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Geriatrics > Polypharmacy & CAM > Flashcards

Polypharmacy & CAM Flashcards

1
Q

What is the 4th leading cause of death?

A

ADRs 4th leading cause of death ahead of pulmonary disease, diabetes, AIDS, pneumonia, accidents, and automobile deaths

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2
Q

Are ADRs preventable?

A
  • Nearly one third of adverse drug events in ambulatory settings are preventable
  • Half of adverse drug events in nursing facilities are preventable
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3
Q

What are some common iatrogenic drug problems (drug specific)

A

Confusion, dry mouth, constipation, blurred vision, urinary retention and orthostatic hypotension with anticholinergics

Confusion and unsteady gait with tricyclics

Digoxin toxicity with normal serum concentrations

CNS toxicity with long-acting benzodiazepines

Confusion with narcotics

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4
Q

Can benzodiazepines make you drowsy?

A

Yes Indeedy

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5
Q

Older adults (age>50) get 2-3 x as many prescriptions. Typical 85yr old older adult takes 8-9 prescriptions and 2 OTC drugs at once. Why???

A

More acute & chronic disease
More doctors visits
Drugs often given to counteract a side effect of another drug
Several other factors arising from prescribers, patients and the system

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6
Q

What is the prescribing cascade?

A

Prescribing cascade-often give drugs to counteract the side effects of another

ADE interpreted as new med condition so given another drug

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7
Q

ADRs look like ‘growing old’. What are some of them?

A

Unsteadiness
Dizziness
Confusion
Nervousness
Fatigue
Insomnia
Drowsiness
Falls
Depression
Incontinence

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8
Q

Misdiagnosis due to what is a key cause of polypharmacy?

A

An atypical presentation

Hyperthyroidism:

Young patient=
Tremor
Anxiety
Weight loss
Diarrhoea

Elderly patient=
Depression
Cognitive impairment
Muscle weakness
Atrial fibrillation
Heart failure
Angina

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9
Q

What are some healthcare provider factors that contribute to polypharmacy?

A

No med review with patient on regular basis

Prescribes without sufficiently investigating clinical situation

Evidence that a particular drug is the “best” drug for a problem

Complicated by the existence of many problems and multiple providers

Provides unclear, complex or incomplete instructions about how to take meds

No effort to simplify medication regimen

Ordering automatic refills

Lack of knowledge of geriatric clinical pharmacology

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10
Q

What CAM modalities have minimal potential for harmful interaction?

A
  • Mind-body therapies
  • Sensory therapies
  • Body therapies (massage-depending on oils used, chiropractor etc)
  • Movement based therapies
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11
Q

What CAM modalities have the potential for interaction with drug treatments?

A
  • Dietary modifications
  • Food supplements
  • Herbal medicines
  • CAM systems
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12
Q

What CAM modalities have no interactions?

A
  • Movement based disciplines
  • External ‘energy’
  • Mind-body
  • Sensory
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13
Q

How to avoid harms with herbal meds?

A
  • Use regulated & tested herbal meds
  • Avoid uncontrolled meds
  • Consult a qualified herbalist or integrative medical practitioner
  • Always take herbal med Hx
  • Avoid herbs which cause severe toxicity/use cautiously
  • Use certain herbal meds with caution (e.g. anticholinergic side effects)
  • Consider and report interactions
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14
Q

Mediterranean diet has similar … to statins

A

NNT (reduction in CVD events)

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15
Q

In terms of depression and anxiety how does exercise help?

A

Improves symptoms and halves relapse rate in depression

In anxiety it reduces in patients with chronic physical health problems

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16
Q

What are the effects of exercise on diseases?

A

Reduced progression from pre-diabetes to diabetes

Symptoms and prognosis of heart and lung disease improved

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17
Q

In mild to moderate to depression what is Hypericum (st johns wort) as effective as?

A

Antidepressants

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18
Q

What is CAM?

A

A ‘broad set of health care practices that are not part of that country’s own tradition and are not integrated into the dominant health care system’.

CAM approaches are diverse and include modalities such as herbal and homeopathic therapies, acupuncture, aromatherapy, Reiki, Shiatsu and yoga.

Few CAM approaches are supported by robust efficacy, effectiveness or safety data

Use is wide-spread, with women reportedly the major users both in health and disease

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19
Q

Is Homeopathy available on the NHS?

A

YES

60% of Scottish GP practices use homeopathic and or herbal preparations.

Concerns about CAM:
Implausibility of most therapies
Evidence of harm
Adverse Effects / Herb-Drug Interactions

20
Q

Why do people use CAM?

A

Desire to have personal control over their own health.

Dissatisfied with conventional treatment

Perception that conventional medicine lacks/disregards an holistic approach.

Concerns about the side effects of prescribed medications

21
Q

All herbals contain … ingredients

A

ACTIVE

22
Q

Why does it matter that people in pregnancy use herbals?

A

No safety or efficacy data
Teratogenesis
Fetogenesis
Drug-Herb Interactions

23
Q

What is the risk associated with St Johns Wort ?

A

St Johns wort-potent enzyme inducer-interferes with metabolism and therefore can cause failure of other treatments (such as HIV or immunosuppressants for prevention of organ rejection)

24
Q

What arrangement was put in place for pharmacovigilance?

A

Yellow card system

25
Q

How does age effect absorption of drugs and what may this lead to?

A

Physiological changes occur that effect the rate but generally not the extent of absorption from the GI tract

May lead to a delay in onset of action

Examples=A reduction in saliva production may result in a reduction in the rate of absorption of buccally administered drugs e.g. glyceryl trinitrate (GTN)

26
Q

Why as an exception is there an increased absorption of Levodopa in the elderly?

