Patient Assessment, Special Populations, and Polypharmacy

Question 1

What are some barriers that could impact how a patient is able to communicate with a health professional?

Answer 1

Hearing loss
Decreased vision
Speech production problems
Cognitive/memory issues
Language/cultural diversity

Question 2

What can help when a patient needs assistance with communication?

Answer 2

Hearing aids
Assistive listening devices
Interpreter
Family member/caregiver

Question 3

What is history that is relevant to audiology for adults?

Answer 3

History of ear surgeries and trauma/concussion
History of recent hospitalizations
Drug history including all OTC medications
History of specific diseases (diabetes, HBP or LBP, bleeding disorders, strokes, history of tumors requiring chemo or radiation, and mental health conditions)

Question 4

What is history that is relevant to audiology for children?

Answer 4

History of pregnancy, birth, and delivery
History of medications used, including medications used by mother during and right after pregnancy
Results of newborn hearing screening
Academic and developmental history including language
Otitis media and upper respiratory tract infections
Infectious diseases such as CMV, Zika, measles, and meningitis
History of ear surgeries, hospitalizations, trauma, & concussion
History of tumors requiring chemotherapy and/or radiation
Academic history
Family history of genetic and hearing/vestibular disorders
Social history

Question 5

What is the privacy rule of HIPAA?

Answer 5

Permit disclosure of health information needed for patient care and other important purposes - who can you share that information with

Question 6

What is the security rule of HIPAA?

Answer 6

A series of administrative, physical, and technical safeguards for covered entities and their business associates to assure the confidentiality, integrity, and availability of electronic protected health information

Question 7

Why is reviewing drug history with a patient critical?

Answer 7

There are many patient factors that can affect drug metabolism and adverse drug reactions (which can result in ototoxicity)

Question 8

What are some factors for adverse drug reactions?

Answer 8

Age
Pregnancy and lactation
Diet and environment
Diseases
Preexisting auditory (SNHL) and vestibular disorders
Pharmacogenomics
Metabolic drug interactions (polypharmacy)

Question 9

Are many biotransformations slow in young children and elderly?

Answer 9

Yes

Question 10

Are neonates able to carry out the phases of the drug cycle?

Answer 10

They can carry out most of phase 1 reactions in the liver
Both phase 1 and 2 enzyme systems mature gradually over the first 2 weeks of life and throughout childhood
Insufficiency of the phase I and II enzymes can quickly lead to toxic levels of drugs in neonates and younger children

Question 11

Do children have increased skin and mucous membrane permeability?

Answer 11

Yes
They absorb medication more quickly and readily than adults
Leads to quicker toxic drug levels

Question 12

How is pediatric drug dose calculated?

Answer 12

By a child’s weight
To avoid size differences and prematurity
Typically, the pediatric drug dose is half that of the adult dose, but proper pediatric doses should be calculated

Question 13

Why must you be careful prescribing drugs to elderly?

Answer 13

There is a general decrease in metabolic capacity due to age-related changes in liver mass, hepatic blood flow, hepatic enzyme activity (aging appears to affect the P450 (cyp) enzymes preferentially)
Alternate metabolic pathways including those involving phase II enzymes are spared with aging

Question 14

How might drug doses be altered for elderly?

Answer 14

They might be lowered
High doses often contribute to CNS side effects (dizziness/falls, disorientation/cognitive decline, drowsiness)

Question 15

What is the primary concern for drugs during pregnancy?

Answer 15

Teratogenicity and side effects
Ideally, no drug should be given during pregnancy
The placental barrier is not strong for most drugs
Highest risk to the fetus is during the first trimester

Question 16

What is the primary concern for drugs during lactation?

Answer 16

Whether the drug will enter breast milk and be transferred to the infant
Drug amounts in breast milk is ~ 1 to 2% of the maternal dose
Most drugs delivered through breast milk are of limited significance for the infant

Question 17

What are some drug contraindications during lactation?

