Week 1 Flashcards
ADLs
DEATH mnemonic
ADLs
Dressing Eating Ambulation Toileting Hygiene
IADLs
SHAFTT mnemonic
IALDs
Shopping Housekeeping Accounting (money) Food prep Transportation Telephone
3 common iatrogenic problems in geriatrics
- adverse drug events
- acute kidney injury
- adverse surgical outcomes
what are four components of pharmacokinetics?
which one is least impacted by age?
- absorption (least impacted by age)
- distribution
- metabolism
- elimination
older adults have (higher/lower) total body water and (higher/lower) body fat
What is the effect on lipophilic medications?
- (smaller/larger) volume of distribution?
- (shorter/longer) elimination phase?
- (shorter/prolonged) therapeutic effect?
OA have LOWER total body water and HIGHER body fat
effect on lipophilic meds:
- larger volume of distribution
- longer elimination phase
- prolonged therapeutic effect
albumin (increases/decreases) with prolonged illness
What is the effect on free fraction of highly bound acidic drugs (eg naproxen, phenytoin, warfarin)?
albumin DECREASES with prolonged illness
causes INCREASE in free fraction (unbound) medication
- more likely to experience ADE or toxic effect
- free fraction may be toxic range
Impact of aging on liver size and function:
phase I metabolism of medications is via ______
phase II metabolism is via ______
Liver: decreases in size, decreased perfusion
-quantitative changes in LFT minimal
phase I: CYP450
*high variability between patients even in young adults
phase II: glucuronidation, acetylation, sulfation (to create water soluble metabolites for elimination)
**this phase not affected by aging
Serum creatinine (increases/decreases) in older adults due to (increased/decreased) muscle mass
decreased serum Cr
decreased muscle mass
What are the 4 criteria to start/continue a medication in older adults?
Four Criteria to start/continue medication:
(1) a patient’s life expectancy
(2) the time until benefit from medication
(3) goals of care
(4) treatment targets
What should always be included in your list of differential diagnoses when an older adult presents with a new complaint (or increasing dysfunction)?
adverse drug effect think polypharmacy
BEERS criteria
what is the recommendation re: use of sliding scale insulin?
-higher risk hypoglycemia without improvement in hyperglycemia management
AVOID regimens that only have rapid/short acting insulins WITHOUT basal or long acting insulin
BEERS criteria
what is the recommendation re: use of benzos and benzo-receptor agonists (Z drugs)?
AVOID
older adults are more sensitive, decreased metabolism with long acting agents
INCREASE risk cognitive impairment, delirium, falls, fractures, MVC
NO improvement in sleep latency and duration
BEERS criteria
what is the recommendation re: antidepressants eg amitriptyline, paroxetine
AVOID
highly anticholinergic
sedating
orthostatic hypotension
BEERS criteria
what is the recommendation re: digoxin?
AVOID as first line for afib rate control or heart failure
decreased renal clearance –> high risk of toxic effects
BEERS criteria
what is the recommendation re: nitrofurantoin?
AVOID in long term use or if CrCL <30 mL/min
Risk pulmonary toxicity, hepatoxicity, peripheral neuropathy
BEERS criteria
what is the recommendation re: first generation antihistamines eg dimenhydrinate, diphehydramine, hydroxyzine
AVOID (unless acute severe allergic reaction)
highly anticholinergic
decreased clearance
tolerance when used as hypnotic
BEERS criteria
what is recommendation re: androgens eg testosterone
AVOID
CV risk
contraindicated with prostate ca
BEERS criteria
what is recommendation re: use of estrogens +/- progestins
AVOID systemic (po or topical)
vaginal estrogen safe and effective for dyspareunia, recurrent UTI, vaginitis
BEERS criteria
what is the recommendation re: sulfonylureas eg glyburide
AVOID
risk severe hypoglycemia
BEERS criteria
what is the recommendation re: metoclopramide
AVOID unless for gastroparesis (limit to <12 weeks)
risk extrapyramidal effects tardive dyskinesia
BEERS criteria
what is the recommendation re: mineral oil po
AVOID
risk of aspiration
BEERS criteria
what is the recommendation re: PPI
AVOID
Risk C diff, bone loss, fractures
avoid scheduled use > 8 weeks UNLESS high risk (eg oral corticosteroids, chronic NSAIDs, Barrett’s esophagitis etc)
BEERS criteria
what is the recommendation re: NSAIDs
GI bleed, peptic ulcer in high risk groups (age 75+, on corticosteroids, anticoagulants, antiplatelet agents).
