Introduction to Geriatric PT Flashcards
What are the three primary goals of health care in the elderly?
- Improve physical function and prevent disability
- Maintain independence (Avoid institutionalization)
- Prevent drug-related adverse consequences
As we age, the number of receptors ____________. The sensitivity of the receptors _________.
a. decreases
b. increases
Why does the BBB have increased permeability as we age?
Decrease in p-gp efflux transporter activity
What happens to the liver as we age?
Mass decreases
Blood flow decreases
Phase I metabolism activity decreases (1st pass effect)
PHASE II METABOLISM= NO CHANGE
What happens to the kidneys as we age?
Loss of function due to:
decreased mass and blood flow
decreased filtration and secretion
decreased GFR
What is the net effect of aging that can alter the body’s clinical response to medications?
Age-related changes PK and PD changes Concurrent medication use increases Comorbidities Frailty due to limited reserve capacity
As we age __________ transport activity decreases. What is the effect on PK?
ACTIVE; results in decreased bioavailability of nutrients, vitamins and ions
As we age hepatic first pass extraction ________________, which will increase what PK parameter?
How does this affect dosing?
Decreases; bioavailability for non-prodrugs.
Use lower doses in the elderly
As we age, we have lower lean body mass and total body water. How does this affect medication therapy?
Decreased volume of distribution which will increase plasma concentrations of hydrophilic drugs
As we age, we have a _________ in body fat. How does this affect medication therapy?
INCREASE
- Increased volume of distribution and half-life for lipophilic drugs
How does aging affect albumin levels? How does this affect medication therapy?
No change or decrease in serum albumin
- Increased amount of free, active drug resulting in more activity
Due to the decrease in Phase _____ metabolism, how are clearance and half-life affected?
Phase I metabolims
- Clearance = decreased
- Half-life = increased
Explain why as we age, we have decreased hepatic first pass extraction and how this affects drug metabolism.
a. Due to decreased number of receptors
b. This decreases clearance of the drugs while INCREASING bioavailability
Lorazepam is a safer option to use in the elderly for anxiety. Why?
It undergoes Phase II reactions readily (due to existing polarity) which are unchanged as we age so accumulation and toxicity risks are decreased compared to drugs who must undergo Phase I reactions for excretion
Why is SCr not a good measure of kidney function in the elderly?
Their SCr may look normal but in fact may not be due to:
- Lower lean body mass = decreased creatinine production
- Have a decreased GFR
What do we use to estimate GFR?
CrCl
Rounding an elderly patients CrCl to 1 may __________________ their renal function.
UNDERESTIMATE
If Cl is decreased and half-life is increased due to decreased GFR as we age, what are we more likely to notice with medication therapy?
Increase in side effects and active metabolites of drugs
Why do we want to avoid benzodiazepine use in elderly? What other medication class can we use for anxiety?
Increased sensitivity to CNS effects
a. sedation and psychomotor impairment
Use SSRIs/SNRIs instead
Why do we want to avoid Opioid analgesic use in the elderly?
Have higher level and duration of pain relief which means using lower doses
Why are we concerned about B-blocker use in the elderly?
Decreased HR and BP response resulting in a HIGHER DOSE NEEDED
Why are we concerned about B-agonist use in the elderly?
Decreased bronchodilation response resulting in a HIGHER DOSE NEEDED
Why are we concerned about digoxin use in the elderly?
Increased sensitivity of the heart; USE LOWER DOSE
Why are we concerned about anticoagulant therapy in the elderly?
Increased bleeding risk to due increased response
USE A LOWER DOSE
Why do we want to avoid anticholinergic agents in the elderly?
Increased sensitivity to adverse effects, confusion and sedation being the main effects we want to avoid
What are the 4 major drug related problems that occur when treating elderly patients?
- Polypharmacy: Administration of more medications than are indicated (55 to 59%)
- Inappropriate prescribing when the risk of using a drug outweighs the benefit
- Medication underuse: Omission of a medication that is indicated
- Non-adherence: ~40 to 86% of patients that INCREASES health care use/cost
Who is considered a geriatric patient?