Answer 17

Lithium (e.g., treatment for bipolar disorders)
A majority of chemotherapeutic agents
Radioactive pharmaceuticals (e.g., radioactive drugs used in medical imaging such as radioactive iodine to diagnose/treat thyroid problems)
Several classes of antibiotics

Question 18

Can diet and environment affect drug metabolism?

Answer 18

Yes
Can inhibit or induce cytochrome P450 (CYP) enzyme in the liver
Grapefruit juice, contains chemicals that inhibit the CYP3A4 enzyme in the small intestine and decreases phase 1 metabolism (important when taking drugs like calcium-channel blockers (hypertension) and statins (cholesterol))
Grapefruit juice in higher doses will decrease metabolism and lead to high plasma levels of these drug causing potential
Liver damage
Rhabdomyolysis – rare (severe muscle damage)

Question 19

Where are endogenous substances used in phase II derived from?

Answer 19

The diet
Nutrition can affect drug metabolism by altering the pool of substances needed for phase II enzymes

Question 20

Can environmental pollutants affect the P450 enzyme function?

Answer 20

Yes, like cigarette smoke and petroleum products

Question 21

Can liver disease significantly slow drug metabolism and result in higher concentrations of active drug forms and toxic drug effects?

Answer 21

Yes
P450 and other liver enzymes are crucial for drug metabolism

Question 22

What can liver disease include?

Answer 22

Hepatitis
Cirrhosis (scar tissue) of the liver (often caused by chronic alcoholism or chronic infection)
Cancer
Fatty infiltration of the liver
Hemochromatosis (iron overload – body absorbs too much iron from food and stores it. Can be genetic)

Question 23

Should drug dosage be lowered for patients with liver disease?

Answer 23

Yes

Question 24

Can comorbid cardiac and liver disease also affect drug metabolism?

Answer 24

Yes
With cardiac disease, blood flow is compromised leading to suprathreshold levels of drugs in patients with heart failure

Question 25

Do thyroid hormones regulate the body’s basal metabolic rate and, therefore, drug metabolism?

Answer 25

Yes
Hyperthyroidism can increase the metabolic rate of some drugs
Hypothyroidism can decrease the metabolic rate of other drugs

Question 26

Are most drugs eliminated from the kidneys?

Answer 26

Yes
Accumulation and toxicity can develop rapidly if dosages are not adjusted in patients with impaired renal function
In addition to a reduced glomerular filtration rate, patients with renal disease often have alterations in pharmacokinetics such as drug bioavailability, protein binding, and volume distribution

Question 27

What is compliance?

Answer 27

The degree to which a patient’s behavior matches medical advice
Noncompliance, therefore, is any behavior that does not follow medical advice

Question 28

What is compliance defined as in pharmacology?

Answer 28

The degree of correlation of the actual dosing history with the prescribed medical therapy
It is the amount of drug taken vs. the amount of drug prescribed

Question 29

Does medical noncompliance increase the incidence of chronic disease?

Answer 29

Yes
It also affects audiologists, for e.g., when patients do not regularly wear HAs or carry out a tinnitus or vestibular treatment regimen

Question 30

How does the world health organization define noncompliance?

Answer 30

A multidimensional phenomenon determined by the interplay of five sets of factors (patient related, condition related, therapy related, health system factors, and social factors)

Question 31

How often is noncompliance?

Answer 31

It can range from 20% to 80% depending on the treatment
On average, patients follow the advice of healthcare providers about 50% the time
Compliance can even lower for complicated treatments or regimens involving lifestyle changes

Question 32

What are the types of noncompliance?

Answer 32

Prolonged intervals between dose administrations (lapses of greater or equal to 3 days are called drug holidays)
Non-persistence (cessation of medication) - ultimate expression of noncompliance
White coat compliance (improved compliance around doctors’ visits, can cause diagnostic and therapeutic confusion)

Question 33

Can parents and caregivers affect compliance?

