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Psychiatry and Elderly Medicine > Therapeutics in the Older Patient > Flashcards

Therapeutics in the Older Patient Flashcards

1
Q

Therapeutics:

  • ‘The medical treatment of disease.’
  • ‘The branch of medicine concerned with the treatment of disease.’
  • ‘The branch of medicine concerned with the use of remedies to treat disease.’
  • ’……the science or art of healing.’
A
  • ‘The medical treatment of disease.’
  • ‘The branch of medicine concerned with the treatment of disease.’
  • ‘The branch of medicine concerned with the use of remedies to treat disease.’
  • ’……the science or art of healing.’
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2
Q

1 in … people (…%) born in the UK* in 2012 will live until they are 100 years of age…. - dependent on postcode

A

1 in 5 people (20%) born in the UK* in 2012 will live until they are 100 years of age…. - dependent on postcode

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3
Q

Pharmacological Treatment - Elderly

A
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4
Q

Polypharmacy: elderly

How much is enough?* How many is too many?

A

* “Some is plenty, enough is too much.”

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5
Q

What is polypharmacy?

A

•The use of at least four to five medicines

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6
Q

Polypharmacy - appropriate vs problematic (elderly)

  • Appropriate: prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence
  • Problematic: prescribing of multiple medications inappropriately or where intended benefit is not realised e.g. treatments not evidence based, risk of harm outweighs benefits, medicines interactions present, unacceptable pill burden etc.
A
  • Appropriate: prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and where the medicines are prescribed according to best evidence
  • Problematic: prescribing of multiple medications inappropriately or where intended benefit is not realised e.g. treatments not evidence based, risk of harm outweighs benefits, medicines interactions present, unacceptable pill burden etc.
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7
Q

Polypharmacy – Facts and Figures

  • By 2018 3 million people in the UK will have a long-term condition managed by polypharmacy
  • 2 million prescriptions are issued each day in England.
  • The number of prescriptions issued has increased by 55.2% since 2004.
  • Approximately …%of prescriptions are issued to people aged 60 years and over.
  • A person taking ten or more medicines is ….% more likely to be admitted to hospital.
  • A … of people aged 75 years and over are taking at least six medicines.
    • Source: CPPE Polypharmacy DLP 2016
A
  • By 2018 3 million people in the UK will have a long-term condition managed by polypharmacy
  • 2 million prescriptions are issued each day in England.
  • The number of prescriptions issued has increased by 55.2% since 2004.
  • Approximately 60%of prescriptions are issued to people aged 60 years and over.
  • A person taking ten or more medicines is 300% more likely to be admitted to hospital.
  • A third of people aged 75 years and over are taking at least six medicines.
    • Source: CPPE Polypharmacy DLP 2016
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8
Q

By 2018 … million people in the UK will have a long-term condition managed by polypharmacy

A

By 2018 3 million people in the UK will have a long-term condition managed by polypharmacy

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9
Q

… million prescriptions are issued each day in England.

A

2 million prescriptions are issued each day in England.

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10
Q

The number of prescriptions issued has increased by …% since 2004. (2016)

A

The number of prescriptions issued has increased by 55.2% since 2004. (2016)

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11
Q

Approximately …% of prescriptions are issued to people aged 60 years and over.

A

Approximately 60%of prescriptions are issued to people aged 60 years and over.

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12
Q

A third of people aged 75 years and over are taking at least … medicines.

A

A third of people aged 75 years and over are taking at least six medicines.

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13
Q

Dangers of Polypharmacy:

  • … effects
  • Drug-drug …
  • … of drug therapy
  • Poor …
  • C…
  • Decreased … of …
A
  • Adverse effects
  • Drug-drug interactions
  • Duplication of drug therapy
  • Poor adherence
  • Cost
  • Decreased quality of life
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14
Q

Challenges for prescribing in the elderly:

  • Multiple medical …
  • Multiple …
  • Multiple P…
  • Different M… and R…
  • Lack of … for use in the elderly
  • A… and cost
A
  • Multiple medical conditions
  • Multiple medications
  • Multiple prescribers
  • Different metabolisms and responses
  • Lack of evidence for use in the elderly
  • Adherence and cost
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15
Q

