Pharmacotherapy and Polypharmacy Flashcards
Why do geriatric patients require modifications to medication doses?
The phenomenon of declining organ function and reserve, including alterations in medication response to PK and PD changes
How many medications does one need to be prescribed in a given week to be defined as hyper-polypharmacy?
At least 10
________ describe the manner in which the body affects a drug, whereas _________ descibes the manner in which the drug affects the body
PK’s and PD’s
Use of what medications can interfere with drug ionization in geriatric patients?
Proton-pump inhibitors and antacids
What can impact GI absorption in geriatric patients?
Markedly modified with increase in age
Decrease in
- Gastric acid secretion
- Gastric motility
- Peristalsis/Colonic Transit
Bioavailabilty of a medication is dependent on
Dependent on
- Amount of drug absorbed by GI mucosa
- Amount of drug flowed through liver unchanged
- Amount of first-pass metabolism that occurs
What medications require adjustment in renal impaired geriatric patients?
- Antibiotics: aminoglycosides, cephalosprins, flouroquinalones, PCN
- Anticonvulsants: gabapentin, oxcarbazepine, primidone
- Cardiovascular: Lisinopril, ramipril, sotalol, diuretics, digoxin
- Miscellaneous: enoxaparin, metformin, morphine
Are the effects of calcium channel blockers altered in older patients?
Yes, they will expereince a greater decrease in SBP
However, reflex tachycardia will not be seen in elderly
Decreases in kidney function in older patients can result in reduced delivery of loop diuretics to their site of action in the nephron, therefore what may need to be prescribed as an alternative?
Where in the nephron do loop diuretics act?
Heart failure patients in need of diuresis may require the addition a different diuretic, like a thiazide-like diuretic that will act on a different part of the nephron
Loop of Henle
Increased sensitivity to central nervous system-active medications in older age have been reported, what are the effects?
Enhanced pharmacological effects
- Inc. sensitivity (Concern for fall)
Increased sensitivity to benzodiazepines in elderly patients is of considerable clinical importance because of what adverse effects?
The association with higher risk for falls and hip fractures
What are the adverse effects of opioid use in older patients?
What associated CNS disturbances lead to the increased risk?
Patients older than 60 years on opioids have a 2-8 fold higher risk of respiratory depression compared to younger patients
*The incidence of nausea and vomiting is decreased in geriatric patients
Hallucinations
A 2002 study found that the most commonly prescribed medications to geriatric patients were:
- Conjugated estrogens
- Levothyroxine
- HCTZ
- Atorvastatin
- Lisinopril
What are the consequences of polypharmacy?
- Adverse drug reactions
- Increaesed direct costs
- Drug interactions
- Non-adherence
- Diminished functional status
- Geriatric syndromes
Geriatric patients are at especially high risk for drug-drug interactions due to
- Polypharmacy
- Comorbidities
- Decreased nutritional status
Should beta-blockers be given to diabetics?
No, a very common drug-disease interaction
What modifiable risk causes diminished ADLs/IADLs in geriatric patients?
Polypharmacy
Can drugs commonly cause delirium and dementia in geriatric patients?
Yes
The number of medications is an independent risk factor
What are the most common drugs associated with delirium?
- Opioids
- Benzodiazepines
- Anticholinergics
What drug classes can exacerbate dementia?
- Benzodiazepines
- Anticonvulsants
- Anticholinergic drugs (TCAs, in particular)
What medications can increase risk of falls in elderly?
- Psychotropic
- Cardiovascular
What are some approaches to improving polypharmacy?
- Obtain and update medication histories
- Encourage patients and caregivers to bring in all prescriptions and OTCs to each visit
- Include OTC’s in medication histories
What are some risk factors for chronic pain?
- Advancing age
- Female sex
- Lower SES
- Lower educational level
- Obesity
- Tobacco use
- History of injury
- History of physically strenous job
- Childhood trauma
- Depression and anxiety
What is the preferreed treatment for older patients with mild or moderate pain?
Does this med improve physical function or stiffness?
Acetaminophen
No, not when compared to placebo
What NSAID is the least harmful to the CV system?
Naproxen
What should be monitored in geriatric patients taking NSAIDs for longer than 2-weeks?
BP, renal function, and GI adverse effects should all be monitored
What pain medication should be considered for nociceptive pain in those who do not respond to acetaminophen/NSAIDs?
Tramadol
A 75-year-old female patient presents with confusion, fever, and a productive cough. Physical examination reveals decreased breath sounds in the right lower lobe. What is the most likely diagnosis?
What is the recommended antibiotic therapy?
Community Acquired Pneumonia
Amoxicillin-Clauvunate plus Doxycycline
Per UptoDate guidance on elderly and immunocompromised, important thing with elderly and antibiotic use is being mindful of their kidney function
An 80-year-old male patient with a history of hypertension and diabetes presents with bilateral leg swelling and shortness of breath. On examination, you note bilateral pitting edema and elevated jugular venous pressure. What is the most likely diagnosis, and what is the initial management?
CHF
The initial management of CHF in the elderly with acute symptoms typically involves addressing both the underlying cause and symptom relief. Key steps include diuretic therapy, lifestyle modifications, and medication adjustments.
An 85-year-old man with a history of heart failure presents with pedal edema, shortness of breath, and fatigue. His current medication regimen includes furosemide and lisinopril. Which medication adjustment is most appropriate to manage his symptoms?
A) Increase the dose of furosemide
B) Decrease the dose of lisinopril
C) Add a thiazide diuretic
D) Discontinue furosemide
Add a thiazide diuretic
Adding a thiazide will allow for diuretic therapy at a different part of the nephron and enhance the therapy of the other medications. Discontinuing furosemide (loop diuretic) is not going to help his heart failure. Additionally increasing the dose or decreasing the dose of lisinopril (ACE) will not balance his heart failure and diureses.
An 80-year-old woman with a history of osteoporosis presents with a vertebral compression fracture. Which class of medications is commonly used to treat osteoporosis in older adults?
Bisphosphinates
