Introduction

Question 1

What is defined as senior? What is this age conventionally used?

Answer 1

Conventionally age 65 in Canada

• Age when many Canadians begin to receive social services
• Former age of mandatory retirement

Organization for Economic Cooperation and Development (OECD) also uses this definition

Question 2

Is there a debate between researchers on the age for defining “senior” or “older adult”?

Answer 2

With increased longevity, 65y is still relatively young

Encompasses a lot of heterogeneity – 65 y vs 100+y

Question 3

Define the aging process?

Answer 3

Aging is a very heterogeneous process

heterogeneity varies more as we age

Question 4

What is the relationship and implication of aging and diversity?

Answer 4

Because of this ↑ diversity with age, protocols and guidelines are less useful in geriatric care than for younger ages

Care, including drug therapy, must be individualized

Question 5

What are some other factors that affect health in older ages?

Answer 5

Genetics

Socioeconomic status

Education

Social engagement and support

Lifestyle: Exercise, diet, smoking and alcohol use

Question 6

Define “Life Expectancy” Is it the same throughout life?

Answer 6

To what proportion of the maximum age a person may live

Life expectancy changes throughout the course of life

Question 7

Define health span

Answer 7

Number of years that are spent free from functional limitations, morbidity, and pain

Question 8

What is the major goal of geriatric models of care?

Answer 8

Goal of most geriatric models of care -> prolong the health span

Question 9

Define functional capacity. What are the categories?

Answer 9

Indicator of ability to carry out everyday tasks

1) Activities of Daily Living (ADLs)
2) Instrumental Activities of Daily Living (IADLs)

Question 10

Define ADL’s

Answer 10

A term used to collectively describe fundamental skills required to independently care for oneself

Things to do to get up and get up in the morning essentially

Question 11

Define IADLs

Answer 11

Things you do every day to take care of yourself and your home

Supportive taks to. achieve independence butnot required

Question 12

What are some examples of ADL’s

Answer 12

Dressing, toileting, eating, bathing, walking

Question 13

What are some examples of instrumental activities of daily livings?

Answer 13

Instrumental Activities of Daily Living (IADLs)

Shopping, housekeeping, food preparation, medication management, financial management

Question 14

Define the Clinical Frailty Scale

Answer 14

1-3 –> Not considered frail

4-5 –> Mildly frail (some evidence but still mostly able to mange independently)

Question 15

Define frailty

Answer 15

Accumulation of functional impairments

Question 16

Define functional reserve

Answer 16

Body systems generally have capabilities beyond what is needed for everyday activities (functional reserve)

Question 17

When does impairment in function occur in geriatrics?

Answer 17

Impairment in function = demands exceed functional capacity

Question 18

Describe the functional reserve compared to younger adults? Example?

Answer 18

Older adults have ↓ functional reserve compared to younger adults

↑ risk of decline when faced with illness or injury

E.g. older adult with dementia is more likely to experience post-operative delirium

Question 19

Define functional decline

Answer 19

Reduction in ability to perform ADLs and IADLs due to decreased physical and/or cognitive function

Question 20

What is age a factor for? Is it the only one? Explain.

Answer 20

Age is a factor in functional decline and health resource utilization, but not the only factor

Older seniors (75+) did not always report higher healthcare use than younger seniors

–> Higher healthcare utilization was reported among those with more chronic medical conditions, regardless of age

Question 21

Describe the basics of the pharmacokinetics

Answer 21

ADME

Heterogenous

Most PK studies in relatively healthy adults < 80 years

–> Limited data in oldest-old, frail

Question 22

What PK changes occur in the Gastrointestinal system in geriatrics? What type of drug dosing is effected?

Answer 22

↓ gastric acid secretion
Slower gastric emptying
Delayed intestinal transit
↓ blood flow

Question 23

Describe some exceptions for oral absorption pharmacokinetic changes in geriatrics? Examples? Management?

Answer 23

↓ gastric acid secretion may decrease the extent of absorption of some medications:

Iron supplements
Ketoconazole/intraconazole (anti-fungals)
Calcium carbonate

Suggestions to combat:

Empty stomach with iron supplements
Use citrate form of calcium

Question 24

Describe the percutaneous absorption changes in geriatric patients. Examples?

Answer 24

Aged skin tends to be drier, lower lipid content

↓ rate of percutaneous absorption of lipophyllic medications

Fentanyl
Testosterone
Estradiol

Overall extent generally remains the same

Question 25

Describe the distribution pharmacokinetic changes that occur in geriatrics

Answer 25

Changes in body composition with aging:

25-30% ↑ body fat
25-30% ↓ muscle mass/body water

Gradual progression over time

¼ of body mass will change from muscle to fat

Question 26

What are some medications with altered distribution in older adults? Clinical Effects?