‘Guideline medicine’ often won’t help (Polypharmacy - elderly)

A
  • If you follow NICE Guidance
  • Patient with
    • Type 2 diabetes (23 drugs recommended)
    • Depression (13 drugs recommended)
    • Heart failure (11 drugs recommended)
  • Study looked at how many interactions there would be with 11 other common conditions e.g. CKD, Osteoarthritis, Hypertension, COPD
  • If NICE guidelines followed
    • 133 drug-drug interactions with Diabetes guidelines
    • 89 for Depression guidelines
    • 111 for heart failure
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16
Q

Challenges for prescribing in the elderly:

A
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17
Q

Meet ‘Mrs Anderson’

  • 87 year old lady, presented to A&E via ambulance from nursing home
  • Found on floor at 0730 - unable to recall events. NH staff reports that patient was put to bed at 2130 and, when checked at 2330, was asleep in bed.
  • PC: Right hip and back pain, agitated - says “yes” when asked if she is in pain.
  • PMH - Type 2 Diabetes - on s/c insulin, Peripheral Neuropathy, Anaemia, COPD, Parkinson‘s Disease (2014), Recurrent UTI’s
  • Drug History: AS SHOWN
  • Why is Mrs Anderson at Risk?
A
  • 87 year old lady, presented to A&E via ambulance from nursing home
  • Found on floor at 0730 - unable to recall events. NH staff reports that patient was put to bed at 2130 and, when checked at 2330, was asleep in bed.
  • PC: Right hip and back pain, agitated - says “yes” when asked if she is in pain.
  • PMH - Type 2 Diabetes - on s/c insulin, Peripheral Neuropathy, Anaemia, COPD, Parkinson‘s Disease (2014), Recurrent UTI’s
  • Drug History: AS SHOWN
  • RISK FACTORS - Multiple Drugs:, Risk of ADE is proportional to number of drugs, Increased probability of drug-drug interactions, Physiological Changes:, Associated with disease state, Associated with normal ageing
18
Q

Physiological changes associated with disease states:

  • Cardiac disease:
    • Impaired cardiac output (decreased absorption, metabolism, clearance)
    • Greater … to cardiac adverse effects
  • Kidney and Liver diseases:
    • … drug clearance, metabolism changes
  • Neurological diseases:
    • … neurotransmitter levels
    • … cerebral blood flow
    • Greater … to neurological effects
A
  • Cardiac disease:
    • Impaired cardiac output (decreased absorption, metabolism, clearance)
    • Greater susceptibility to cardiac adverse effects
  • Kidney and Liver diseases:
    • Decreased drug clearance, metabolism changes
  • Neurological diseases:
    • Reduced neurotransmitter levels
    • Impaired cerebral blood flow
    • Greater sensitivity to neurological effects
19
Q

Physiological changes associated with disease states:

  • Cardiac disease:
    • Impaired cardiac output (… absorption, metabolism, clearance)
    • Greater susceptibility to cardiac … effects
  • Kidney and Liver diseases:
    • Decreased drug …, metabolism changes
  • Neurological diseases:
    • Reduced … levels
    • Impaired … blood flow
    • … sensitivity to neurological effects
A
  • Cardiac disease:
    • Impaired cardiac output (decreased absorption, metabolism, clearance)
    • Greater susceptibility to cardiac adverse effects
  • Kidney and Liver diseases:
    • Decreased drug clearance, metabolism changes
  • Neurological diseases:
    • Reduced neurotransmitter levels
    • Impaired cerebral blood flow
    • Greater sensitivity to neurological effects
20
Q

Physiological changes associated with normal ageing:

  • … Water
  • … fat
  • … muscle mass
  • … hepatic metabolism
  • Decreased renal excretion
  • Decreased responsiveness of baroreceptors
A
  • Less Water
  • More fat
  • Less muscle mass
  • Slower hepatic metabolism
  • Decreased renal excretion
  • Decreased responsiveness of baroreceptors
21
Q

Physiological changes associated with normal ageing:

