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PMCOL 200 > Lecture 23: Drug Therapy in Geriatrics > Flashcards

Lecture 23: Drug Therapy in Geriatrics Flashcards

1
Q

Why is geriatrics a unique specialty?

A

changes associated with primary aging
secondary aging
multimorbidity
geriatric syndromes
multiple medications
setting of care
policy decisions
psychosocial issues
ethics (and advocacy)

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2
Q

What is the definition of life span?

A

greatest age reached by any member of a species

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3
Q

What is the definition of life expectancy?

A

greatest age reached by members of a population

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4
Q

What are the age categories within older adults?

A

young-old (65-74)

middle-old (75-84)

old-old (85+)

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5
Q

What is a centenarian?

A

someone who has lived to be 100 years

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6
Q

What is a super centenarian?

A

someone who has lived to be 110 years

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7
Q

What is a semi-supercentenarian?

A

someone aged 105-109 years

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8
Q

What are the heath care considerations for geriatrics?

A

chronic conditions

76% of seniors have at least 1 chronic condition

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9
Q

What is multimorbidity?

A

associated with age

linear associated with number of medications

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10
Q

What is frailty?

A

a state of increased vulnerability from age-associated decline in reserve and function resulting in reduced ability to cope with everyday or acute stressors

no universally agreed upon definition

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11
Q

What is the pathophysiology of frailty?

A

a gradual decrease in physiological reserve occurs with aging

in frailty, this decrease is accelerated and homeostatic mechanisms start to fail

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12
Q

What is the definition of geriatric syndrome?

A

a multifactorial condition that involves the interaction between identifiable situation-specific stressors and underlying age-related risk factors, resulting in damage across multiple organ systems

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13
Q

What are key features of geriatric syndrome?

A

clinical and multifactorial conditions in older persons

associated with poor heath outcomes

do not fit into disease categories (comorbidities)

require a multidimensional treatment approach

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14
Q

What are the risks of geriatric syndromes?

A

clinical conditions that do not fit a disease category

multi-factorial, multi-system

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15
Q

What are potentially inappropriate medications?

A

also identified as “PIM”

a medication or medication class where harm outweighs the benefit, and there are safer alternatives available

the Beers Criteria are explicit

the Beers Criteria are used by CIHI to identify PIM

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16
Q

What is the goal of medication safety?

A

reduce severe, avoidable medication-related harm by 50% over 5 years

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17
Q

What are the priority actions of medication safety?

A

high risk situations; includes children, older adults

polypharmacy

transitions in care

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18
Q

Who is at risk for adverse drug reactions?

A

people with multiple chronic conditions

women

people over the age of 65

19
Q

What is the definition of polypharmacy?

A

literal definition: 2 or more medications

most commonly accepted definition in practice: 5 or more medications (Rx or OTC)

the use of 2 or more drugs without indications or for the same purpose

the use of a drug to treat the adverse reactions of another drug

the use of 2 or more drugs from the same class to treat different indications

clinically meaningful: when a medication is not needed

20
Q

What are prescribing cascades?

A

use of one drug to treat the adverse effects of another

21
Q

What are potential prescribing omissions (PPO)?

A

undertreatment

not prescribing medications to patients who would benefit

often seen in patients with polypharmacy

22
Q

What are examples of potential prescribing omissions?

A

statins for lipid management

anticoagulation for AF

LMWH for venous thromboprophylaxis

osteoporosis treatment

recent studies of hospitalized patients show 83% admitted had a PPO per START criteria

23
Q

What are different forms of aging?

A

chronological aging
physiologic aging
social age
legal age
functional age

24
Q

What is aging?

A

is NOT synonymous with disease

changes are experienced by all human beings

some changes may be due to lifestyle choices, social determinants of health, exposure to particular chemicals, etc.