Answer 26

Highly lipophilic: increased distribution, increase dose (diazepam, amiodarone) - More in the fat

Highly hydrophilic: decreased distribution, decrease dose (lithium, aminoglycosides) - More in blood

Question 27

Describe the pharmacokinetic changes in distrubution reagrading protein binding in geriatrics. Examples and management?

Answer 27

↓ albumin levels in frail/malnourished older adults

↓ protein-binding of highly-protein-bound medications:

Phenytoin
Warfarin

Over time, increased metabolism/elimination compensate for this increased free fraction

Start low, go slow

Question 28

Describe the metabolism changes in PK in geriatrics? (Liver changes)

Answer 28

Liver size and blood flow decrease significantly with age

20-40% ↓ liver mass
~35% ↓ hepatic blood flow

Question 29

What is a major change that occurs in metabolism and its effect on medications?

Answer 29

Major change here is first pass effect

Meds with significant first pass effect –> less first pass effect, increased F, increased effect

Question 30

Describe the first-pass PK changes in metabolism in geriatrics? Examples? Management?

Answer 30

Question 31

Describe the changes in phases of metabolism. Examples?

Answer 31

No change in Phase II metabolism (conjugation) with aging

Medication examples:
Acetaminophen
Lorazepam, oxazepam, temazepam
Zaleplon
Valproic acid

Question 32

Describe the PK changes in elimination in geriatrics?

Answer 32

↓renal size, blood flow, glomerular filtration rate, and tubular secretion with aging

~10% ↓ GFR per decade after age 30

Question 33

Describe the key points in kidney function in geriatrics

Answer 33

Serum creatinine alone not reliable

–> Muscle mass tends to ↓ with age, so SCr may be falsely low

–> Does not account for the effect of age on kidney function

Question 34

What equations can be used to estimate kidney function?

Answer 34

Several equations available to estimate kidney function

CKD-epi
MDRD
Cockcroft-Gault

Question 35

Describe the CKD-epi equation

Answer 35

What the Sask Health Authority labs currently use to generate the quoted eGFR

Some drugs have dosage adjustments recommended based on eGFR

Question 36

MDRD Equation

Answer 36

Used more for the staging of kidney disease

Question 37

Describe the Cockgroft - Gault Equation

Answer 37

Estimates CrCl

The equation drug-dosing recommendations are generally based on

Underpredicts renal function for those weighing less than their ideal body weight (IBW)

Overpredicts renal function for those weighing more than their IBW

If overweight/obese – use IBW to calculate CrCl

Question 38

What causes some pharamcodynamic changes that occur in geriatrics? What does this lead to?

Answer 38

Changes in medication response associated with aging

Due to changes in receptor sensitivity, or altered homeostatic mechanisms

• Causes a narrowing of the “therapeutic window”

Question 39

Describe some pharmacodynamic changes in the cardiovascular system in geriatrics?

Answer 39

↓ blood pressure-lowering response to beta-blockers

↓ arterial compliance and ↓ baroreceptor reflex

Predispose to orthostatic hypotension (fall risk in adults)

↑ stiffness of large blood vessels -> isolated systolic hypertension

↑susceptibility to QT prolongation (older women are a high risk group)

Question 40

Describe the pharmacodynamic changes in the CNS in geriatrics?

Answer 40

↑ permeability of blood-brain-barrier with age

↑ susceptibility to CNS adverse effects of medications
Anticholinergics
Benzodiazepines
Dopaminergic medications

↓dopaminergic neurons in substantia nigra - ↑ susceptibility to extrapyramidal side effects of dopamine-blocking medications (FGA’s, Metoclopramide)

Question 41

Describe the pharmacodynamic changes in fluid and electrolyte homeostasis?

Answer 41

↓ thirst response
↓ glomerular filtration rate
↓ response to antidiuretic hormone
↓ response to aldosterone

Question 42

Fluid and electrolyte homeostasis: Geriatric patient is more susceptible to:

Answer 42

Dehydration
Hyponatremia
SIADH (Syndrome of inappropriate secretion of antidiuretic hormone)
Hyperkalemia

Question 43

Describe the hematolgical pharamcodynamic changes

Answer 43

↓ hematopoietic reserve (cell producing bone marrow)
↑ risk of hematological toxicities associated with chemotherapeutic drugs

Question 44

Anti-epileptic use in geriatrics: Pharmacodynamic changes?

Answer 44

↑ response to antiepileptic drugs at a lower serum concentration

Also ↑ susceptibility to adverse effects

Question 45

Describe immunosenescene

Answer 45

Immunosenescence refers to aging-related changes to the immune system

Question 46

What are some pharmacodynamic immune system changes in geriatrics?

Answer 46

Reduced ability to fight infections
Reduced immune response following vaccination
↑ susceptibility to malignancy
↓ regenerative capacity of gastric mucosa
↑ risk for GI bleeds

Question 47

Describe an overall concept of the pharmacodynamic changes in geriatric patients

Answer 47

As frailty increases, difference between therapeutic effect and toxicity (adverse effects) becomes more narrow