  • Less Water
  • More fat
  • Less muscle mass
  • … hepatic metabolism
  • … renal excretion
  • … responsiveness of baroreceptors
A
  • Less Water
  • More fat
  • Less muscle mass
  • Slower hepatic metabolism
  • Decreased renal excretion
  • Decreased responsiveness of baroreceptors
22
Q

Absorption - older patient

  • … rate of absorption
  • …. saliva production
  • … gastric acid secretion (increased gastric pH)
  • …. gastric emptying
  • Reduced GI motility
  • Decreased GI surface area
  • These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or malabsorption syndromes, doses may need to be increased
A
  • Reduced rate of absorption
  • Reduced saliva production
  • Reduced gastric acid secretion (increased gastric pH)
  • Delayed gastric emptying
  • Reduced GI motility
  • Decreased GI surface area
  • These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or malabsorption syndromes, doses may need to be increased
23
Q

Absorption - older patient

  • Reduced rate of absorption
  • Reduced saliva production
  • Reduced gastric acid secretion (increased gastric pH)
  • … gastric emptying
  • … GI motility
  • …. GI surface area
  • These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or … syndromes, doses may need to be increased
A
  • Reduced rate of absorption
  • Reduced saliva production
  • Reduced gastric acid secretion (increased gastric pH)
  • Delayed gastric emptying
  • Reduced GI motility
  • Decreased GI surface area
  • These factors alone do not usually necessitate avoiding drugs or adjusting doses. However, if combined with problems such as diarrhoea or malabsorption syndromes, doses may need to be increased
24
Q

Distribution - Older patient

  • …. adipose tissue (… fat)
  • ↑ VD and t ½ of … drugs
  • … body water (less H2O)
  • ↓ VD of water soluble drugs
  • Decreased a… (↓ muscle mass)
  • ↑ concentration (‘free’ concentration increase) of … bound drugs (warfarin, digoxin, phenytoin) – Lower maintenance doses required
  • Reduced systemic perfusion
A
  • Increased adipose tissue (more fat)
  • ↑ VD and t ½ of lipophilic drugs
  • Reduced body water (less H2O)
  • ↓ VD of water soluble drugs
  • Decreased albumin (↓ muscle mass)
  • ↑ concentration (‘free’ concentration increase) of albumin bound drugs (warfarin, digoxin, phenytoin) – Lower maintenance doses required
  • Reduced systemic perfusion
25
Q

Distribution - Older patient

  • …. adipose tissue (more fat)
  • ↑ VD and t ½ of lipophilic drugs
  • Reduced body water (less H2O)
  • ↓ VD of water soluble drugs
  • Decreased albumin (↓ muscle mass)
  • ↑ concentration (‘free’ concentration increase) of albumin bound drugs (warfarin, digoxin, phenytoin) – Lower … doses required
  • … systemic perfusion
A
  • Increased adipose tissue (more fat)
  • ↑ VD and t ½ of lipophilic drugs
  • Reduced body water (less H2O)
  • ↓ VD of water soluble drugs
  • Decreased albumin (↓ muscle mass)
  • ↑ concentration (‘free’ concentration increase) of albumin bound drugs (warfarin, digoxin, phenytoin) – Lower maintenance doses required
  • Reduced systemic perfusion
26
Q

Metabolism - Older patient

  • ↓ first pass metabolism → ↑…
  • … in hepatic blood flow
    • … delivery of drug to liver
    • ↓ … → ↑ t ½ and peak concentration
  • Metabolic capacity
    • Reduced by up to 60%
    • ↑ blood levels and t ½
A
  • ↓ first pass metabolism → ↑bioavailability
  • Reduction in hepatic blood flow
  • Reduced delivery of drug to liver
  • ↓ metabolism → ↑ t ½ and peak concentration
  • Metabolic capacity
  • Reduced by up to 60%
  • ↑ blood levels and t ½
27
Q

Metabolism - Older patient

  • ↓ … pass metabolism → ↑bioavailability
  • Reduction in … blood flow
    • Reduced delivery of drug to …
    • ↓ metabolism → ↑ t ½ and peak concentration
  • Metabolic capacity
    • Reduced by up to …%
    • ↑ … levels and t ½
A
  • ↓ first pass metabolism → ↑bioavailability
  • Reduction in hepatic blood flow
  • Reduced delivery of drug to liver
  • ↓ metabolism → ↑ t ½ and peak concentration
  • Metabolic capacity
  • Reduced by up to 60%
  • ↑ blood levels and t ½
28
Q

