Pharmacotherapy and Polypharmacy

Question 1

Why do geriatric patients require modifications to medication doses?

Answer 1

The phenomenon of declining organ function and reserve, including alterations in medication response to PK and PD changes

Question 2

How many medications does one need to be prescribed in a given week to be defined as hyper-polypharmacy?

Answer 2

At least 10

Question 3

________ describe the manner in which the body affects a drug, whereas _________ descibes the manner in which the drug affects the body

Answer 3

PK’s and PD’s

Question 4

Use of what medications can interfere with drug ionization in geriatric patients?

Answer 4

Proton-pump inhibitors and antacids

Question 5

What can impact GI absorption in geriatric patients?

Answer 5

Markedly modified with increase in age

Decrease in

• Gastric acid secretion
• Gastric motility
• Peristalsis/Colonic Transit

Question 6

Bioavailabilty of a medication is dependent on

Answer 6

Dependent on

• Amount of drug absorbed by GI mucosa
• Amount of drug flowed through liver unchanged
• Amount of first-pass metabolism that occurs

Question 7

What medications require adjustment in renal impaired geriatric patients?

Answer 7

• Antibiotics: aminoglycosides, cephalosprins, flouroquinalones, PCN
• Anticonvulsants: gabapentin, oxcarbazepine, primidone
• Cardiovascular: Lisinopril, ramipril, sotalol, diuretics, digoxin
• Miscellaneous: enoxaparin, metformin, morphine

Question 8

Are the effects of calcium channel blockers altered in older patients?

Answer 8

Yes, they will expereince a greater decrease in SBP

However, reflex tachycardia will not be seen in elderly

Question 9

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?

Answer 9

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

Question 10

Increased sensitivity to central nervous system-active medications in older age have been reported, what are the effects?

Answer 10

Enhanced pharmacological effects

• Inc. sensitivity (Concern for fall)

Question 11

Increased sensitivity to benzodiazepines in elderly patients is of considerable clinical importance because of what adverse effects?

Answer 11

The association with higher risk for falls and hip fractures

Question 12

What are the adverse effects of opioid use in older patients?

What associated CNS disturbances lead to the increased risk?

Answer 12

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

Question 13

A 2002 study found that the most commonly prescribed medications to geriatric patients were:

Answer 13

• Conjugated estrogens
• Levothyroxine
• HCTZ
• Atorvastatin
• Lisinopril

Question 14

What are the consequences of polypharmacy?

Answer 14

• Adverse drug reactions
• Increaesed direct costs
• Drug interactions
• Non-adherence
• Diminished functional status
• Geriatric syndromes

Question 15

Geriatric patients are at especially high risk for drug-drug interactions due to

Answer 15

• Polypharmacy
• Comorbidities
• Decreased nutritional status

Question 16

Should beta-blockers be given to diabetics?

Answer 16

No, a very common drug-disease interaction

Question 17

What modifiable risk causes diminished ADLs/IADLs in geriatric patients?

Answer 17

Polypharmacy

Question 18

Can drugs commonly cause delirium and dementia in geriatric patients?

Answer 18

Yes

The number of medications is an independent risk factor

Question 19

What are the most common drugs associated with delirium?

Answer 19

• Opioids
• Benzodiazepines
• Anticholinergics

Question 20

What drug classes can exacerbate dementia?

Answer 20

• Benzodiazepines
• Anticonvulsants
• Anticholinergic drugs (TCAs, in particular)

Question 21

What medications can increase risk of falls in elderly?

Answer 21

• Psychotropic
• Cardiovascular

Question 22

What are some approaches to improving polypharmacy?

Answer 22

• 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

Question 23

What are some risk factors for chronic pain?

Answer 23

• 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

Question 24

What is the preferreed treatment for older patients with mild or moderate pain?

Does this med improve physical function or stiffness?

Answer 24

Acetaminophen

No, not when compared to placebo

Question 25

What NSAID is the least harmful to the CV system?

Answer 25

Naproxen

Question 26

What should be monitored in geriatric patients taking NSAIDs for longer than 2-weeks?

Answer 26

BP, renal function, and GI adverse effects should all be monitored

Question 27

What pain medication should be considered for nociceptive pain in those who do not respond to acetaminophen/NSAIDs?

Answer 27

Tramadol

Question 28

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?

Answer 28

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

Question 29

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?

Answer 29

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.

Question 30

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

Answer 30

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.

Question 31

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?

Answer 31

Bisphosphinates