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121 Cards in this Set

  • Front
  • Back
  • 3rd side (hint)
who are the leading consumers of medications
65 and older
what percentage of geriatrics take > 1 med daily
80%
community or nusing home do ger take more meds
nursing home -9
community-4
4 reasons why women liver longer than men?
1) protective effect of estrogen
2) men smoke more
3) men less likely to seek med attn
4) men wrk in more hazardous jobs
what is the correlation b/t doctors, prescriptions, and med error
more doctors, more rxs, more med errors
mrp
medical related problem
mrp def
undesirable event experience by a patient
causes of mrp
1) drug therapy
2) interferes with desired patient outcome
3 categories of medication related problems
1) medical condition that requires new or additional drug therapy

2) wrong drug for patient's medication condition
a) correct drug, dose too low
b) correct drug, dose too high

3) Adverse drug rxn
a) pat not taking the med correctly
b) pat taking an unnessary medicaiton given present condition
t/f pharm help to reduce the cost of medication related problems
true, they have 3.6 billion
why are older individuals at greater risk for problems w/ medications? (7)
1) multiple chronic disease
2) multiple prescribers
3) multiple medications
4) types of medications prescribed
5) minimum in clinical trials >75 yrs
6) shortage of trained geriatrics mds
7) pharmacokinetic and pharmacodynamic changes
potential symptoms of mrp
speech (change)
confusion
insomina

falls
incontinence

delirium
appetite (loss)
depression

parkinsons
o- nothing
w weight gain
w weakness/ lethargy
sci fi dad poww (no o )
common chronic illness in the elderly
heart disease

osteoperosis
dementia
diabetes

cancer: prostate, breast, skin
arthritis
respiratory conditions (copd)
sensory deficits (hearing, vision, loss)
h odd cars
t/f elderly have inc prevalence of disease
true
anticholinergic drugs can cause 3 physio symp
-bph
- constipation
-confusion
benzodiazepines can cause 3 symp
-depression
-dementia
- gait
Functional System: Sensory Losses

Functional Changes: ?
Reduced sense of taste, smell, sight, hearing, touch
Functional System: oral health status

Functional Changes ?
Xerostomia - dry mouth caused by hyposalivation
Dentures and periodontal problems
Functional System: gi fxn

Functional Changes?
Hypochlorhydria
Constipation
Functional System: metabolism

Functional Changes?
Decreased glucose tolerance
15-20% decline in resting metabolic rate
Functional System: Cv fxn

Functional Changes?
Blood vessels become less elastic and total peripheral resistance increases
♂: cholesterol peak ~60 y.o..
♀: total cholesterol and LDL continue to rise until ~70 y.o.
aging effects on the body , what are the functional systems it affects
- sensory loss
- gi fxn
- oral health status
- metabolism
- cv fxn
cho peaks for men and women
- men: cho peak at 60
- women: total cho and ldl continue to rise untill 70
def: pharmcokinets
def: pharmacodynamics
pharmacokinetics: what the body does to the drug

dynamics: what the drug does to the body
Pharmakokinetics affects
-absorption
-distribution
-metabolism
-elimination/ excretion
Absorption

1) most drugs are absorbed via?
2) bioavail of drug use to age related physiologic changes?
3) what decreases ? consequence?
1) passive diffusion
2) no major changes
3) first pass effect, results in increased bioavail and higher plasma concentrations
Distribution
- causes physiologic changes (4)
1) ↓ in total body water: Volume of distribution of hydrophilic drugs is decreased
2) ↓ in lean body mass
3) ↑ in body fat: Volume of distribution of lipophilic drugs is increased
4) Decrease in albumin
with age is gi absorption increase or decreased?
unchanged
- no significant change in quanitity absorbed
- time to onset of peak may be delayed
4 things change with age for gi absorption
↓ gastric emptying rate

↓ intestinal motility

↓ intestinal blood flow and surface area

↓ gastric acid output - ↑ gastric pH
Im absorption changes (3) and outcome
↓ muscle mass
↓ peripheral circulation
↑connective tissue

