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phty2230 > L34: Medicine Use in the Elderly > Flashcards

L34: Medicine Use in the Elderly Flashcards

1
Q

Mrs Smith –70 year old Current medicines

  • PC: nociceptive pain
  • PMH: Heart failure, angina, AF GORD, Depression
  • Medicines in her webster pack: Diuretic (Frusemide), Heart tablets, stomach tablet, tablets for bones, statin, tablet for depression

You think she would benefit from a NSAID: Place a post it not on the wall if you would recommend / note recommend. Write on the post it note your reasoning

A

No recommending- she already has heart and stomach problems

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2
Q

What are 6 conditions of NSAIDS?

A
  1. Heart failure
  2. Angina
  3. Atrial fibrillation
  4. Gastro-oesophageal reflux disease
  5. Osteoporosis
  6. Depression

NSAIDS can increase risk of heart attack (even if they have no prior risk)

Not good for AACE inhibition

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3
Q

Imagine you are 85

  • You see your doctor/ allied health professional. You suffer from arthritis and have the option of the following drugs:
  • A: Drug A increases your life expectancy by 2 years but has a risk of muscle pain of 10% and severe muscle pain of 1%
  • B: Drug B reduces the pain of your arthritis from 5/10 to 3/10 but increases your chance of heart attack or dying within the next 5 years from 10% to 12%

Which one do you choose?

A
  • B- Preferred choice
  • Drugs depends on patient’s experience
  • The sensation of pain is different for everyone (even for the same stimulus)
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4
Q

What are the 3 benefits of medicine?

A
  1. Prolong life
    • Cholesterol lowering drugs in cardiovascular disease -statins
  2. Improve symptoms -quality of Life
    • Levodopa in Parkinson’s disease
    • Omeprazole in reflux disease
    • NSAIDS
  3. Save lives
    • Penicillin
    • Insulin in diabetes
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5
Q

What is statin?

A

Very good medication

  • Long life
  • Well tolerated
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6
Q

Without penicillin, pre WWII, what used to happen?

A

Pre WWII –> infection –> progress –> sepsis –> death (or amputation if lucky)

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7
Q

What are the 3 problems with medicines?

A
  1. Medicine related:
    • Estimated 2-3% of all hospital
    • 20-30% of all hospital admission in aged >65yrs Estimated 230,000 drug-related hospital admissions
    • Thought that 50% preventable
  2. Adverse drug reactions
  3. Reasons Medicine use is increasing
    • Population aging in Australia
    • Aged pensioners use 22% of all prescription drugs
    • 65 to 74 years 39% prescribed 5 -9 medicines and
    • >75 years 45% prescribed 5 -9 medicines and 30% ≥ 10 medicines 100% have a ADRs
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8
Q

What is the problem with anti-depressants?

A

Anti-depressants can be very addictive

New medicine = might have side effects but we don’t know now

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9
Q

What is polypharmacy?

A

Concurrent use of five or more drugs

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10
Q

What are 3 things that medicine increases the likelihood of?

A
  1. Side effects
  2. Falls
  3. Drug interactions
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11
Q

Why is it important to stimulate medication reviews?

A
  • Type of medicine used and
  • Dose used
    • Medicines used are appropriate
    • Medicines are still necessary
    • Medicines are still effective
    • Medicine doses are still correct- eg. declining renal function
      • Still on massive doses from when they were 50yrs –> now they are 75yrs
      • Need lower doses –> due to BMI..etc
    • Choice of medicine is still correct
    • There are no significant drug interactions/ ADRs happening
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12
Q

What does the evil cycle of drug use look like with polypharmacy? (eg. drug A)? What is the solution

A

Solution: Stop drug A or give another type

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13
Q

What is an example of evil cycle of drug use with Atorvastatin?

A
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14
Q

What is pharmacokinetics?

A

What the body does to the drug

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15
Q

What are the 3 characteristics of pharmacokinetics?

