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QM Geriatrics > Polypharmacy > Flashcards

Polypharmacy Flashcards

1
Q

Meanings of polypharmacy?

A

Multiple definitions :
▫ Too many tablets
▫ “Unnecessary drug use”
▫ “Medication use without indication”

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2
Q

Prevalence of polypharmacy?

A

Common – 20% of those >70 take 5 or more drugs
• Increasing – mean no of items prescribed to over 60’s
per year has doubled (21.2 to 40.8) since 2000
• Inappropriate – up to 40% are inappropriate prescriptions
• Associated with bad outcomes – readmissions, falls, adverse drug events, mortality, length of stay, cost

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3
Q

What can lead to polypharmacy?

A
  • Multiple co-morbidities
  • Guidelines/NICE
  • Lack of evidence base
  • Infrequent review
  • Poor communication
  • Undetected non-adherence
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4
Q

What is pharmacokinetics?

A

ADME

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5
Q

How does ageing affect Absorption?

A
  • Decrease gut motility thus potentially longer intestinal transit time
  • Decrease GI blood flow
  • Increase gastric pH
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6
Q

How does ageing affect Distribution?

A
  • Decrease body water
  • Decrease lean body mass
  • Increase fat stores
  • Decrease plasma protein (albumin)

Hydrophillic drugs have decreased Vd.

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7
Q

How does ageing affect Metabolism?

A
  • Decrease in hepatic mass and blood flow
  • Decrease in first pass metabolism leading to increase in bioavailability
  • Multi-drug therapy leading to interactions
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8
Q

How does ageing affect Excretion?

A
  • Renal function is significantly reduced
  • Decrease blood flow to the kidneys
  • Decrease number of functional nephrons
  • Decrease tubular secretion
  • Decrease kidney size
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9
Q

What is pharmacodynamics?

A
  • Study of the interaction between a pharmacological agent and its target tissue
  • Study of the mechanism, intensity, peak and duration of a drug’s physiological actions
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10
Q

What changes in the old persons body affecting drug use?

A
  1. Changes in drug receptor sensitivity and receptor population
    ▫ affects sensitivity to pharmacological agents
    ▫ increased adverse effects
  2. Homeostasis changes
    ▫ decreased capacity to respond to physiological challenges (e.g. orthostatic hypotension)
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11
Q

In what ways can meds be implicated in problems with the elderly?

A
  • Medications and Falls
  • Medications and Anti-cholinergic burden • Medications and Constipation
  • Medications and Delirium
  • Medications and Frailty
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12
Q

How do you go about categorising causes of falls?

What drug classes may increase falls?

A

• Syncopal
▫ Cardiac arrhythmia, neurological, orthostatic
hypotension

• Non- syncopal
▫ Environmental challenges
▫ Vision/Hearing Loss
▫ Delirium

• Iatrogenic falls risk increased by: 
– Sedatives
– Antihypertensive medications
– Drugs that prolong QT interval
– Drugs that cause delirium
– Drugs that reduce vision
– Postural hypotension
– Drugs causing Hypoglycaemia
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13
Q

What is an anticholinergic agent? How does it work? Categories?

A
  • Blocks action of Acetylcholine at synapses in CNS + PNS
  • Inhibits parasympathetic nerve impulses

• Divided into 3 categories:
▫ Antimuscarinic agents
▫ Ganglionic blockers
▫ Neuromuscular blockers

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14
Q

Anticholinergic effects?

A
  • Dry mouth, constipation and urinary retention
  • Linked to poor cognition and physical decline
  • Associated with falls, and increased mortality and cardiovascular events.
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15
Q

Common meds that have anticholinergic effects?

A
  • Antidepressants ( TCA)
  • Antipsychotics
  • Urinary antispasmodics
  • Sedative medication
  • Antihistamines
  • H2 receptor antagonists
  • Spasticity
  • Others
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16
Q

Medications that cause constipation?

A
  • Antacids
  • Antimuscarinics
  • Antidepressants
  • Anti-epileptic medications
  • Antipsychotics
  • Calcium supplements
  • Diuretics
  • Iron supplements
  • Opioids
17
Q

Medications and delirium?