Outcome: possible ↓ IM absorption
- im vaccines hurt them more
transdermal absorption changes (3) and outcome
↓ skin hydration
↓ surface lipids
↓ peripheral circulation
↑ keratinization

Outcome: Possible↓ absorption from a transdermal patch
volume of distribution: physiologic changes with aging?
(5)
↓ in total body water: ↓ Volume of distribution of hydrophilic drugs

↓ in lean body mass (muscle mass)

↓ cardiac output- altered regional blood flow

↑ in body fat: ↑ Volume of distribution of lipophilic drugs

Decrease in albumin
for im absorption, ct inc or dec:
inc
for transdermal absorption: keratinization inc or dec
inc
for protein binding changes, alpha 1 acid glycoprotein inc or dec
inc
what organ is responsible for drug metabolism
liver
how is the liver fxn affected by age -2
1) ↓ hepatic mass
2) ↓ hepatic blood flow
how is metabolism affected by age-3
1) decreased phase 1 metabolism (oxidation)
2) phase II metabolism (conjuative) in tact, less affected by age
3) cyp 450 activity- unchanged
age affects phase 1 metabolism how?
- phase I metabolism is dec
- ↓ clearance of drug and ↑ half life of drug
drugs affected by phase 1 metab w/ age
↓ clearance of drug and ↑ half life of drug (e.g.. Diazepam, theophylline, quinidine, alprazolam, flurazepam)
DATQF
age affects phase 2 metab how?
doesn't , less affected by age than phase 1
drugs affected by phase 2 metab w/ age
- lorazepam
-oxazepam,
- safer to give b/c doesn't stay as long as diazepam
for im absorption, ct inc or dec:
inc
for transdermal absorption: keratinization inc or dec
inc
for protein binding changes, alpha 1 acid glycoprotein inc or dec
inc
what organ is responsible for drug metabolism
liver
how is the liver fxn affected by age -2
1) ↓ hepatic mass
2) ↓ hepatic blood flow
how is metabolism affected by age-3
1) decreased phase 1 metabolism (oxidation)
2) phase II metabolism (conjuative) in tact, less affected by age
3) cyp 450 activity- unchanged
age affects phase 1 metabolism how?
- phase I metabolism is dec
- ↓ clearance of drug and ↑ half life of drug
drugs affected by phase 1 metab w/ age
↓ clearance of drug and ↑ half life of drug (e.g.. Diazepam, theophylline, quinidine, alprazolam, flurazepam)
DATQF
age affects phase 2 metab how?
doesn't , less affected by age than phase 1
drugs affected by phase 2 metab w/ age
- lorazepam
-oxazepam,
- safer to give b/c doesn't stay as long as diazepam
Renal excretion physiologic changes (4) and outcome
Physiologic Changes
↓ Renal blood flow
↓ GFR – creatinine clearance (CrCl)
↓ Tubular secretion function
Stable serum creatinine due to ↓ muscle mass

Outcome: CrCl decrease by 50% between age 25 and 85 despite maintained SCr of 1.0 mg/dL
clinical effects of renal changes with age (2) and consequences (2)
Clinical Effects:
↑ half life of renally excreted drugs
↑ concentration of renally excreted drugs

1) More significant for drugs with narrow therapeutic index
Aminoglycosides
Digoxin

2) Primary goal: prevent toxicity
narrow therapeutic index drugs that are affected by the renal
- aminoglycosides
- digoxin
changes in pharmacodynamics (3)
Changes in:
1) Number of receptors
2) Sensitivity of receptors
3) Counter-regulatory mechanisms
what are the alterations in sensitivity to drugs with age? (3)
1) ↑ Receptor sensitivity to:
benzodiazepine, warfarin, opioids