A
  1. Absorption
    • Slowing of GI tract and reduced blood flow reduced absorption
  2. Distribution of the drug
    • More fat than muscle (Less lean body mass) –lipid soluble (Lipophilic) drugs effect can last longer
    • Than normal –> hard to metabolism and get rid of
  3. Excretion –kidneys/ liver
    • Declining function so drugs not removed from body as quickly
    • Many drugs require kidney function –> need to give lower doses otherwise it can be dangerous
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16
Q

What is the absorption process in pharmacokinetics?

A

Slowing of GI tract and reduced blood flow reduced absorption

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17
Q

What is the distribution of the drug process in pharmacokinetics?

A

More fat than muscle (Less lean body mass) –lipid soluble (Lipophilic) drugs effect can last longer

  • Than normal –> hard to metabolism and get rid of
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18
Q

What is the excretion –kidneys/ liver process in pharmacokinetics?

A

Declining function so drugs not removed from body as quickly-

Many drugs require kidney function –> need to give lower doses otherwise it can be dangerous

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19
Q

What is pharmacodynamics?

A

What the drug does to the body

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20
Q

What are the 2 undesired effects of pharmacodynamics?

A
  1. Usually minor pharmacological effect
  2. Arise in certain circumstances
    • impaired kidney function
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21
Q

How do you increase sensitivity of organs to drugs?

A

Psychotropic CNS (blood brain barrier leaky, less reserve)

Cells on vessels = designed to prevent toxins going into the brain

  • Sometime even the useful drugs
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22
Q

What are the 3 changes of the cardiovascular system?

A
  1. ↓cardiac output
  2. ↓compliance blood vessels
  3. ↓baroreceptor responsiveness
    • Blood pressure receptors = respond by increase blood pressure and blood flow
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23
Q

What is an issue with drugs with the cardiovascular systems?

A

Postural hypotension

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24
Q

What are the 3 changes of the central nervous system?

A
  1. ↓brain size
  2. ↑BBB permeability
  3. ↓baseline cogntion
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25
Q

What are 2 issues with drugs with the cardiovascular systems?

A
  1. ↑delirium/confusion
  2. Dizziness, sedation
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26
Q

What is a change of the gastrointestinal system?

A

↓motility

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27
Q

What is an issue with drugs with the cardiovascular systems?

A

↑constipation

28
Q

What is a change of the renal (kidney) system?

A

↓Function

29
Q

What are 2 issues with drugs with the renal (kidney) systems?

A
  1. ↓drug excretion
  2. Prone to drug induced kidney damage
    • Poor renal function = increase risk of renal damage
30
Q

What is a change of the genitourinary system?

A

incontinence

31
Q

What are 2 issues with drugs with the genitourinary systems?

A
  1. Drug induced
  2. Drugs to treat have effects on CNS
32
Q

What drugs are removal by the kidneys?

A

Opioids (codeine, morphine)

33
Q

When is codeine (opioids)?

A

Needs prescription –> no longer available over the counter due to risk of addiction ?

34
Q

What drugs increase the risk of acute kidney failure?

A

Non-steroidal anti-inflammatory drugs (ibuprofen)

35
Q

What drugs affect gastrointestinal tract?

A

Non-steroidal anti-inflammatory drugs (ibuprofen)

  • Ulceration and haemorrhage
36
Q

What drugs increase the risk of heart attack failure?

A

NSAIDs esp ibuprofen

37
Q

What are 4 drugs that cause CNS effects - confusion and delirium?

A
  1. Opioids -morphine
  2. Benzodiazepines (Sleeping tablet) (diazepam, temazepam) and withdrawal
    • Can cause delirium if you stop immediately (withdrawals) –> need to ween off gradually
  3. Antipsychotics (risperidone, quetiapine)
    • Used to treat delirum but can be the cause if too high dose
  4. Anticholinergics eg. Stemetil(prochlorperazine), oxybutynin
    • Confusion and delirium
38
Q

What are 5 drugs which cause adverse effects?