Adults age 65+
List the drug classes associated with STRONG ANTICHOLINERGIC Properties. (9)
- Antihistamines
- Antidepressants
- Antiparkinsonian agents
- Antiemetics
- Antipsychotics
- Skeletal muscle relaxants
- Antiarrhythmics
- AntiMUSCARINCS
- Antispasmodics
Drug Class: Clozapine
Antipsychotic
Drug Class: Olanzapine
Antipsychotic
Drug Class: Benztropine
Antiparkinsonian agents
Drug Class: Cyclobenzaprine
Skeletal muscle relaxants
Drug Class: Dicyclomine
Antispasmodics
Drug Class: Oxybutynin
AntiMUSCARINCS
Drug Class: Tolteridine
AntiMUSCARINCS
Drug Class: Trospium
AntiMUSCARINCS
Drug Class: Hyoscyamine
Antispasmodic
Drug Class: Scopolamine
Antispasmodic
Drug Class: Nortriptyline
SSRI (Antidepressant)
Drug Class: Dimenhydrinate
Antihistamine
Drug Class: Doxylamine
Antihistamine
Drug Class: Meclizine
Antihistamine
Drug Class: Chloropheneriamine
Antihistamine
Drug Class: Cyproheptadine
Antihistamine
Drug Class: Clemastine
Antihistamine
Drug Class: Amitriptyline
Antidepressant
Drug Class: Doxepin
Antidepressant
The BEERS Criteria is a resource used to identify what?
Potentially inappropriate medications to be avoided in elderly patients
BEERS: What 3 classes mentioned in class should be avoided due to high anticholinergic side effects?
1st Gen Antihistamines
Antispasmodics
Antidepressants
BEERS: Why should we avoid using Peripheral alpha blockers for HTN in the elderly?
Increased risk of orthostatic hypertension
BEERS: Why should we avoid using digoxin for AFib/CHF in the elderly?
Narrow therapeutic window easily resulting in toxicity due to decreased Cl as we age
BEERS: Why should we avoid using amiodarone as an antiarrhythmic in the elderly?
Easily results in toxicity due to decreased Cl as we age; Use only if rhythmic control is preferred over rate control
BEERS: Why should we avoid using antipsychotics for behavior modification in the elderly?
Increased risk of congnitive decline in dementia and CV risk resulting in pneumonia
Use only when behavior interventions fail AND there is risk of harm to self or others is present
BEERS: Why should we avoid benzodiazepines and benzo receptor agonists in the elderly?
Increased risk of cognitive impairment, falls and fractures as well as motor vehicle accidents
BEERS: Why should we avoid long term use of nitrofurantion in elderly patients with a CrCl of <30 mL/min?
Can result in toxicity:
a. pulmonary, liver, kidney and peripheral neuropathy
BEERS: Why should we avoid PPIs in the elderly?
Increased risk of C. Diff infection and fractures due to decreased BMD
BEERS: Why should we avoid metoclopramide in the elderly?
Increased risk of Extrapyramidal symptoms (EPS) and dyskinesia
BEERS: Why should we avoid NSAIDs in the elderly?
Increased risk of GI bleeding, peptic ulcer disease and fluid retention
BEERS: Why should we avoid Indomethacin in the elderly?
Increased risk of GI bleeding, peptic ulcer disease, acute kidney injury AND CNS adverse effects
BEERS: Why should we avoid skeletal muscle relaxants in the elderly?
Excessive sedative effects which can increased fall risk
BEERS: What drugs should not be used in patients with Parkinson’s disease?
Dopamine antagonists that may worsen symptoms
BEERS: Why should we avoid estrogen and peripheral alpha blockers in elderly women?
Increased risk of urinary incontinence
What is SIADH?
Syndrome of Inappropriate ADH secretion
- Due to hyponatremia and hypo-osmolality signalling excess ADH secretion
BEERS: Give a few examples of drugs that may induce SIADH. What lab parameter should you monitor?
Monitor SODIUM levels!
- SSRIs/SNRIs
- Antipsychotics
- Oxcarbazepine / Carbamazepine
- Diuretics
- TCAs
- Mirtazapine
Which drug class used to treat HTN may increase syncope episodes in the elderly with a history of syncope?
Vasodilators