2) ↓ Receptor sensitivity to beta-blockers

3) ↓ Baroreceptor sensitivity
Orthostatic hypotension with
vasodilators, TCA, antihypertensives
Alterations in sensitivity to drugs with age, ↑ Receptor sensitivity to:? (3)
- Benzodiazepines
- Warfarin
- Opiods
Alterations in sensitivity to drugs with age,↓ Baroreceptor sensitivity (3)
-Orthostatic hypotension with
vasodilators
- TCA
-antihypertensives
Etiology for Altered Pharmacodynamics (6)
1) Receptor changes: Decrease in number of some receptors (β receptors)

2) Altered reserve capacity

3) Homeostatic changes

4)Increased sensitivity to drug therapeutic and adverse effects

5)Increased co-morbid diseases

6) Increased drug interactions from polypharmacy
se of pharmacodynamics (5)
1) ↑ risk of Tardive Dyskinesia and psuedoparkinsonism with the Antipsychotic agents ( receptor sensitivity)

2) ↑ sensitivity to anticholinergic effects

3)↑ sensitivity to warfarin (risk of bleeding)

4) ↑ sensitivity of Na+, K+, ATPase:
↑ toxicity with digoxin especially with hypokalemia

5) ↓ renin and aldosterone levels:
a) ↓ response to ACE-I and beta blockers
b) ↑ risk of hyperkalemia with NSAID, ACE-I, K+ sparing diuretics
↑ sensitivity to warfarin causes?
inc in bleeding
see inc in sensitivity to warfarin w/ age
↑ sensitivity of Na+, K+, ATPase affects what?
↑ toxicity with digoxin especially with hypokalemia
↓ renin and aldosterone levels causes ?
1) ↓ response to ACE-I and beta blockers

2) ↑ risk of hyperkalemia with NSAID, ACE-I, K+ sparing diuretics
factors that influence adherence (compliance) in the elderly- 11
1) Dementia, forgetfulness

2)Sensory impairments- Poor eye sight, can’t read the label; Poor hearing, can’t hear the instructions

3)Inability to understand English, medical terminology

4)Denial - don’t believe will work or is not necessary

5)Unable to afford their medications

6)Inadequate transportation or mobility

7)Unable to open containers

8) Unable to swallow large tablets or capsules or use inhalers, eye drops, etc.

9) Unmotivated – lack of understanding of therapy goal

10) Never properly counseled on how to take their medications

11) Polypharmacy, complicated regimens
Adverse drug reactions in the Elderly- 8
Gastrisis, anorexia
GI Bleeding
Confusion
Cognitive impairment
Syncopal attacks
Mechanical Falls
Extrapyrmadial symptoms
Digoxin- induced arrythmias
G(ood) G(od) CC SM & ED
Extrapyramidal symptoms
- involuntary movments
- tremors and rigidity
- body restlessness
- muscle contractions
Anticholinergic Effects

acronym she wants us to know
Increased sensitivity in the elderly, leading to:
Confusion/Delirium
Xerostomia
Constipation
Urinary Retention
↑Intraocular pressure

SLUD
salvation
lacrimation
urination
defecation
CXCU
7 medications categories with anticholinergic properties
1) antidepressants
2) antipsychotics
3) antihistamines
4) narcotics
5) urinary retention
6) muscle relaxants
7) others
Medications with Anticholinergic Properties Antidepressants (3)
Amitriptyline
Desipramine/Imipramine
Doxepin
Medications with Anticholinergic Properties Antipsychotics-2
Olanzapine
Clozapine
Medications with Anticholinergic Properties Antihistamines-6
Diphenhydramine
Hydroxyzine
Meclizine
OTC antihistamines
Prochlorperazine
Scopolamine
Medications with Anticholinergic Properties Urinary Retention- 2
Oxybutynin
Toleterodine
Medications with Anticholinergic Properties Muscle Relaxants-2
Cyclobenzaprine
Carisoprodol
Medications with Anticholinergic Properties others - 8
Ipatropium
Captopril
Furosemide
Nifedipine
Cimetidine/Ranitidine
Theophylline
Warfarin
Glycopyrrolate
ncr if wig
who falls more men or women
women
long acting bdz
- flurazepam
-diazepam
- chlordiazepoxide
effect of bdz and falls in elderly
- bdz inc fall risk


Among elderly Medicaid patients, those taking long-acting BDZ such as flurazepam, diazepam, and chlordiazepoxide had an 55% greater chance of having a hip fracture.