↑ BP and induce acute kidney injury
AVOID long term use unless alternatives not effective
if long term use with PPI
BEERS criteria
which NSAIDs has the most adverse effects?
indomethacin
GI bleed, PUD, BP, AKI
BEERS criteria
what is the recommendation re: skeletal muscle relaxants eg cyclobenzaprine, methocarbamol
AVOID
most poorly tolerated
some anticholinergic
sedation, risk fracture
BEERS criteria
what is the risk of use of antipyschotics in patients who have delirium or dementia?
Antipsychotics associated with ↑ risk of CVA and mortality in patients with dementia
• AVOID use for behavioural problems unless nonpharm have failed/not possible AND older adult is threatening substantial harm to self or others
BEERS criteria
drug classes to avoid in patient with delirium?
- anticholinergics
- antipsychotics
- corticosteroids (po and systemic)
- H2-receptor antagonists eg famotidine, ranitidine
- meperidine
- BZD
- non benzo and Z-drugs
BEERS criteria
drug classes to avoid in patients with hx of falls or fractures?
associated risks?
History of falls or fractures • Antiepileptics • Antipsychotics • BZD, nonBZD, Z drugs • Antidepressants: TCAs, SSRIs, SNRIs • Opioids (to be used only in management of acute severe pain)
Risk of ataxia, impaired psychomotor function, syncope
BEERS criteria
drug classes to avoid in patients with Parkinson disease?
associated risks?
- antiemetics (metoclopramide, prochlorperazine)
- all antipsychotics EXCEPT quetiapine, clozapine
dopamine-receptor antagonists can worsen Parkinson symptoms
BEERS criteria
drug classes to avoid in patients with hx of gastric or duodenal ulcers?
associated risks?
History of gastric or duodenal ulcers
• ASA > 325 mg/day
• Non-COX-2 selective NSAIDS
risk of aggravating / inducing ulcers
BEERS criteria
drug class to avoid in patients with CKD or CrCl <30 mL/min)?
NSAIDs
-risk of acute kidney injury, worsening kidney function
BEERS criteria
what drug classes may cause or exacerbate SIADH or hyponatremia?
Antipsychotics Carbamazepine Diuretics Mirtazapine Oxcarbazepine SNRIs SSRIS TCAs Tramadol
**monitor Na closely
BEERS criteria
what medication poses risk of hyperkalemia when used concurrently with ACE-I or ARB?
trimethoprim-sulfamethoxazole
if concurrent ACE-I or ARB in presence of decreased CrCl
BEERS criteria
What common drugs may have interactions with warfarin?
Amiodarone Cipro Macrolides (except azithro) TMP-SMX NSAIDs
- increased risk of bleeding
- monitor INR and bleeding
BEERS criteria
Potential risk of interaction between corticosteroids (po or parental) and NSAIDs?
-increased risk of PUD or GIB
avoid
if not possible to avoid, offer PPI
BEERS criteria
what is the risk of using cipro in older adults with decreased renal function?
risk of CNS effects (seizures, confusion), tendon rupture
BEERS criteria
what is the risk of using Septra in older adults with decreased renal function?
risk of worsening renal function, hyperkalemia
- renal dosing
- AVOID if CrCl <15
BEERS criteria
what is the risk of using cimetidine, famotidine, ranitidine in older adults with decreased renal function?
mental status change
*reduce dose
BEERS criteria
examples of drugs from each class with strong anticholinergic properties?
- antidepressants
- antiemetics
- antihistamines
- antimuscarincs
- antiparkinsons
- antipsychotics
- skeletal muscle relaxants
- antidepressants: amitriptyline, doxepine, paroxetine
- antiemetics: prochlorperazine, promethazine
- antihistamines: first generation (gravol, benadryl, atarax)
- antimuscarics: oxybutynin, solifenacin
- antiparkinsons: benztropine
- antipsychotics: clozapine, loxapine, olanzapine, chlorpromazine
- skeletal muscle relaxants: cyclobenzaprine
What are some signs and symptoms of digoxin toxicity?
Ocular Neuropsychiatric Gastrointestinal Potassium Cardiac
Ocular – yellow or green vision, halos, photophobia
Neuropsychiatric – delirium, drowsiness, headache, hallucinations, convulsions
Gastrointestinal – nausea and/or vomiting, abdominal pain, anorexia, weight loss
Potassium levels – low OR high
Cardiac symptoms – brady dysrhythmia (acute toxicity), tachy dysrhythmia (chronic toxicity), ventricular tachycardia.
