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Module 308 > Prescribing in Older People > Flashcards

Prescribing in Older People Flashcards

1
Q

Common Scenario:
85 yr old frail female admitted after a fall
Meds include: Warfarin, Perindopril, Diazepam, Ibuprofen, Furosemide, Sertraline, Amlodipine, Betahistine, Prochorperazine
What problem meds can you identify?

A

Warfarin and Ibuprofen = increased risk of bleeding
Ibuprofen/Diuretic/perindopril - affect ARF
Sertraline - low sodium/GI bleeds
Diazepam - sedation
Antihypertensives in those who fall (amlodipine)
Prochlorperazine - Parkinsonism

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2
Q

Patients over 65 years constitute …% of the population but use about …% of the medications

A

13% of population, 30-40% of medication

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3
Q

Elderly patients use … drugs and have … diseases

A

Elderly patients use multiple drugs and have multiple diseases

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4
Q

Greatly increased risk of drug … as well as … effects with multiple drugs

A

Greatly increased risk of drug interactions as well as adverse effects with multiple drugs

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5
Q

Drug absorption in the elderly

A 
Reduced saliva
Reduced gastric acid
Decreased GI motility
Reduced SA for absorption
Reduced splanchnic blood flow
overall - rate of absorption decreased and increased time to steady state
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6
Q

Levodopa competes with …

A

nutrients - plan dosing regimes to avoid meal times

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7
Q

Bisphosphonates - advise to take on a …

A

empty stomach, sitting up, 30 min before food

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8
Q

Drug distribution in the elderly

A

Decreased lean body mass (muscle)
Decreased volume of distribution for drugs that distribute into muscles e.g. digoxin
= increased plasma concentration

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9
Q

Digoxin toxicity

A

Cardiac (heart block, bradycardia, junctional tachycardia), Psychiatric (delirium, fatigue, malaise), Visual, GI side effects

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10
Q

Digoxin toxicity - Cardiac (3)

A

heart block, bradycardia, junctional tachycardia

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11
Q

Digoxin toxicity - A patient with normal digoxin levels (1-2 ng/mL), 6 hours post dose but renal insufficiency or severe hypokalemia may have more serious cardiotoxicity than a patient with high digoxin levels and no renal or electrolyte disturbances.
Treat how? withdrawing drug/correcting electrolytes

A

withdrawing drug/correcting electrolytes

Severe- digoxin specific antibody fragments (Digibind)

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12
Q

Drug Distribution in the elderly

A

increased body fat, increased volume of distribution for fat soluble drugs e.g. benzodiazepines, haloperidol = increased half life
e.g. diazepam - vol of distribution increased by x2 in elderly - half life increases from 24 hours to 90 hours in the elderly

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13
Q

Benzodiazepines side effects

A

Drowsiness, confusion, ataxia, dependence

Treat iv flumazenil 200mcg, antagonist, shorter half life than diazepam and so patient may become re-sedated

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14
Q

Drug distribution in the elderly - body water - what is the affect on distribution of water soluble drugs?

A

Decreased body water, decreased vol of distribution of water soluble drugs e.g. gentamicin
= increased plasma conc, loading doses are lower

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15
Q

Serum albumin - drug distribution in the elderly - what happens?

A

↓Albumin 12-25% - further depressed by heart failure, renal disease, rheumatoid arthritis, hepatic cirrhosis some malignancies
Drug binding capacity ↓ 12-25%
↑ free drug

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16
Q

Phenytoin toxicity

A

Nausea, vomiting, tremor, ataxia, nystagmus, coarse facies, hepatitis

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17
Q

Warfarin - Aspirin Interaction

A

Warfarin is highly bound to plasma albumin (99%)
Warfarin has narrow therapeutic index
Warfarin has a small volume of distribution
Aspirin can displace warfarin from plasma albumin
finish card

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18
Q

Adverse effects - antiplatelet agents e.g. aspirin

A 
Antiplatelet agents - aspirin 
Peptic ulcer disease
bleeding tendency
fluid retention
renal failure
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19
Q

Anticoagulants eg warfarin or DOAC adverse effects

A

Bleeding tendency

Interaction with other drugs

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20
Q

Digoxin toxicity - Psychiatric

A

delirium, fatigue, malaise, confusion, dizziness

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21
Q

Digoxin toxicity - Visual

A

blurred or yellow-green vision, halos, double vision, photophobia

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22
Q

Digoxin toxicity - Gastrointestinal

A

nausea, vomiting, anorexia, diarrhoea, abdominal pain

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23
Q

Drug distribution in the elderly - decreased body water - what is the affect on loading doses of water soluble drugs?