Elderly patients taking both short and long-acting BDZ had a >50% chance of falling compared to those not using BDZ.
Most falls occurred within the first 7 days of treatment.
Adverse drug reactions that may increase fall risk in older patients- 5
1) TCAs: Orthostatic hypotension, tremor, cardiac arrhythmias, sedation

2) Benzodiazepines /sedative hypnotics: Sedation, weakness, confusion

3) Narcotic analgesics: sedation, confusion, ↓ coordination

4) Antipsychotics: Orthostatic hypotension, sedation, extrapyramidal effects

5) Antihypertensives: Orthostatic hypotension
adverse drug reactions that may increase fall risk in older patients: orthostatic hypotension is seen with what drugs
- tca
-antipsychotic
- anti hypertensives
def of delirium
A clinical state characterized by an acute, fluctuating change in mental status, with inattention and altered levels of consciousness
Risk factors for delirium
Risk factors include:
-advanced old age
- underlying dementia
- functional impairment
- medical comorbidity and its treatments.

also caused by
Causes/ risk factor for delirium- 8
1)Drug use

2) Electrolyte and physiologic abnormalities

3) Lack of drugs

4) Infection

5) Reduced sensory input
I

6) intracranial problems

7) Urinary retention and fecal impaction

8) Myocardial problems
classes of drug drugs that cause drug induced delirium
- sedative hypnotics
- antidepressants
-anticholingergic
- opiods
- antipsychotics
- anticonvolsants
-antiparkinsons drugs
- h2 blockers
oh 5a's
anticholingergic drugs
- diphenhydramine
- oxybutynin
-benztropine
- atropine
- scopolamine
antiparkinsons drugs
- levodopa
- bromocriptine
- trihexyphenidyl
- amantadine
h2 blocker drugs
- famotidine
-cimetidine
- ranitidine
- nizatidine
beers list risk catagories

def: high severity
def: lower severity
High Severity
Adverse outcome both likely to occur and would be a clinically significant event.

Lower Severity
Adverse outcome may occur, but would not be as clinically significant as above.
high risk beers list drugs -11
chlorpropamide

meprobamate

digoxin

pentazocine

amitriptyline and doxepin

flurazepam, diazepam, and chlordiazepoxide (long acting bdz)

methyldopa

gi antiplasmodics (dicyclomine, hyoscyamine)

meperidine

barbiturates (secobarbital, pentobarbital)

ticlodipine
c md paf
mgm bt
Pentazocine
-High risk beer drug

-Increased CNS effects including confusion and hallucinations
Amitriptyline and Doxepin
- High Risk Beer Drug

-Highly anticholinergic and sedating
Flurazepam, Diazepam, and Chlordiazepoxide
- High Risk Beers Drug

-Extremely long t ½ in the elderly = prolonged sedation and ↑ fractures
Chlorpropamide
-High Risk Beers Drug

-Prolonged t ½ in the elderly = prolonged and serious hypoglycemia
Meprobamate
- High Risk Beers Drug

-Highly sedating and addicting anxiolytic
Digoxin
- High Risk Beers Drug

-Doses > .125mg/day accumulate due to decreased renal function
Methyldopa
- HRBD

-May cause bradycardia and exacerbate depression in the elderly
GI Antispasmodics - give eg (2)
- HRBD

-(dicyclomine, hyoscyamine)

Highly anticholinergic + substantial CNS depression effects


-
Barbiturates- eg (2)
- HRBD

-secobarbital, pentobarbital)

-Increased sedative side effects + highly addicting
Meperidine
- HRBD

Less efficacious, metabolite accumulation may lead to seizure
Ticlodipine
- HRBD

- Neutropenia-Considerably more toxic than aspirin-
Lower Risk Beers List drugs -8
1) Propoxyphene

