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AGEING > Prescribing in the Elderly > Flashcards

Prescribing in the Elderly Flashcards

1
Q

What is meant by pharmacokinetics and pharmacodynamics?

A 
Kinetics = how drug works on the body
Dynamics = how the body works on the drug
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2
Q

What are the 4 parts of Pharmacokinetics?

A

A - Absorption
D - Distribution
M - Metabolism
E - Excretion

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3
Q

What difference occurs in the elderly when patients are prescribed BOTH atorvastatin and dabigatran (DOAC)?

A

This combination in the elderly increases the activity of dabigatran(DOAC) by 18%

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4
Q

Give examples of patient groups in which doses/strengths must be altered

A

Decreased renal function

Overweight/obese

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5
Q

What are the 2 main principles of drug absorption?

A

Acidic drugs require an acidic environment for absorption

Basic drugs require a basic environment for absorption

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6
Q

Give examples of acidic drugs which require an acidic envrionment for absorption?

A

Phenytoin
Aspirin
Penicillins

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7
Q

Give examples of basic drugs which require a basic environment for absorption?

A

Diazepam

Morphine

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8
Q

Elderly patients tend to have a higher gastric pH than younger patients. TRUE/FALSE?

A

TRUE

therefore their stomach is more basic and basic drugs get absorbed better

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9
Q

What condition may affect the absorption of drugs via a transdermal patch?

A

Oedema

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10
Q

What is the best way to deliver drugs in patients with dysphagia?

A

Liquid formulations (syrups etc)

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11
Q

What is the best way to deliver drugs to patients with an NG or PEG feeding tube?

A

Consult BNF to check if any tablets can be crushed for use in these devices

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12
Q

If patients are confused and refusing tablets, in what ways can these medications be delivered?

A

Patches
Intravenous infusions
Intramuscular injections?

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13
Q

If patients are null by mouth in preparation for surgery, which of their medications can and cant they omit?

A
  • Antiplatelets should be taken
  • Statins can be missed
  • BP should be checked and judgement made on the reading (if they become hypertensive this can be sorted in surgery)
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14
Q

How are drugs distributed throughout the body?

A
  • Bound to proteins
  • Bound to lipids/dissolved in lipid
  • Dissolved in water
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15
Q

What protein molecules are responsible for binding acidic and basic drugs?

A

ACIDIC = albumin (=> albumin itself is BASIC)

BASIC = Alpha-1 Acid Glycoprotein (=> it is ACIDIC)

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16
Q

Explain the ratio of albumin to alpha-1 acid glycoprotein in the elderly and how this contributes to pharmacodynamics?

A

Elderly have LOWER albumin than alpha-1 acid glycoprotein

=> they absorb more BASIC drugs

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17
Q

A loss in muscle mass contributes to increased fat in the elderly. How does this affect drugs which are lipid soluble?

A

Gives lipophilic drugs a bigger volume to distribute themselves across

=> drug has a longer half life

18
Q

What can decrease the volume of distribution of certain drugs in the elderly?

A

Less body water in older people

=> less Vd for water soluble drugs (Lithium and Digoxin)

19
Q

What factors can affect hepatic metabolism in the elderly?

A

Reduced liver function due to:

  • decreased size
  • decreased blood flow
  • disease
  • bio-transforming enzymes are reduced in the elderly
20
Q

Why is it a problem if elderly patients cannot complete first pass metabolism?

A

Some drugs require this process to be broken down into their active parts
=> patient wont receive any benefit from drug if their liver cannot break it down

21
Q

A small concentration of drug in the blood means what in regards to the volume of distribution?

A

Means the drug is very lipid soluble and dissolved in a large Vd and not much has dissolved in blood

22
Q

What happens to lipid soluble drugs when patients become cahectic?

A
  • Cahectic patients break down fat stores for energy/metabolism
  • the drugs which have been stored in the adipose tissue are then released and drug concentrations increase if these are measured
23
Q

Generally lower doses achieve same effect in the elderly. TRUE/FALSE?

A

TRUE

e.g. think alcohol

24
Q

Why should drugs with a narrow therapeutic index be avoided?

A

there is not much between their effective concentration and their toxic concentration
=> dangerous for elderly patients with differences in pharmacodynamics

25
Q

Give examples of drugs with a narrow Therapeutic Index (TI)

A

Warfarin
Lithium
Digoxin
Gentamicin

26
Q

Elderly patients are more likely to experience adverse drug reactions than younger patients. TRUE/FALSE?

A

TRUE

27
Q

What 4 drugs top the list for the most elderly patients developing adverse drug reactions?

A
  1. Warfarin
  2. Digoxin
  3. Insulin
  4. Benzodiazepines
28
Q

In what situations can we anticipate drug side effects and prescribe preventative measures?

A

Opioids
- Begin laxative prophylactically

Steroids

  • Osteoporosis prevention
  • beware of Steroid induced diabetes

Levothyroxine – Calcium interferes with absorption
=> take thyroxine in morning and Ca at night

29
Q

What drugs should be avoided if possible due to known side effects in the elderly?

A

NSAIDs - GI bleed, decline in GFR
OPIOIDS/ Benzodiazepines - falls/confusion
ANTIBIOTICS - Resistance, CDiff

30
Q

What is the BEERS criteria and what are the 3 sections it possesses?

A

Criteria of medication that shouldn’t always be used in older adults

3 sections:

1) ALWAYS avoided
2) POTENTIALLY inappropriate – depending on comorbidity
3) Used with CAUTION

31
Q

What would make an older patient at risk of side effects/ ADRs?

A
  • Recent discharge from hospital
  • Use of multiple drugs and prescribers
  • Impaired cognitive status
  • Drugs with a narrow therapeutic index
  • Use of OTC meds alongside others
32
Q

What is the average number of prescription and non-prescription medicines taken by a patient > 65 years of age?

A

4 prescription drugs

2.5 over-the-counter medicines

33
Q

What is the average number of prescription drugs given to patients >65 in a nursing home?

A

7 medicines

34
Q

What principles should be used to avoid/ fix polypharmacy?

A
  • Review medications and indications regularly
  • Discontinue unnecessary medication
  • Avoid treating adverse reactions/side effects
  • Prescribe a drug that will treat >1 problem (e.g CCB/BB for BP and angina)
  • If stable, use combination preparations
35
Q

What is the STOPP-START tool and how is it used?

A

STOPP: Screening Tool of Older People’s Potentially Inappropriate Prescriptions

START: Screening Tool to Alert Doctors to Right Treatments

=> List of drugs to STOP in certain pts and list to START if not on already

36
Q

Give an example of a GI drug which is on the STOPP list for patients with undiagnosed diarrhoea?

A

Loperamide OR codeine phosphate

prescribing these drugs causes a risk of delayed diagnosis as it temporarily fixes the problem

37
Q

Give an example of a GI drug which is on the START list?

A

PPIs should be started for patients >80 years on anti-platelets and SSRIs

38
Q

Give an example of a cardio drug on the STOPP list?

A

Statins
Atorvastatin 80mg for no longer than 6 months post-MI
- dose should be titrated down

39
Q

What factors may influence an elderly patients adherence/compliance to medication?

A

Can they open the pill container?
Do they understand when and how to take it?
Are they remembering to take their medications?

40
Q

What was the FAME trial and what did it show?

A

Trial with patients aged ≥ 65 years on >4 chronic medications who were living independently.

Patients were educated on their tablets
Given regular follow-up (2 monthly)
Medication arranged into customized blister packs

Showed increase in compliance from 60 to ~97%

AGEING (11 decks)

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