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Geriatrics > Polypharm > Flashcards

Polypharm Flashcards

1
Q

What are the risks of adverse drug events in persons 65 and older?

A
  • 13% w/ 2 or more meds
  • 58% w/ 5 meds
  • 82% w/ 7 or more meds
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2
Q

What is polypharmacy?

A
  • 4 or more medications
  • more meds the pt takes, the greater the chance of having an adverse drug event
  • adverse drug events are responsible for about 100,000 hospitalizations/yr
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3
Q

What are some examples of adverse drug events?

A
  • falls
  • orthostatic hypotension
  • heart failure
  • delirium
  • MC causes of death from adverse drug rxns:
    GI bleeding, intracranial bleeding and renal failure
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4
Q

Why is polypharm such a problem?

A
  • b/c new prescriptions are being made but the old prescriptions that may be potentially inappropriate aren’t being d/c (EMRs help decrease inappropriate Rx but don’t alert when to d/c old meds, has alert fatigue)
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5
Q

What are the MC drugs assoc w/ adverse events?

A
  • antithrombotics
  • antidiabetics
  • diuretics
  • NSAIDs
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6
Q

Common sxs that may be secondary to adverse drug rxn?

A
  • falls
  • orthostatic hypotension
  • heart failure
  • delirium
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7
Q

How does drug metabolism differ in older adults?

A
  • liver:
    hepatic blood flow decreases by 40%, decreased 1st pass metabolism: warfarin, BZDs, opiates reqr smaller doses
  • kidneys:
    renal blood flow can decrease by about half at 80 yo
  • decreased lean body wt to body fat ratio - alters the distribution of drugs in body compartments
  • decreased serum protein: drugs that are protein bound are now free to act resulting in small dose needed for desired effect
  • substance abuse: 10% are problems drinkers, can cause a change in drug metabolism
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8
Q

How can we prevent polypharm?

A
  • more than half of all hosp admissions for adverse drug rxns are potentially preventable
  • med review and reconciliation at each visit
  • include drug rxn in your ddx for new complaints
  • be familiar w/ Beers criteria
  • STOPP: screening tool of older persons’ potentially inappropriate rxs
  • START: screening tool to alert prescribers to right tx
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9
Q

What is the Beers criteria?

A
  • MC used criteria, most recent revision 2015
  • sponsored by American Geriatrics Society
  • 2 lists of meds to be avoided in older adults
  • 1 list of meds that should be used w/ caution
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10
Q

What are some examples of meds on the Beers criteria?

A
  • Nitrofurantoin (macrobid)- potential for pulm toxicity, lack of efficacy w/ CrCl less than 60 ml/min due to inadequate drug concentration in urine
  • digoxin in doses over 125 mcg: increased risk of toxicity, due to decreased renal clearance and decreased protein binding
  • sliding scale insulin: higher 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 misoprostol decreaes risk
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11
Q

What are drugs that may worsen constipation?

A
  • antimuscarinics for urinary incontinence: oxybutynin, tolterodine,
  • nondihydropyridine CCBs: verapamil, diltiazem
  • 1st gen antihistamines
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12
Q

What drugs may causes SIADH or exacerbate underlying syndrome?

A
  • SNRIs
  • SSRIs
  • antipsychotics
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13
Q

What are inappropriate drugs to use in elderly?

A
  • diphenhydramine (benadryl)
  • amitriptyline (elavil)
  • aprazolam (xanax)
  • diazepam (valium)
  • chlorpropamide and glyburide
  • digoxin in doses over 0.125
  • Gi antispasmodics: belladonna, dicyclomine, hyoscyamine
  • meperidine (demerol)
  • methyldopa (aldomet)
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14
Q

Why should benadryl be avoided in older pop?

A

should generally be avoided in older adults, causes dry mouth, confusion, urinary retention, constipation, source of in hospitatl morbidity/delirium, is in many OTC products for sleep/URI/allergy

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15
Q

Why should digoxin be avoided in the elderly?

A
  • can cause anorexia, confusion even at therapeutic drug levels, renal excretion can change over time as age related renal fxn declines
  • 0.125 mg/day most often adequate
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16
Q

What is the STOPP criteria?

A
  • 65 clinically significant criteria for potentially inappropriate rx in older adults
  • overlaps w/ Beers criteria
17
Q

What is the START criteria?

A
  • study done to determine if meds that are approp according to EBM were omitted
  • 600 adults admitted to teaching hospital
  • 58% of pts had drug omissions w/o documentation as to why med was not offered or rx
  • MC ommissions:
    statins in atherosclerosis (26%)
    warfarin in chronic a fib (9.5%)
    anti-platelet therapy in arterial disease (7.3%)
    calcium/vit d supplementation in sx osteoporosis (6%)
18
Q

Choosing Wisely initiative?

A
  • initiative of American board of internal medicine
  • 2 lists of 5 things physicians and pts should question, addresses screening tests, meds
  • don’t use antipsychotics as first choice to tx behavioral and psychological sxs of dementia
  • avoid using meds to achieve A1C of less than 7.5% in most adults 65 and older
  • don’t use benzos or other sedative hypnotics in older adults as 1st choice fo insomnia, agitation, or delirium
  • don’t use antimicrobrials to tx bacteriuria in older adults unless specific UT sxs are present
  • don’t rx cholinesterase inhibitors for dementia w/o periodic assessment for perceived cognitive benefits and adverse GI effects
  • avoid using Rx appetite stimulants or high calorie supplements for tx of anorexia or cachexia in older adults
  • don’t rx a med w/o conducting a med review
19
Q

How can we reduce adverse drug effects?

A
  • look for meds that were started at young age that might now need to be adjusted - ex: atenolol
  • meds used as an inpt are often at higher doses than needed for chronic therapy - diuretics
  • avoid adding meds to tx adverse effects of another med if possible - instead decrease dose, change or DC drug
  • capture all herbal and OTC meds that pt is taking “brown bag”
  • if drug levels are subtherapeutic must verify compliance prior to increasing dose
  • drugs for pain, behavior and cognition need to be regularly assessed for response and try to avoid long term tx w/ these
  • start low and go slow
  • have pt return for regular f/u to monitor for ADE, avoid starting 2 new meds in same pt at one time
  • incorporate a standardized method for med review (Beers, START, STOPP)

Geriatrics (16 decks)

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