Elimination: - Older patient

  • … renal function
  • Reduction in size by ….%
  • Loss of ~ 30% of functioning g…
  • Reduced clearance leads to extended … … and increased serum levels - accumulation and toxicity
  • Can also be affected by … illness
A
  • Decreased renal function
  • Reduction in size by ~20%
  • Loss of ~ 30% of functioning glomeruli
  • Reduced clearance leads to extended half life and increased serum levels - accumulation and toxicity
  • Can also be affected by acute illness
29
Q

Pharmacodynamics is..

A
  • What the drug does to the body.
    • Changes in sensitivity to particular agents
    • Change in receptor binding
    • Change in receptor number
30
Q

Examples of Pharmacodynamic Changes:

  • … response
    • Warfarin
    • Benzodiazepines
    • Diltiazem
  • … response
    • Beta-Blockers
    • Beta2-Agonists
    • Furosemide
A
  • Increased response
    • Warfarin
    • Benzodiazepines
    • Diltiazem
  • Decreased response
    • Beta-Blockers
    • Beta2-Agonists
    • Furosemide
31
Q

Fall: why did Mrs Anderson fall?

  • … Status:
    • Uses walker at baseline
    • Dependent in other ADLs
  • … Impairment:
    • Peripheral neuropathy
  • … Diseases:
    • Dementia
    • Parkinson’s disease
  • …-… Diseases
    • Cardiovascular (syncope)
    • Diabetes (hypoglycaemia)
    • Anaemia (hypotension)
A
  • Functional Status:
    • Uses walker at baseline
    • Dependent in other ADLs
  • Sensory Impairment:
    • Peripheral neuropathy
  • CNS Diseases:
    • Dementia
    • Parkinson’s disease
  • Co-Morbid Diseases
    • Cardiovascular (syncope)
    • Diabetes (hypoglycaemia)
    • Anaemia (hypotension)
32
Q

Why is ‘Mrs Anderson’ Confused?

A
  • Head Injury?
  • Dementia?
  • Delirium?
  • Infection?
  • Drugs?
  • Hospital environment?
33
Q

What is Delirium?

  • More than confusion!
    • … onset
    • Inattention
    • … thinking or altered level of consciousness
    • Associated with low levels of …
    • Low levels in patients with …
A
  • More than confusion!
    • Acute onset
    • Inattention
    • Disorganised thinking or altered level of consciousness
    • Associated with low levels of acetylcholine
    • Low levels in patients with dementia
34
Q

D.E.L.I.R.I.U.M.

A
35
Q

Pharmacological Tug of WAR - older patients

A
36
Q

Anticholinergic Drugs: problems?

  • Examples:
    • …
    • … antidepressants
    • Antispasmodics and muscle …
  • Side effects:
    • .. Mouth
    • … retention
    • Constipation
    • …, delirium
A
  • Examples:
    • Antihistamines
    • Tricyclic antidepressants
    • Antispasmodics and muscle relaxants
  • Side effects:
    • Dry Mouth
    • Urinary retention
    • Constipation
    • Confusion, delirium
37
Q

Anticholinergic Drugs: problems?

  • Examples:
    • Anti…
    • T… …
    • Anti…. and muscle relaxants
  • Side effects:
    • … Mouth
    • Urinary ….
    • C…
    • Confusion, delirium
A
  • Examples:
    • Antihistamines
    • Tricyclic antidepressants
    • Antispasmodics and muscle relaxants
  • Side effects:
    • Dry Mouth
    • Urinary retention
    • Constipation
    • Confusion, delirium
38
Q