A

• Drugs are a common risk factor for delirium.
• Medications can account for 12–39% of delirium
cases.

• The most common medications to cause delirium are:
▫ Opiates
▫ Benzodiazipine medications
▫ Anti-cholinergic medications

18
Q

Medications and frailty?

A
  • Highest risk of medication side effects due to reduced physiological reserve
  • Unlikely to derive any of the intended long term benefits

• Need to review treatment targets:
▫ BP–avoidBP<150/90if over 80
▫ Blood sugar control – avoid lowering HbA1c < 65 (T2DM)
▫ Avoid the use of combination blood thinners
▫ HR control – reduce/stop rate limiting medications if pulse < 60

19
Q

How common are ADRs?

A

• ADRs are implicated in 6.5% of hospital
admissions
- Falls
- Bleeding
• ADRs are the 4th leading cause of death—ahead of pulmonary disease, diabetes, pneumonia, RTAs etc.

  • NSAID – short course with PPI
  • Diuretics – confirm indication
  • Warfarin/DOACs – think about risk and benefit, in particular life expectancy
  • Antibiotics – policy differs for older/frail patients!
20
Q

Reasons for non-adherence?

A
  • Affects up to 50% pts with chronic conditions
  • Why is the patient non-adherent?

Unintentional:

  • Cognitive impairment
  • Sensory impairment
  • Supervision/ administration
  • Formulation/ swallowing

Intentional:

  • Understanding/beliefs
  • Self neglect

▫ What is keeping patients from using their meds?
▫ Set up reminders, organizational systems. …
▫ Identify cost-cutting strategies. …
▫ Address mental barriers and stigma. …
▫ Direct symptom, side effect management.

21
Q

What resources can you uses for medications reconciliation?

A

• Solutions to these challenges :
▫ Beer’s Criteria
▫ STOPP/START

ID and reduction of inappropriate medication use, potential drug-drug interactions.

22
Q 
Medication class:
ALPHA-ADRENERGIC ANTAGONISTS
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

eg doxazosin
Has a direct effect on smooth muscles and also a level of spinal cord ganglia and nerve terminals

Can caused reduced bladder outlet resistance

23
Q 
Medication class:
ALPHA-ADRENERGIC AGONISTS
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

eg clonidine, methyldopa

Mimic action of norepinephrine at receptors

May contract bladder sphincter and cause retention

24
Q 
Medication class:
ANTIPSYCHOTICS
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

eg dopamine antagonists like haloperidol or serotonin receptors.

Gives alpha-adrenergic blockage, dopamine blockage, cholinergic action on the bladder.

Can lead to complex drug interactions.

25
Q 
Medication class:
ANTIDEPRESSANTS
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

Hard to generalise action; inhibitors of norepinephrine and or serotonin, some are antagonists at adrenergic, cholinergic or histaminergic receptors

Can lead to urinary retention / overflow incontinence.

26
Q

Medication class:
DIURETICS
Mechanism / Desired effect?
Side effect / Adverse symptoms?

A

Formation of urine

Frequency, urgency, overwhelming bladder capacity.

27
Q 
Medication class:
CCBs
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

Decrease smooth muscle contractility in the bladder

Urinary retention / overflow

28
Q 
Medication class:
SEDAtIVE/ HYPNOTICS
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

Sedation, and relaxation of striated muscle (urethra).

Immobility / functional incontinence.
Weak flow / retention / overflow.

29
Q 
Medication class:
MUSCLE RELAXANTS /SEDATIVE
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

eg diazepam, chlordiazepoxide

Cause sedation or drowsiness; relax the urethra.

Frequency, stress incontinence, sedation.

30
Q

Medication class:
ACEi, ARBs
Mechanism / Desired effect?
Side effect / Adverse symptoms?

A

Decrease both detrusor overactivity and urethral sphincter tone.

Reduced urge incontinence and increased stress incontinence.

31
Q 
Medication class:
ANTIHISTAMINE
Example?
Mechanism / Desired effect?
Side effect / Adverse symptoms?
A

eg chlorpheniramine

Relaxation of the bladder

Can lead to urinary retention.

QM Geriatrics (12 decks)

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