Polypharm

Question 1

Define polypharmacy.

Examples of adverse drug events. (**Anytime you have a pt with one of these problems you have to r/o adverse drug event)

Answer 1

Polypharmacy: takeing 4 or more medications.

Adverse drug events:

• falls
• orthostatic hypotension
• heart failure
• delirium
• MC cause of death from adverse drug reactions = GI bleeding, intracranial bleeding, and renal failure.

Question 2

How does polypharmacy occur?

What are the MC drugs associated with adverse events?

List the common sx that may be 2ndry to an adverse drug reaction.

Answer 2

Occur:
new prescriptions, failure to discontinue old prescriptions

MC drugs w/ Adverse events:

• antithrombotics
• antidiabetics
• diuretics
• NSAIDS

Common Sx of adverse drug rxn:
-falls, orthostatic hypotension, heart failure, delirium

Question 3

Describe how drug metabolism differs in older adults in each of the following:

• liver
• kidneys
• weight
• serum protein
• substance abuse

Answer 3

Liver: hepatic blood flow is decreased by 40% leading to decreased first pass metabolism. (ex. warfarin, BZD, opiates require smaller doses)

Kidneys: renal blood flow can decrease by about half at 80 YO.

Weight: decreased lean body weight to body fat ratio alters the distribution of drugs in the body

Decreased serum protein; drugs that are protein bound are now free to act resulting in a small dose needed fro the desired effect.

Substance abuse: can cause a change in drug metabolism.

Question 4

What tools are beneficial to consult when deciding what medications to avoid/use in your elderly patients?

Answer 4

Beers criteria is a list of inappropriate medication use in elderly persons.

STOPP is another screening tool that says consider stopping this medication in elderly patients

START: screening tool to alert prescribers to right treatment

Question 5

What are some examples of medications found on the BEERS criteria that are potentially inappropriate for elder patients. Why are they on this list?

Answer 5

Nitrofurantioin - potential for pulmonary toxicity. lack of efficacy with CrCl less than 30ml/min d/t inadequate drug concentration in urine

Digoxin doses greater than 125mcg; increased risk of toxicity d/t decreased renal clearance and decreased protein binding.

Sliding scale insulin: high risk of hypoglycemia w/o improvement of hyperglycemia management

Sulfonylureas: glyburide = prolonged hypoglycemia

Non-cox-selective NSAIDS:

• increased risk of GI bleeding, PUD
• use of PPI or misprostol decreases risk

Question 6

What are some drugs that may worsen constipation?

Answer 6

antimuscarinics for urinary incontinence… Oxybutynin, tolterodine

nondihydropyridine calcium channel blockers…verapamil, diltiazem

first generation antihistamines

Question 7

Which medications may cause or exacerbate SIADH?

What are 12 inappropriate drugs in the elderly?

Answer 7

SNRIs, SSRIs, Antipsychotics

Inappropriate:

• diphenhydramine (Benadryl)
• Amitriptyline (elavil)
• Alprazolam (xanax)
• Diazepam (Valium)
• chlorpropamide and glyburide
• digoxin (greater than 0.125mcg)
• GI antispasmodics: belladonna, dicyclomine, hyoscyamine
• meperidine (demerol)
• mathyldopa (aldomet)

Question 8

Diphenhydramine:
-SE

Digoxin:
-SE

Answer 8

diphenhydramine SE:
-dry mouth, confusion, urinary retention, constipation

Digoxin SE:
-anorexia, confusion

Question 9

According to START,what are the MC drug omissions?

Answer 9

• statins in atherosclerotic dz
• warfarin in chronic afib
• anti-platelet therapy in arterial dz
• calcium/vitD supplementation in symptomatic osteoporosis

Question 10

what is “choosing wisely”?

Answer 10

initiative of the american board of internal medicine, 2 lists of “Five things physicians and patients should question”. Addresses screening tests, medications, etc.

Question 11

Can antipsychotics be used as first choice to treat behavioral and psychological sx of dementia?

Should you avoid using medications to achieve A1C of less than 7.5% in most adults greater than 65?

It is okay to use benzodiazepines or other sedative hypnotics in older adults as first choice for insomnia, agitation, or delerium..T/F?

It is safe to use antimicrobials to treat bacteriuria in older adults w/o sx, T/F?

Do not prescribe cholinesterase inhibitors for dementia without periodic assessment for preceived cognitive benefits and adverse GI effects, T/F?

Answer 11

No, antipyschotics cannot be used as first choice.

Yes, you should avoid using medications to achieve A1C greater than 7.5%

False. do not use benzos.

False, do not use antimicrobials to treat bacteriuria in older adults unless specific urinary tract sx are present.

True, do not prescribe cholinesterase inhibitors for dementia without period assessment.

Question 12

Avoid using prescription appetite stimulants or high-calor supplements for tx of anorexia or cachexia in older adults, T/F?

What are some ways to reduce adverse drug events?

Answer 12

True, avoid using prescription appetite stimulants.

Reducing adverse drug events:
-look for meds that were started at a young age that might now need to be adjusted. ex. atenolol

-meds used as inpatient are often at higher doses than needed fro chronic therapy. ex: diuretics

**Avoid adding meds to treat adverse effects of another medication, if possible. Instead decrease the dose, change or D/C the drug.

• start low and go slow
• have pt return for regular follow-up to monitor ADE (adverse drug event)
• avoid starting 2 new meds at the same time