Principles + goals of drug therapy in the elderly

  • Avoid … drug therapy: - Is it necessary – is there a non-drug alternative?
  • Effect of treatment on quality of life
  • Treat the … rather than the …: A patient presenting with ‘indigestion’ won’t benefit from a PPI if the cause is angina.
  • … History: - Crucial – establishes allergies, previously ineffective treatments, helps avoid potentially serious interactions
  • Concomitant medical illness: as discussed; e.g. cardiac failure, renal impairment, hepatic dysfunction – all can and do impact on drug handling.
  • Choosing the drug: Remember the ‘circles’ – efficacy + tolerability + lifestyle
  • Dose …: Most ADRs are type A – i.e. dose-related, pharmacologically predictable with attenuation likely – therefore start low + go slow.
  • the most appropriate … form: Is there a syrup a suspension or effervescent tablet (possibly a trans-dermal form) rather than large tablets or capsules?
  • … and …: Can your arthritic patient mange with blister-packs, Child-resistant containers? Also, would large–print labels help?
  • Regular … and … of treatment.
A
  • Avoid unnecessary drug therapy: - Is it necessary – is there a non-drug alternative?
  • Effect of treatment on quality of life:
  • Treat the cause rather than the symptom: A patient presenting with ‘indigestion’ won’t benefit from a PPI if the cause is angina.
  • Drug History: - Crucial – establishes allergies, previously ineffective treatments, helps avoid potentially serious interactions
  • Concomitant medical illness: as discussed; e.g. cardiac failure, renal impairment, hepatic dysfunction – all can and do impact on drug handling.
  • Choosing the drug: Remember the ‘circles’ – efficacy + tolerability + lifestyle
  • Dose titration: Most ADRs are type A – i.e. dose-related, pharmacologically predictable with attenuation likely – therefore start low + go slow.
  • the most appropriate dosage form: Is there a syrup a suspension or effervescent tablet (possibly a trans-dermal form) rather than large tablets or capsules?
  • Packaging and labelling: Can your arthritic patient mange with blister-packs, Child-resistant containers? Also, would large–print labels help?
  • Regular supervision and review of treatment.
39
Q

Principles + goals of drug therapy in the elderly

  • Avoid unnecessary drug therapy: - Is it necessary – is there a non-drug alternative?
  • Effect of treatment on … of …
  • Treat the cause rather than the symptom: A patient presenting with ‘indigestion’ won’t benefit from a PPI if the cause is angina.
  • Drug History: - Crucial – establishes allergies, previously ineffective treatments, helps avoid potentially serious …
  • Concomitant medical illness: as discussed; e.g. cardiac failure, renal impairment, hepatic dysfunction – all can and do impact on drug handling.
  • … the drug: Remember the ‘circles’ – efficacy + tolerability + lifestyle
  • … titration: Most ADRs are type A – i.e. dose-related, pharmacologically predictable with attenuation likely – therefore start low + go slow.
  • the most appropriate … …: Is there a syrup a suspension or effervescent tablet (possibly a trans-dermal form) rather than large tablets or capsules?
  • Packaging and …: Can your arthritic patient mange with blister-packs, Child-resistant containers? Also, would large–print labels help?
  • Regular … and … of treatment.
A
  • Avoid unnecessary drug therapy: - Is it necessary – is there a non-drug alternative?
  • Effect of treatment on quality of life:
  • Treat the cause rather than the symptom: A patient presenting with ‘indigestion’ won’t benefit from a PPI if the cause is angina.
  • Drug History: - Crucial – establishes allergies, previously ineffective treatments, helps avoid potentially serious interactions
  • Concomitant medical illness: as discussed; e.g. cardiac failure, renal impairment, hepatic dysfunction – all can and do impact on drug handling.
  • Choosing the drug: Remember the ‘circles’ – efficacy + tolerability + lifestyle
  • Dose titration: Most ADRs are type A – i.e. dose-related, pharmacologically predictable with attenuation likely – therefore start low + go slow.
  • the most appropriate dosage form: Is there a syrup a suspension or effervescent tablet (possibly a trans-dermal form) rather than large tablets or capsules?
  • Packaging and labelling: Can your arthritic patient mange with blister-packs, Child-resistant containers? Also, would large–print labels help?
  • Regular supervision and review of treatment.
40
Q

When to start, how to stop? elderly medicine

A
41
Q

Warning/recommendations in therapeutics in the elderly (1)

A
42
Q

Warning/recommendations in therapeutics in the elderly (2)

A

Psychiatry and Elderly Medicine (14 decks)

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