2) Antihistamines (diphenhydramine, hydroxyzine, promethazine)

3)Indomethacin

4) Muscle Relaxants (cyclobenzaprine, carisoprodol)

5) Short Acting BDZ (alprazolam ,triazolam ,zolpidem)

6)Trimethobenzamide

7)Dipyridamole

8) Reserpine
DR SPAM IT
Propoxyphene
- LRBD

-Questionable efficacy over APAP + narcotic side effects and accumulation of metabolites
Antihistamines (3)
- LRBD

-diphenhydramine, hydroxyzine, promethazine

-Potent anticholinergic effects may cause sedation, constipation and confusion
Indomethacin
- LRBD

-Of all NSAIDS, produces most CNS effects
Muscle Relaxants - eg (2)
-LRBD

-cyclobenzaprine, carisoprodol

-Increased side effects in elderly- anticholinergic, sedation and weakness
Short Acting BDZ (3)
- LRBD

-alprazolam ,triazolam ,zolpidem)
I
- Increased sensitivity requiring smaller doses
Trimethobenzamide
- LRBD

-Least effective anti-emetic + possibility of EPS
Dipyridamole
- LRBD

-Can cause orthostatic hypotension in the elderly
Reserpine
- LRBD

-Causes depression, sedation, and orthostatic hypotension in the elderly
Beers List Disease State Interactions

Disease State: Hypertension
Medication:
Justification:
Disease State: Hypertension
Medication: Amphetamines
Justification: inc bp
Beers List Disease State Interactions

Disease State: copd
Medication:
Justification:
Disease State: copd
Medication: sedatives/ hypnotics
Justification: slow respirations
Beers List Disease State Interactions

Disease State: ulcers
Medication:
Justification:
Disease State: ulcers
Medication: nsaids,
Justification: exacerbate gi disease
Beers List Disease State Interactions

Disease State: seizures
Medication:
Justification:
Disease State: seizures
Medication: thoarazine, thioridazine, conventional antipsychotics
Justification: seizure threshold
Beers List Disease State Interactions

Disease State: bph
Medication:
Justification:
Disease State: bph
Medication: antihistamines, muscle relaxants, gi antipasmodics
Justification: anticholinergic impair, micturation
Beers List Disease State Interactions

Disease State: constipation
Medication:
Justification:
Disease State: constipation
Medication: anticholinergics, narcotics
Justification: worsen constipation
Beers List Disease State Interactions

Disease State: arrythmias
Medication:
Justification:
Disease State: arrythmias
Medication: tca
Justification: induce arrythmias
Beers List Disease State Interactions

Disease State: syncope/falls
Medication:
Justification:
Disease State: syncope/ falls
Medication: long acting bdz, beta blockers
Justification: contribute to falls
2003 additions to the beers list high risk drugs - 10
1) ketorolac
2) orphenadine
3) nitrofurantoin
4) doxazosin
5) mineral oil
6) amphetamines
7) anticholinergics
8) fluoxitine
9) amiodarone
10) traditional nsadis
2003 additions to the beers list low risk drugs- 4
-clonidine
- cimetadine
- ferrous sulfate > 325
- estrogen in women
Drug Disease interactions additions 2003 - (6)
1) Anticholinergics with stress incontinence

2)Clopidogrel with anticoagulant therapy

3)Tolterodine with bladder outflow obstruction

4)Calcium Channel Blockers with constipation

5)Bupropion with seizures

6) Metoclopramide with Parkinson's
10 common drug drug interactions in the elderly
1) Warfarin- NSAIDs

2)Warfarin - sulfa drugs, macrolides, quinolones

3)Warfarin- phenytoin

4)ACE inhibitors- potassium supplements

5) ACE inhibitors- Spironolactone

6) Digoxin- amiodarone

7) Digoxin- verapamil

8) Theophylline- Quinolone

9) Aspirin- NSAIDs

10) ASA- COX-2