A

Used for Parkinsons disease. Substantial mucosal metabolism of this drug occurs by the enzyme dopa-decarboxylase, there is a reduced amount of dopa decarboxylase in the elderly- leading to a substantial increase in the absorption of levodopa in the elderly. Elderly patients show a slightly higher peak plasma level and a shorter time to peak than healthy young subjects.

27
Q

How does distribution of drugs change in the elderly?

A

Body composition changes
- Reduced muscle mass
- Increased adipose tissue
Fat soluble drugs: ↑ Vd, ↑ T1/2, ↑ duration of
action e.g. diazepam

  • Reduced body water
    Water soluble drugs: ↓Vd, ↑ serum levels e.g. digoxin

Protein binding changes
Decreased albumin
↓ binding, ↑ serum levels acidic drugs e.g. furosemide

-Increased permeability across the blood-brain barrier

28
Q

Hepatic metabolism in the elderly is affected by decreased liver mass and decreased liver blood flow. What are the consequences of this?

A

Toxicity due to reduced metabolism/excretion

Reduced first pass metabolism
↑ in bioavailability with some drugs e.g. propranolol
Can cause ↓ bioavailability of pro-drugs e.g. enalapril

29
Q

How is excretion of drugs affected by ageing?

A

Renal function decreases with age

Reduces clearance and increases half-life of many drugs leading to toxicity

30
Q

Pharmacodynamics: As ageing occurs there is increased sensitivity to particular meds. What is this due to?

A

Due to:
change in receptor binding,
decrease in receptor number,
altered translation of a receptor initiated cellular response into a biochemical reaction.

Examples: diazepam (↑ sedation), warfarin (↑ anti-coagulation)

More anticoag as the liver is producing fewer clotting factors (therefore higher INR)

31
Q

What are key principles in prescribing for older people?

A

Where possible, be clear about the diagnosis to avoid prescribing a drug to manage an adverse effect

Consider whether drug therapy is the best therapeutic action

Lower doses (or reduced frequency of administration) are generally needed

Think about whether the drug causes particular problems in elderly patients

Check whether a lower dose is recommended in the elderly: start at the lowest dose and titrate up slowly (‘start low, go slow’)

Review the new drug and check whether it is achieving its aim

32
Q

What is good to remember in prescriptions and regimes in elderly?

A

Review all prescriptions regularly and stop any medicines that are not beneficial

Try to keep regimens as simple as possible

Consider compliance issues which elderly patients in particular may experience

33
Q

Why is there lack of evidence of drug effects in elderly?

A

Clinical trials are often performed in a younger population which may mean that benefits do not translate to an older age group

Elderly patients should not be denied proven beneficial medicines on the basis of age

34
Q

What are some examples of prescribing tools and guides for meds in the elderly?

A

Beers’ criteria
List of ‘inappropriate’ drugs for older people
Updated occasionally but many weaknesses

START-STOPP criteria (O’Mahony et al)
Advice on medical optimisation
A lot to remember, so mostly research tool

NHS Scotland Polypharmacy Guidance

35
Q

What is deprescribing?

A

To reduce, substitute or discontinue a drug

36
Q

What are some common drugs associated with admission due to ADR?

A

NSAIDs
Diuretics
Warfarin
ACEI

MOST ADVERSE EVENTS ARE FROM ANTICHOLINERGICS & SEDATIVES

37
Q

What are some common anticholinergic (antimuscarinic) effects?

A

Peripheral:
- Dry mouth
- Dry eyes
- Constipation

Central:
- Memory impairment
- Confusion
- Delirium
- Falls

38
Q

What are some common anticholinergic (antimuscarinic) effects?

A

Peripheral:
- Dry mouth
- Dry eyes
- Constipation

Central:
- Memory impairment
- Confusion
- Delirium
- Falls

39
Q

Why should care be taken when treating ‘agitation’ in the elderly?

A

Sedatives problematic
Increased effects of benzodiazepines
- Falls, confusion

Anti-psychotics
Increased adverse effects
- Postural hypotension, stroke, confusion, movement disorders

Anti-depressants
Less effective, more dangerous?-falls

40
Q

What adverse effects of NSAIDs are increased?

A
  • Renal impairment
  • GI bleeding

NSAIDs-highly protein bound and renally excreted

41
Q

Because the elderly are more sensitive to the effects of opioids, how does this affect their dosing?

A

Lower doses needed

Pethidine and tramadol may be less useful

42
Q

Digoxin: Effects on elderly?

A

Increased toxicity-lower doses needed

43
Q

What are the issues with diuretics in the elderly?

A

Decreased peak effect, but reduced clearance-
Abnormal urea and electrolytes

Other issues around continence and mobility

Often inappropriate indication (swollen legs)

44
Q

Why do anti-HTs pose a risk in the elderly?

A

May have exaggerated effects on BP and HR
More likely to be issues with postural hypotension

ACE inhibitors often pro-drugs which may not be metabolised to the active form

Renal adverse effects

45
Q

How can Warfarin be problematic in the elderly?

A

Anti-coagulants
- More sensitive to warfarin
- Greater risk from warfarin i.e. GI bleeding, falls

46
Q

Abx: What increased adverse effects can they cause in the elderly?

A

Diarrhoea and c. diff infection
Blood dyscrasias (trimethoprim, co-trimoxazole)
Delirium (quinolones)
Seizures
Renal impairment (aminoglycosides)

47
Q

… Colitis due to C.diff is very common

A

Pseudomembranous colitis due to C.diff is very common

Geriatrics (4 decks)

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