A
  1. Antihypertensive
    • Orthostatic hypotension
  2. Benzodiazepines (diazepam)
    • Drowsiness, confusion, falls
  3. Beta blockers (heart medication –angina)
    • Reduced effect (receptors less responsive), falls
  4. Anticoagulants (warfarin, rivaroxaban, apixaban)
    • Increased effect –bleeding, increased risk SDH if falls
  5. Diuretics (frusemide)
    • Increased loss of fluid, acute kidney failure
39
Q

What adverse effects are used by antihypertensive?

A

Orthostatic hypotension

40
Q

What adverse effects are used by benzodiazepines (diazepam)?

A

Drowsiness, confusion, falls,

41
Q

What adverse effects are used by beta blockers (heart medication –angina)?

A

Reduced effect (receptors less responsive), falls,

42
Q

What adverse effects are used by anticoagulants (warfarin, rivaroxaban, apixaban)?

A

Increased effect –bleeding, increased risk SDH (Subdural haematoma) if falls Prevents blood clotting Due to postural hypotension

43
Q

What adverse effects are used by diuretics (frusemide)?

A

Increased loss of fluid, acute kidney failure

44
Q

What adverse effects are used by non-steroidal anti-inflammatory drugs?

A

GI bleeding, kidney damage, heart attacks

45
Q

What adverse effects are used by antidepressants?

A

Confusion, hypotension, constipation, falls

46
Q

What adverse effects are used by opioids (morphine, codeine)?

A

Confusion, disorientation, constipation, falls

47
Q

What are 9 risk factors for falls?

A
  1. Blackouts
    • Syncope, epilepsy, TIA
  2. Depression
  3. Cognitive impairment
    • Dementia, delirium
  4. Visual impairment
  5. Orthostatic hypotension
  6. Poor Muscle Strength
  7. Gait/ Balance
  8. Dehydration
  9. Polypharmacy
48
Q

What is the paradox for falls?

A

These are all treatable (with / without drugs) but some drugs to treat these cause falls in themselves

49
Q

What are the 9 anti- medications which related to falls?

A
  1. Antianxiety
    • Benzodiazepines and other sedatives
  2. Anti-pain
  3. Antipsychotics
  4. Antidepressants
  5. Anti-Parkinsonian agents
    • Eg, L-dopa can improve mobility; DA agonists can improve bradykinesia but can cause postural drop if wrong dose –> increase calls
  6. Anti convulsants
  7. Anti-arrhythmics
  8. Antihypertensives
  9. Antidiabetic
    • Falls if they are in high dose (eg. high insulin dose)
50
Q

What are 4 specific medicines?

A
  1. Antihypertensives OR 1.24
  2. Antidepressants OR 1.68
  3. Antipsychotics OR 1.59
  4. Benzodiazepines OR 1.57

Not sure whether half life or total dose is major influence

51
Q

What is important in relation for medicines?

A

Not sure whether half life or total dose is major influence Lowest dose and lowest half life

52
Q

What are the 3 characteristics of Tablet Burden and falls (Polypharmacy)?

A
  1. Increased number of medicines = increased falls
  2. Additive effects
  3. Dizziness, postural hypotension, confusion
    • Greater than 2 psychotropics
    • 2.4 to 4.5 fold increase in falls compared to 1 psychotropic
53
Q

What is important about medication? When is it important and when is it not?

A

Older patients

  • Depressed
  • Anxious
  • Cognitively impaired

Try fix this but sometimes drug prescription is not the answer

Eg. Depressed and lonely –> help them socially –> do not prescript anti-depressants

54
Q

What are 6 reasons why drugs cause falls?

A
  1. Orthostatic Hypotension
  2. Cognitive impairment
  3. Altered gait/ balance
  4. Sedation
  5. Visual Impairment
    • Eg. blurred vision from anticholinergics)
  6. Dizziness
55
Q

Can mechanical falls be caused by drugs?

