polypharm Flashcards
BP changes in older adults
systolic HTN
orthostatic HTN
hear rate and rhythm in older adults
packmaker cells and maximal heart rate decline
more likely to have abnormal heart rate
temperature changes in older adult
more susceptible to hypothermia
skin changes in the older adult
vascularity of the dermis decreases
skin may appear thin, fragile, loose and transparent
actinic purpura-blood that has leaded through the capillaries
eye changes in the older adults
fewer lacrimations
visual acuity in the older adult
gradually diminished between 50 and 70
near vision blurs for all older adults
lens affects in the older adult
increase risk for cataracts, gluacoma, macular degeneration
head and neck changes in older adults
decrease salivary secretions and sense of taste often med related
teeth disease
lung and thorax changes in older adult
chest wall stiffens and hard to move
respiratory muscle may weaken
lungs lose some elastic recoil
cough is less effective
cadiovascular changes in the older adult
neck and vesels-systolic bruits in middle to upper portion of the carotid arteries suggest arterial obstruction from atherosclerosis
Extra heart sounds (S3 and S4)
S3 suggestive of CHF
S4 suggest decreased ventricle compliance
Murmurs
what is the most common complaint in the older adults
memory loss
what is mini mental status used to examine?
test cognitive function among older adults Orientation Attention Memory Language Visual-spatial skills score 0-30
what type of patient typically scores 19-24 on a MMSE
alzheimers
GI changes in older adult
decreased gastric acid delayed gastric emptying slowed intestinal transit time reduced GI blood flow decreased stomach acid leafs to decreased absorption of some meds
pharmacokinetic changes
increased body fat and decreased muscle mass
meds distribute into have have increased volume of distribution
caution with meds like
-diazepam and chlordiazepoxide
meds that distribute into muscle or body water have decreased distribution
-Lithium
protein binding in the older adults
serum albumin usually unchanged in healthy older adults but low in frail or malnourished elderly patients
liver changes
metabolism primarily occurs in the liver
liver can be 20-40% smaller and accompanied by a 35% decrease in hepatic flow
meds with higher 1st pass will shower higher bioavailability
metoprolol, verapamil, morphine, diazepam
GU changes
reduction in renal mass, renal blood flow, GFR, filtration fraction and tubular secretions
Scr derived from muscle mass and assess kidney function not accurate in older adults d/t decreased muscle mass
what will happen to an adult taking at least 5 meds
1 in 3 will experience ADR
95% predictable and 28% preventable
causes of ADR in older adults
polypharmacy
multiple comorbid conditions
poor med adherence
age related pharmacokinetics
what is polypharmacy
over utilization or inappropriate use of multiple meds
RF for polypharmacy
Women>men Institutionalized>independent co-morbiditied>healthier elderly >65yrs old Un-insured cognitive impairment
reason for polypharm
MD/PA/NP are instructed to treat according to guidelines
HTN, DM, COPD, Mental illness
Practitioners/pts/families may want to treat all symptoms
Prescribing Cascades
Treating medication side effects with another drug
examples of prescribing cascades
antipsychotics-extrapyramidal signs-antiparkinson therapy
NSAID-inceased BP-HTN Tx
contributing factors
lack of med renconciliation after hospital discharge lack of continuity of care multiple PCP Mulpt Docs and pharmacies quick med changes- start low go slow
complications of polypharm
functional ability- financial, communication, food shopping, cooking, transport
nutritional status- wt loss, trouble eating, mobility
cognition- temporal orientation, calculation
associated with depression and increased suicides
hepatic enzyme inducer and examples of them
inducers can increase metabolism and decrease Rx concentration
-Grapefruit, Herbal prep- st jogn wort, alcohol, tobacco, cannabis, barbiturates, tegretol, dilantin
drugs that decrease metabolism and increase Rx conc
Prozac
Erythromycin
CCB
meds with long half life and narrow therapeutic window
Lithium,Digoxin,Wafarin
Increased sensitivity
psychoactive meds
long acting benzo
antipsychotic agents
TCA
Adverse effects
falls are major risk
orthostatic HTN
confusion
age related receptor site changes can increase sensitivity
opioids
wafarin
Diphenhydramine
NSAID
how to prevent ADR
always start with lowest dose check for geriatric dosing recommendations
Identify RF
medication review regimen
what is medication regiment review (MMR)
Evaluation of medication regimen
Promoting positive outcomes
Minimizing adverse events
MRR indications
Indication/reason for medication Effectiveness Dose Presence of monitoring Presence of duplicative therapy Food and or drug interactions Presence of potential adverse drug reactions (ADR)
when to do a MRR
Review of patient’s medications should be done at initial assessment, every 3 to 6 months thereafter, and with any medication change
check to make sure Rx are not just treating symptoms
need to establish accurate diagnosis
beers criteria
For patients > 65 years of age
Based on expert consensus developed through an extensive literature review evaluated by experts in geriatric care, clinical pharmacology, and psychopharmacology
Adopted by the Centers for Medicare and Medicaid Services in July 1999 for nursing home regulation
