week 4 Flashcards
(4) General physiological changes in elderly
- inc fat
- dec skeletal muscle
- dec bone; more in women
- dec intracellular water
- extracellular water stays the samw
CV changes (3), diagnosis
- dec cardiac outpt
- dec function; changes in conduction (arthymias)
- atherosclerosis
- inc HTN and TIA/CVA
CNS changes (5)
- dec rate of conduction
- dec strength of transmission
- threshold for arousal blurred
- reduced adaptation to physiologic stressors
- inc recovery time
respiratory changes (2)
- dec expiration
- dec function ( dec ventilation & PaO2)
kidney function changes and diagnosis
- nephron degeneration (starts at 35)
- dec rBF
- diseases: inadequate fluid intake, fluid loss, shock, cardiac failure, sepsis
consequence of dec kidney function
- dec clearance leads to supra therapeutic levels @ norm doses of renally eliminated drugs
gynecologic changes in older woman and diagnosis
- abrupt estrogen deprivation
- atrophy
- dec secretions
- lead to diagnosis of urinary incontinence, dyspareunia, s/s menopause
reproductive changes in older men and diagnosis
- gradual dec testosterone
- dec libido, muscle mass, body hair
- diagnosis: DM, CVD, metabolic syndrome, BPH, ED
gastrointestinal changes
- dec stomach acid
- malnutrition state
- dec liver metabolism ( dec size, BF, cyp450 enzyme)
- dec motility
skeletal changes
- atrophy, erosion, dec o2
skin and derm changes
dec elasticity
dec turgor
inc pigmentation
sensory changes
- dec vision
- dec hearing
homeostenosis
diminished homeostatic reserve capacity of all organ systems
geriatric syndrome
polypharmacy and iatrogenesis
5 indicators of frailty
weight loss
self- reported exhaustion
low energy expenditure
slow galt
weak grip strength
absorption changes in elderly
delayed stomach emptying time
dec rate of absorption
less stomach acid production
bioavailability changes in elderly and effect on prodrugs
reduced 1st pass effect = inc bioavailability for some drugs but dec bioavailability of prodrugs
no change to oral absorption or bowel metabolism. examples clopidogrel, quinapril
transdermal changes
drier and fatter= less prefusion
-less absorption of hydrophilic compounds
- dec absorption and overall drug conct of fentanyl NOT A GOOD OPTION.
Distribution changes in elderly
- dec lean mass- leads to dec vd of skeletal muscle distribution, leads to inc digoxin conct
- inc fat, leads to inc vd of lipophilic drugs, longer 1/2 life - benzos
- dec water- leads to dec vd, inc conct of hydrophilic drugs- aminoglycosides
Albumen changes
dec in older pts with underlying, sever or chronic illness
- major binding protein, a dec leads to inc of unbound fraction = inc drug effects ex. sertraline
AAG changes
elevated in acute illness, CA, infection, inflammation
- no change with age
- high affinity for basic drugs
- dec unbound concts
- TCAs, lidocaine
CYP3A4 activity
reduced
phase 1 activity in elderly
reduced hydroxylation and demethylation
phase 2 activity in elderly
glucuronidation reduced in >80 yo
high clearance and low clearance drugs
high- fentanyl, labetalol
low/mod=- NSAIDS, CCBs, Benzos
causes for dec metabolism in elderly
frailty
dec phase 1
dec cardiac output due to HF
CNS effects
pgp activity dec leads to inc CNS drug cont and inc time in CNS
anticoag changes
dec doses of warfarin needed for response due to
- dec clearance
- inc sensitivity
what is prescribing/iatrogenic cascade
using meds to treat a side effect of another med
beers table 2
Antihistamine
Anti-infective (nitrofurantoin)
CV (Aspirin, warfarin, rivaroxaban , doxazosin, clonidine, amiodarone, digoxin)
Antidepressants
Antipsychs
Benzos and z-drugs
Barbiturates
testosterone
estrogen
insulin sliding scale
Sulfonylareas
Growth hormone
PPIs
Metoclopramide
Antispasmodics (atropine)
non cox2 selective NSAIDs (diclofenac, IBU, naproxen, indomethacin)
Smooth muscle relaxants
safety issues caused by anticholinergics and drugs in this class
- significant SEs, impair ADL
- ex. Muscle relaxants (cyclobenzaprine, methocarbamol), TCAs, Antispasmodics (dicyclomine), antihistamines (diphenhydramine), Urinary incontinence ( Oxybutynin)