A

Yes

Deconditioned, with poor mobility –> high risk due to drugs

Eg. tripped over; related to mobility

56
Q

What are 3 characteristics of Orthostatic Hypotension?

A
  1. Upright posture fall in blood pressure
    • > 20-30mmHg systolic or
    • > 10mmHg diastolic blood pressure within 3 mins of standing/sitting
  2. Can be delayed and prolonged
  3. Elderly vulnerable due to
    • ↓baroreceptor responsiveness
    • ↑vascular stiffness
    • Dehydration
57
Q

What are 2 characteristics of upright posture fall in blood pressure in Orthostatic Hypotension?

A
  1. > 20-30mmHg systolic
  2. > 10mmHg diastolic blood pressure within 3 mins of standing/sitting
58
Q

Orthostatic Hypotension can be ____ and ____.

A

delayed; prolonged

59
Q

What are 3 things that elderly are vulnerable to with Orthostatic Hypotension?

A
  1. ↓baroreceptor responsiveness
  2. ↑vascular stiffness
    • Blood vessels can dilate/constrict according to needs
  3. Dehydration
    • Eg. can’t grab the water esp. when patient is imobile
60
Q

What are the 6 drugs with help with orthostatic hypotension?

A
  1. Antidepressants
    • Tricyclic –TCA (amitriptyline) > Selective Serotonin reuptake inhibitors SSRIs (Sertraline)
  2. Antipsychotics
    • espclozapine
  3. Antiparkisoniandrugs
    • Levodopa
  4. Diuretics
    • Sodium and water loss (frusemide)
  5. Glyceryltrinitrate / Isosorbide mononitrate- Spray/tablet under the tongue
    • angina- Help with heart pain…etc
  6. Alpha-blockers
    • Prazosin–BPH- Benign prostatic hyperplasia , antihypertensive
61
Q

What is the problem with PD and PD medication? What can you do?

A

Problem

  • PD causes OH
  • PD medication causes OH

What can you do?

  • Give the right dose –> smallest risk of falls
62
Q

What are 5 drugs which cause cognitive impairment?

A
  1. Antipsychotic
    • 1stversus 2ndgeneration
    • Can cause cognitive impairment (older versions of drugs)
  2. Antidepressant
  3. Anticonvulsant
  4. Anticholinergic
  5. Anti-Anxiety
    • Benzodiazepines
63
Q

What are 3 other drug risks for falls?

A
  1. Altered gait/ balance
    • Anticonvulsant, Antipsychotic
  2. Sedation
    • Benzodiazepines
  3. Visual Impairment
    • Anticonvulsant, anticholinergics
64
Q

What are 7 characteristics of antipsychotics in dementia?

A
  1. Don’t treat all behaviours
    • Don’t treat wandering or calling out Treat aggression, agitation
  2. NNT = 6 or 7
  3. NNH 100 (1/100) over 10-12 weeks for death due to stroke
  4. Symptoms wax and wane
    • Should be ceased every 3 months
    • To see if the patient still needs it
  5. May make behaviour worse
  6. Often prescribed by time poor doctors and given by time poor nurses
  7. Delirium vs dementia
65
Q

Case study-Josephine

  • 82 year old
  • GP diagnosed dementia
  • Rx for risperidone 500mcg od prn

Medications

  • Atorvastatin10mg od- Muscle pain/aches
  • Amitriptylline50mg on- Tricylic anti-depressant –> increase sedation falls
  • Oxybutynin5mg nocte- Tricylic anti-depressant –> increase sedation falls
  • Trimethoprimrecently started for UTI
  • Coloxyland senna1 prn

What are you thoughts about josephine’s meds?

A

Keep statin and UTI medication –> egt rid of rest

66
Q

Every Complex Problem has a solution that is simple, neat and wrong. How can it related to drugs?

A

Elderly patients that use drugs –> complex –> have co-morbidities. Etc

Use other treatment options instead of treatment with drugs (important to have medication review very frequently)

MDT is very important

phty2230 (24 decks)

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