A

decreased body water = increased plasma conc, loading doses are lower

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24
Q

What drugs bind to albumin and require lower doses in the elderly?

A

phenytoin, warfarin, propranolol, diazepam levothyroxine,digoxin, furosemide

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25
Q

Phenytoin toxicity symptoms

A 
Nausea, vomiting
Tremor
Ataxia
Nystagmus
Coarse facies
Hepatitis
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26
Q

Warfarin – Aspirin interaction

A

Warfarin is highly bound to plasma albumin (99%)
Warfarin has narrow therapeutic index
Warfarin has a small volume of distribution
Aspirin can displace warfarin from plasma albumin
Displacement of 1-2% of bound warfarin doubles or triples concentration of free warfarin
↑ bleeding

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27
Q

Adverse effects - Antiplatelet agents (5)

A 
aspirin
Peptic ulcer disease
Bleeding tendency
Fluid retention
Renal failure
28
Q

Adverse effects - Anticoagulants warfarin or DOAC (2)

A

Bleeding tendency

Interaction with other drugs

29
Q

Liver metabolism in the elderly

A

↓ liver volume – up to 30% reduction
↓ liver blood flow 12-40% (extremely variable)
↓ first-pass metabolism due to ↓ blood flow
↓ enzyme activity CP450 (frail elderly)-
↓ clearance of drugs = ↑ t1/2
Eg. antidepressants, antipsychotics, beta blockers, opiates, benzodiazepines, calcium channel blockers, theophylline, warfarin, phenytoin, NSAIDS, paracetamol, erythromycin

30
Q

Excretion in the elderly

A

Renal blood flow
↓ Renal mass (20%)
↓ Renal function (nephrons 30%)
GFR declines by 1% per year from age 40

31
Q

Excretion in the elderly

A

Drugs that are more than 60% excreted by kidneys are affected by a reduction in renal function
t1/2 prolonged
↑ serum levels
Drugs excreted primarily by kidneys include: digoxin, atenolol, sotalol, lithium, allopurinol & many antibiotics

32
Q

Excretion in the elderly - Therapeutic implications

A

Reduce dose in once daily preps

Increase dosage interval in more frequently administered drugs

33
Q

Lithium - toxicity

A

12 hour post dose 0.4-0.8 mmol/l
Early toxicity Li 1.5 mmol/l tremor, agitiation, twitching
Intermediate – lethargy
Late Li >2 mmol/l coma, fits, arrhythmia, renal failure – haemodialysis may be needed

34
Q

Morphine undergoes phase II metabolism by …

A

conjugation

35
Q

Morphine

A

Undergoes phase II metabolism by conjugation
Morphine-6-glucuronide 40x more potent
Approx 80% analgesic action derives from Morphine-6-glucuronide
Renal impairment results in accumulation of metabolite
Prolonged effect, ↑ toxicity
NB S/C morphine = 2x potent po

36
Q

Morphine toxicity symptoms (5)

A 
Nausea, vomiting
Constipation
Drowsiness
Respiratory depression
Hypotension

Treatment naloxone iv 400mcg

37
Q

Morphine toxicity treatment

A

naloxone iv 400mcg

38
Q

Pharmacodynamics - aging

A

Effects of aging on biochemical and physiologic effects of drugs and their mechanisms of action are not clearly known
Progressive decline in homeostatic mechanisms

? Due to receptor affinity or number
? Alterations in second messenger function
? Alteration in cellular & nuclear responses

39
Q

drug effects in the elderly - alcohol?

A

Alcohol causes increase is drowsiness and lateral sway in older people than younger people at same serum levels

40
Q

drug effects in the elderly - benzos?