25
What is physiological aging?
each organ system has changes associated with aging, which often start in the 5th decade implications of these changes include: reduced tissue/organ function functional decline increased susceptibility to disease change in behavior differences in PK and PD
26
What are physiological changes associated with aging?
body composition: increased fat CV: decreased cardiac output, decreased beta sensitivity Renal: decreased GFR, decreased nephrons GI: decreased H+, increased gastric emptying time Hepatic: decreased size, decreased blood flow Nervous: decreased blood flow to CNS Pulmonary: decreased cilia Endocrine: decreased hormonal secretions
27
What are the effects on body composition that occur when aging?
loss of muscle mass: start ~age 40, accelerates in 6th decade (i.e. 50's), by age 90, a person has half their muscle mass, some changes may be due to inactivity vs. physiologic aging function and quality of muscle changes, along with neural stimulation, which slows fat mass increases
28
What are the physiological changes to absorption in the GI tract?
increased gastric pH decreased gastric acid secretion decreased GI blood flow decreased gastric surface area decreased GI motility
29
What are the PK implications of the physiological changes to absorption in the GI tract?
potential for delay in absorption minimal impact on extent of absorption of passively absorbed drugs active transport (e.g. B12, iron, calcium) may be reduced
30
What are the physiological changes to absorption in the IM, topical?
decreased blood flow decreased skin hydration
31
What are the PK implications of the physiological changes to absorption in the IM, topical?
slower, erratic, or lower absorption (e.g. antibiotics) NB in immobile patients higher absorption of topical steroids NB if occlusive dressings
32
What is absorption of drugs in older adults?
most drugs are well absorbed in older adults rate of absorption may be delayed in some patients this is relevant for some treatments, e.g. immediate release levodopa, analgesia drug absorption can also be affected by other conditions or medications
33
What is distribution of drugs in older adults?
distribution can be altered by aging or other disease states lipid soluble drugs show an increase in Vd protein changes with aging are insignificant and rarely have an impact on drug therapy protein changes often occur with concurrent illness, not aging
34
What is metabolism of drugs in older adults?
drugs metabolized by Phase 2 are preferred in older adults for medications oxidatively metabolized, reduce dose multiple medications can have more dramatic drug interactions if impacting CYP P450 metabolism can be dramatically affected by illness, particularly acute illness other factors affecting metabolism include chronic illness, genetics, diet, smoking, EtOH use
35
What is the elimination of drugs in older adults?
decreased renal elimination of drugs is the single most clinically significant change in PK due to aging the majority of drug dosage adjustments in older adults are due to renal function note: decreased muscle mass in frail older adults CrCl is an estimate
36
What are changes to pharmacodynamics in older adults?
altered homeostatic balance manifested in a stress environment change in homeostatic regulation change in receptor responsiveness: change in receptor density, change in receptor affinity, post-receptor changes, change in negative feedback implications: increased sensitivity to drugs
37
What are changes to the CNS in older adults?
higher cognitive function mechanism: neuronal loss, receptor downregulation examples: central anticholinergics, stimulants
38
What are changes to postural in older adults?
mechanism: fewer dopamine (D2) receptors in striatum examples: antipsychotics, metaclopramide
39
What are changes to movement in older adults?
tardive dyskinesia mechanism: impaired or decreased dopamine synthesizing neurons examples: dopamine blockers, antipsychotics, anti-emetics (metoclopramide)
40
What are changes to blood pressure in older adults?
orthostasis mechanism: blunting of beta response, receptor down-regulation, changes in vascular tree and autonomic nervous system examples: BP meds, TCA, antipsychotics, diuretics
41
What are changes to CV in older adults?
arrhythmias mechanism: cardiac hypersensitivity examples: antiarrhythmic medication
42
What are changes to coagulation in older adults?
anticoagulation mechanism: poor hepatic production of coagulation factors, dietary intake examples: anticoagulants, thrombolytics
43
What are changes to visceral muscle in older adults?
mechanism: visual disturbances (pupillary autonomic responses) bladder instability (detrusor contractions) intestinal motility decreased examples: anticholinergics
44
What are changes to temperature in older adults?
thermoregulation mechanism: poor temperature regulating mechanisms examples: meds affecting awareness, mobility, muscular activity, vasoconstrictor mechanisms; CNS meds

PMCOL 200 (34 decks)

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