in clinical trials results in limitations in…
- generalizability of clinical findings to older adults or those with frailty
- data on pharmacokinetics in older adults
- safety data in older adults
- medication dosing in older adults
- data on drug interactions
- clinical practice guidelines less likely to have guidance specific to older adults
What are some general practice points for pharmacists?
- older adults are more prone to negative healthcare outcomes due to physiological changes, polypharmacy and multi-morbidity
- pharmacists should consider the geriatric 5M’s when caring for older adults
- many older adults have complex drug regimens, leading to adverse drug reactions and adherence issues
- pharmacists must recognize the clinical signs and symptoms of adverse events and prescribing cascades
- pharmacists must know which medications contribute to poor clinical outcomes in older people and avoid these medications, when possible
- frequent medication reviews and frequent follow are necessary