- Higher cumulative anticholinergic use is associated with an increased risk for dementia
Atropine good
safety issues caused by benzodiazepines
- risk of cognitive impairment, delirium, falls/fractures, motor vehicle crashes
- inc risk of falls w/in 2 weeks of initiation and more after 1 month of continuous use with doses 3mg and up
- same risk between short and long acting
safety issues caused by antidepressants
- falls and anticholinergic ADR
- inc risk of fall with inc dose - SSRI
safety issues caused by NSAIDs
- gi toxicity (ulcers and mortality due to PUD), cv risks, renal considerations
- worst: piroxicam>indomethacin> naproxen>slindac
best ibuprofen - dose dep
- cv risk highest during 1st month and with higher doses ; has FDA warning
- avoid in HF pts
- do not use w/ diuretics due to inc risk of hospitalization in CHF pts
NSAID induced injury prevention and what to do in high risk pts
- misoprostol 800 mcd/day (less effective)
- h2ra (double dose effective)
- ppi (standard dose)
- high risk = cox2 alone or Nsaid+PPI ; cox 2 + ppi
what are the steps to the process of deprescribing
- comprehensive medication hx
- identify potentially inappropriate med
- determine eligibility for deprescribing and prioritize
- plan and initiate w/drawal
- monitor, support and document
drug factors associated with potential drug induced harm
- number of meds prescribed
- use of potentially inappropriate or high risk meds
- past or current toxicity
patient factors associated with potential drug induced harm
- age >80 yo
- cognitive impairment
- multiple comorbidities
- multiple prescribers
how to prioritize deprescribing
- 1st: meds with likelihood of greatest harm and least benefit
- 2nd: easiest to discontinue (no w/drawal or rebound)
- 3rd: patient most willing to discontinue first
time to benefit vs time to harm
- benefit is reported in years, harm is reported in minutes
*consider life expectancy w/ Time to benefit
time to benefit of bisphosphonates for osteoporosis
8-19 months
time to benefit of statins for primary benefit
2-5 yrs
time to benefit for primary prevention for hypertension
1-2 years
time to benefit of aspirin for primary prevention
10 years
time to benefit of intensive glycemic control in DM
10 years
deprescibing benzos algorithm
- slow taper: 25% every 2 weeks, 12.5% reduction near the end, possible drug-free days
- monitor every 1-2 weeks for duration of tapering
- use non drug approaches to manage w/drawal insomnia symptoms
- if symptoms relapse continue dose for 1-2 weeks then continue taper at slow rate
who should you continue benzos
- sleeping disorders
- unmanaged anxiety, depression, physical or mental condition
- alcohol w/drawal
who should be deprescibed benzos
- 65 and up taking BZRA regardless of duration
- 18-64 taking benzos for over 4 weeks
marker of fall
hip fracture
intrinsic risk factors for falls
- age related: muscle weakness
- comorbidities: impaired balance/mobility, arthritis, stroke, HTN, Heart disease and dementia
extrinsic risk factors
- medication use
- poor foot care
- unsafe footwear
- impaired vision
- hearing problems
- an unsafe environment
trends in fall related mortality and fall risk increasing drugs
are directly proportional
cardio drugs that cause falls
loop diuretics
FRIDS
- any psychotropic
- antidepressants (TCA & SSRI)
- benzos
- antipsychotics
- sedative/hypnotics
- tranquilizers
- smooth muscle relaxants (carisoprodol, cyclobenzaprine, methocarbamol)
Benzos risk for falls
- doses 3 and more/ day inc risk of hip fracture by 50%
- inc risk with longer duration of time
possible/small/no frids drugs
statins, ppis, antihypertensive, diuetics, b-blockers, opioids, nsaids
best model for fall reduction
multi-factorial, then individualized interventions, then follow up in 30-90 days
STEADI and fall risk aspects
- for providers
- measure orthostatic pressure, visual activity, assess feet/footwear, assess vit d intake, comorbidies (depression, osteoporosis) , home hazards
What is considered a high risk score on AHRQ
6 or more