A

Benzodiazepines (↑) – enhanced sedation

41
Q

drug effects in the elderly - warfarin?

A

Warfarin (↑)

42
Q

drug effects in the elderly - Hypotensives?

A

Hypotensives (↑) – postural hypotension

43
Q

drug effects in the elderly - NSAIDS?

A

GI effects of NSAIDs (↑)

44
Q

drug effects in the elderly - anticholinergics?

A

Central effects of anticholinergics (↑)

45
Q

drug effects in the elderly - ß1 modulators in cardiac tissue?

A

ß1 modulators in cardiac tissue (↓)- down regulated by 1/3

46
Q

drug effects in the elderly - bronchodilatory response to β-agonists?

A

Reduced & delayed bronchodilatory response to β-agonists

47
Q

drug effects in the elderly - Calcium channel blocking effect?

A

Calcium channel blocking effect on PR interval (↓)

48
Q

Elderly patients medicines should be … …

A

Elderly patients medicines should be reviewed regularly

49
Q

Frail patients may have difficulty swallowing tablets – if left in the mouth … may develop

A

Frail patients may have difficulty swallowing tablets – if left in the mouth ulceration may develop

50
Q

Encourage patients to take medication with enough …, in an upright position, consider … preparation

A

Encourage patients to take medication with enough fluid, in an upright position, consider liquid preparation

51
Q

Antihypertensive medication (ACE inhibitors –eg. ramipril) – side effects

A

Hypotension
Potassium increase
Renal failure
Cough

52
Q

Antihypertensive medication (Calcium channel blockers – e.g amlodipine) – side effects

A

Hypotension
Negatively inotropic
Fluid retention

53
Q

Antihypertensive medication (Diuretics) – side effects

A 
Hypotension
Hypokalaemia
Hyponatremia
Confusion
Dehydration
54
Q

‘Traditional’ antipsychotics – haloperidol - side effects (elderly)

A 
Confusion
Sedation
Parkinsonism
Tardive dyskinesia
Neuroleptic malignant syndrome
55
Q

How to prescribe in the elderly

A 
Consider risk/benefit ratio
Pharmacokinetic/dynamic factors
Start low, go slow
Review the effect
Communicate with patient,relative,other healthcare professionals 
Use the BNF
56
Q

AF Risk of stroke - what score?

A

NICE CHA2DS2-VASc – treat men >1

Assess bleeding with HASBLEED – high risk >3 (European Society Guidelines AF)

57
Q

Assess bleeding risk with what score? (AF)

A

Assess bleeding with HASBLEED – high risk >3 (European Society Guidelines AF)

58
Q

What to do about compliance - elderly

A

Consider cognitive problems – carer to prompt patient with medications
Simplify regimes as much as possible to once or twice daily
Dossit boxes
Consider manual dexterity and vision of the patient
Check inhaler techniques
Syrups if dysphagia for large tablets

59
Q

Adverse drug reactions - elderly

A

Prevalence increases with age, length of stay, number of medications

15.3% of admissions are due to ADR

60
Q

What % of admissions are due to Adverse drug reactions - elderly

A

15.3% of admissions are due to ADR

61
Q

Steroid 3 adverse affects (elderly)

A

Osteoporosis
Gastric irritation/ulcers
Hyperglycaemia

62
Q

Tricyclic antidepressants - 5 adverse affects (elderly)

A 
Cardiac arrhythmias
Drowsiness
Dry mouth
Constipation
Urinary retention
63
Q

Non steroidal anti inflammatory drugs - 3 adverse effects (elderly)

A

Renal failure
Gastric irritation
Fluid retention

64
Q

Selective alpha blockers - 4 adverse effects (elderly)

A

urinary retention (relax smooth muscle in BPH)
drowsiness
hypotension
syncope

65
Q

STOPP/START criteria for potentially … prescribing in older people: version 2

A

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

66
Q

Key Learning Points - prescribing in the elderly

A

Physiological changes in the elderly alter drug responses
Assess the risks and benefits when prescribing
Side effects are common and can be life threatening
Think about polypharmacy and compliance issues
Use the BNF

Module 308 (17 decks)

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