Polypharm Flashcards
Vital sign changes in the elderly
- BP (systolic HTN, ortho hypo)
- HR slows
- Hypothermia
Skin changes in the elderly
- Vascularity of dermis decreases
- Thin, fragile, loose skin
- Actinic purpura (blood that has leaked through poorly supported capillaries)
Head and neck changes in the elderly
- Dry eyes
- Visual acuity diminishes
- Lens changes increasing risk for cataracts, glaucoma, macular degeneration
- Decreased salivation, taste
- Periodontal disease
Lungs and thorax changes in the elderly
- Stiffer chest wall
- Resp muscles weaken
- Lungs lose elastic recoil
- Cough less effective
CV system changes in the elderly
- Systolic bruits in carotids
- Extra heart sounds
- Cardiac murmurs
MC complaint of the elderly?
Memory changes
Scoring of MMSE
0-30
Scores over 25 are normal
Typical MMSE score of Alzheimer’s patients?
19-24
Pharmacokinetic absorption changes in the elderly
- Decreased acid secretion
- Delayed emptying
- Slowed transit time
- Reduce blood flow
Pharmacokinetic distribution changes in the elderly
- Body fat increases, muscle mass decreases
- Meds that distribute into fat stick around longer (e.g. Diazepam, chlordiazepoxide)
- Meds that distribute into muscle or body water don’t distribute as much (e.g. Lithium)
Pharmacokinetic protein binding changes in the elderly
- Serum albumin usually doesn’t change in healthy older adults, but REDUCED in frail or malnourished elderly
- A lot more drug distributing freely and not protein bound (e.g. phenytoin, warfarin, diazepam)
Pharmacokinetic metabolism changes in the elderly
Liver mass and blood flow can be reduced (meds with a high first pass rate will show higher bioavailability so lower doses should be given)
Pharmacokinetic excretion changes in the elderly
- Reduction in renal mass, BF, GFR
- Serum Cr is NOT accurate in older adults due to decreased muscle mass (so use CrCl instead)
Describe ADEs in the elderly
95% are predictable
28% preventable
What causes ADRs in the elderly?
- Polypharm
- Multiple comorbidities
- Poor med adherence
- Age related PK and PD changes
Risk factors for polypharmacy
- Females
- Institutionalized
- Comorbidities
- Over 65 yo
- Cognitive impairments
Why does polypharm occur?
- Providers treating according to guidelines
- Providers/family/pt wants to treat all symptoms
- Prescribing cascades (treating med side effects w/another drug)
How is functional ability measured?
IADLs
Common CYP450 inducers
- Grapefruit juice
- St Johns wort
- Alcohol
- Tobacco
- Cannabis
- Barbiturates
Common CYP450 inhibitors
- Prozac
- CCBs
- Erythromycin
What meds are the elderly more sensitive to?
- Anticholinergics
- Psychoactive meds (long acting BZDs, antipsychotics, TCAs)
- Opioids
- Warfarin
- Diphenhydramine
- NSAIDs
What is a medication regimen review?
- Eval of med regimen
- Promoting positive outcomes
- Minimizing ADEs
What is responsible for most medical errors?
Inaccurate diagnosis
What is used to identify inappropriate meds?
Beers Criteria (updated in 2012)
What is the Beers Criteria?
- For pts over 65 yo
- Identify inappropriate meds
- Classifies meds by “avoid use” and “caution”
What does the MMSE test?
- Orientation
- Attention
- Memory
- Language
- Visual spatial skills
Normal serum albumin levels?
3.2 - 5 g/dL
What meds have a high first pass rate causing higher bioavailability in elderly?
Metoprolol
Verapamil
Morphine
Diazepam
Common complications a/w polypharmacy
- Functional ability
- Nutritional status
- Cognition (MMSE)
- Depression (and possible suicide)
What common meds have narrow therapeutic index?
Lithium
Digoxin
Warfarin
Meds with anticholinergic properties?
- Antihistamines
- Antipsychotics
- Antispasmodics
- Antiparkinsonians
- TCAs
- Ophthalmic drugs
- Plants
How do psychoactive meds affect the elderly?
- Falls are a major risk (even SSRIs)
- Orthostatic hypotension
- Confusion
Which meds affect the elderly due to age-related receptor site changes?
- Opioids
- Warfarin (lower doses)
- Diphenhydramine
- NSAIDs
How are the elderly more sensitive to NSAIDs?
- Increased risk for impaired GFR
- Decreased gastric mucosal repair
- HTN may worsen
How to prevent ADEs in the elderly?
- Always start at lowest effective dose
- Identify risk factors
- Med regimen review
Medication Regimen Review indicators
- Reason for med
- Effectiveness
- Dose
- Presence of monitoring
- Presence of duplicative therapy
- Food and/or drug interactions
- Presence of potential ADEs
When reviewing meds, what should the patient/caregiver understand?
- Why, how, when to take Rx
- Common side effects
- Written/visual culturally and language appropriate instructions
- Accessibility of Rxs
- Set realistic goals
When should a review of meds occur?
- Initial assessment
- Every 3-6 months after
- With any med change
How often should a med list be checked?
2 times a year
Why do elderly patients purposely underreport symptoms?
- Afraid or embarrassed
- Financial issues
- Discomfort of procedures and treatments
- Overlook or attribute to aging
Explain why it is necessary to differentiate between ADEs and aging (prescribing cascades)?
- Make sure HTN is not NSAIDs induced
- Make sure cough is not from ACEI
- Make sure insomnia is evaluated