Answer 33

Yes
Family’s belief regarding susceptibility to disease, disease severity, and benefits of treatment play a role in compliance
Parental anxiety if activity is restricted due to medication, affects compliance and results in under or overdosing

Question 34

Can type of illness or disease affect compliance?

Answer 34

Yes
Rate of compliance for acute illness, including otitis media is about 50%, which is poor
Therapy for chronic diseases shows a slightly better rate of compliance than acute diseases

Question 35

Can intellectual status affect compliance?

Answer 35

Yes
Memory problems (forgetting to take medication or regimen)
Ability to follow and understand directions
Diminished cognitive status
Difficulty with task organization
Fear of needles (belonephobia and trypanophobia)

Question 36

Can physical status affect compliance?

Answer 36

Yes
Visual problems (cannot read labels/instructions)
Musculoskeletal problems (cannot open bottles)
Depression
Chronic and/or comorbid medical conditions
Difficulty swallowing

Question 37

What are some other factors that can affect compliance?

Answer 37

Denial of the illness (including hearing loss)
Stopping or reducing the frequency of drug administration
Long-term compliance (boredom)
Misunderstanding or never receiving directions for use
Literacy issues (inability to read labels/directions)
Managing drugs becomes stressful for many older adults
Lack of confidence in the drug’s effectiveness
Improvement of symptoms or not
Concerns about potential side effects
Apathy (not getting prescriptions filled)
Cost of medications (e.g., choosing between food and medication)
Access to medical care/pharmacy
Transport issues
Socioeconomic status

Question 38

How do you improve compliance?

Answer 38

Education is key (Education of patients, families, and care givers and educating health care providers to recognize barriers to compliance and address them)
Important to remember that if the patient cannot see/hear clearly or remember instructions, frustration and errors with the treatment regimen will set in
Recognize and address dexterity issues if present
Providing older patients with clear and concise written instructions in large print
Improving communication between multiple providers

Question 39

What is polypharmacy?

Answer 39

taking 5 or more medications at the same time
More common in older adults and younger people with chronic medical conditions

Question 40

Does polypharmacy increase the risk of adverse drug-drug or drug-disease interactions?

Answer 40

Yes
Also increases the risk of prescription cascade (side effects of drug interactions are misdiagnosed as symptoms of a new medical condition)

Question 41

Has the use of OTCs increased in the past decade?

Answer 41

Yes, especially among the elderly who are already at risk of polypharmacy
Less than half of patients discuss the use of OTCs with their medical providers
There are safety issues regarding their use, including risks for herb-drug interactions

Question 42

When does polypharmacy become problematic?

Answer 42

When patients are prescribed too many medications by multiple healthcare providers working independently of each other
Optimizing medication regimen is one of the critical elements in comprehensive geriatric care

Question 43

How many prescription medications does the average person >50 years old take?

Answer 43

At least 4

Question 44

What are the 4 basic mechanisms of drug interactions?

Answer 44

Drugs having similar effects (additive, synergistic, potentiation of each other)
Metabolic effects (altered CYP enzymes resulting in enzyme induction or inhibition)
Absorption effects (altered pH, affecting binding of drugs in the stomach)
Displacement of plasma proteins (more active or free drug in circulation)

Question 45

What are some examples of adverse drug interactions?

Answer 45

Aminoglycoside antibiotics and furosemide (diuretic)
Potentiate the ototoxic and nephrotoxic effects of each other when administered IV together relative to when taken alone

Question 46

What kind of drug interactions are cardiovascular drugs involved in?

Answer 46

Drug-drug interactions
Leading to adverse drug interactions such as neuropsychological (e.g., delirium), acute renal failure, and hypotension

Question 47

What are the most dangerous drug interactions?

Answer 47

Medications that affect the CNS
Alter the ability to function
Decreased independence
Ability to drive safely
Ability to ambulate safely without falling

Question 48

Does medicare now require health care providers to ask about drugs being taken by every patient (prescription and OTC)?

Answer 48

Yes