Pharmtx - Final-Geriatrics

Front 1

- Adults age 65 years and older currently comprise approximately _____ % of the
US population but consume ____% of all RX drugs and ____ % of all OTC meds.
- Medication use steadily increases with age in older adults because of
______________________________________.

Back 1

- Adults age 65 years and older currently comprise approximately 13% of the
US population but consume 30% of all RX drugs and 40% of all OTC meds.
- Medication use steadily increases with age in older adults because of
INCREASING COMORBIDITY

Front 2

What is polypharmacy

Back 2

Administration of of several drugs concurrently

Front 3

What are age-related pharmacokinetic changes that may influence drug therapy?

Absorption:
Outcome?

Back 3

-Decreased gastric emptying rate.
-Decreased intestinal motility
-Decreased intestinal blood flow
-Decreased intestinal surface area
-nonsignificant decreased gastric acid output and increased gastric pH

Outcome: No significant change in quantity absorbed; time to onset or peak may be delayed.

Front 4

What are age-related pharmacokinetic changes that may influence drug therapy?

Distribution:
Outcome?

Back 4

-Increased body fat,
-Decreased muscle mass
-Decreased body water
-Decreased cardiac output
-Altered regional blood flow

Outcome: INCREASED Vd of lipid soluble meds(allow sufficient time for ss.)
DECREASED Vd of water soluble meds(LOWER doses)

Front 5

What are the pharmacokinetics of concern in older pts?

Back 5

Absorption, Distribution(protein binding), metabolism, metabolism, Clearance(Renal, hepatic, etc)

Front 6

What are age-related pharmacokinetic changes that may influence drug therapy?

Distribuiton(Protein binding):
Outcome?

Back 6

-Decreased serum albumin
-Decreased protein affinity
-almost same but Increased Alpha1-acid glycoprotein(AAG)
Increased free fraction of highly protein bound meds(phenytoin, warfarin)

Front 7

What are age-related pharmacokinetic changes that may influence drug therapy?

Metabolism:
Outcome?(PI,PII, CYP 450 activity
enzyme induction/inhibition)

Back 7

-Decreased hepatic mass
-decreased hepatic blood flow

Outcome:
Phase 1(oxidation,reduction): decreased
Phase 2(conjugation): unchanged
CYP450 activity: unchanged
enzyme induction/inhibition: controversial

Front 8

Cancer of the Bone - primary - adults

Back 8

Multiple Myeloma

Front 9

Back 9

Front 10

a. What are age-related pharmacodynamic changes that may influence drug therapy?

b. when are p-dynamic changes assumed?

Back 10

a. Homeostatic mechanisms

Receptor and postreceptor mechanisms

b. P-dynamic changes are assumed when p-kinetic changes do not explain alterations

Front 11

What are age-related pharmacodynamic changes that may influence drug therapy?

Homeostatic mechanisms:

Back 11

Homeostatic mechanisms provide the means by
which the body can adjust or counteract a particular
drug effect. For example, in a young adult taking mor-
phine, the expected depression of the respiratory center
is counteracted by reflex stimulation of the respiratory
system. In older patients taking morphine, however,
blunted homeostatic mechanisms predispose to respira-
tory depression; sedation and constipation may also result if the drug is given at doses meant for younger
patients. Less active baroreceptor reflexes may predis-
pose geriatric patients on antihypertensive drugs to pos-
tural hypotension, and an impaired thermoregulatory
response to cooling may predispose those taking barbi-
turates or phenothiazine to hypothermia.
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Front 12

Which is better understood, p-dynamics or p-kinetics? Why?

Back 12

P-kinetics are more understood. There are more variables in p-dynamics because changes are seen in: # of receptors, sensitivity of receptors, counter reulatory mechanisms

Front 13

PHARMACODYNAMICS:
Increased or decreased.

1. receptor sensitivity(benzos, CNS depressants)
2. receptor sensitivity( Beta-adrenergic receptors)
3. baroreceptor sensitivity(OH with vasodilators, TCA's antihypertensives)
4. risk of tardive dyskinesia and parkinsonism with antipsychotics
5. sensitivity to anticholinergic effects
6. sensitivity to warfarin
7. sensitivity of Na+, K+ ATPase- increased toxicity to digoxin, esp, w/ hypokalemia.
8. renin and aldosterone levels-
-response to ACE inhibitors and beta-blockers
-INCREASED risk of _?__ a with NSAIDs, ACE inhibitors and K+ sparking diuretics

Back 13

1. INCREASED receptor sensitivity(benzos, CNS depressants)
2. DECREASED receptor sensitivity( Beta-adrenergic receptors)
3. DECREASED baroreceptor sensitivity(OH with vasodilators, TCA's antihypertensives)

4. INCREASED risk of tardive dyskinesia and parkinsonism with antipsychotics
5. Increased sensitivity to anticholinergic effects
6. Increased sensitivity to warfarin
7. INCREASED sensitivity of Na+, K+ ATPase- increased toxicity to digoxin, esp, w/ hypokalemia.
8. DECREASED renin and aldosterone levels-
-DECREASED response to ACE inhibitors and beta-blockers
9. INCREASED risk of hyperkalemia with NSAIDs, ACE inhibitors and K+ sparking diuretics

Front 14

What are age-related pharmacodynamic changes that may influence drug therapy?

REceptor and postreceptor mechanisms(A-adrenergic, B-adrenergic, opiod receptors)

Back 14

It is theorized that changes in the sensitivity of recep-
tors occur with aging. Sensitivity of receptors may
decrease, increase, or remain unaltered. For example,
the activity of β- adrenergic receptors diminishes with
age; the observed diminution in activity may be from
changes in receptors or post-receptor sites.
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Therefore,
a larger dose of β- agonist or antagonist agents may be
required to produce a given response. On the other
hand, increased sensitivity of receptors is noted with
opioids and benzodiazepines, with a resultant increase
in side effects. Lastly, no change in activity is noted with
α-receptors; α-blockers and agonists are expected to
produce the usual response in geriatric patients.

Front 15

Which classes of medications should be used with caution in older adults?

Back 15

-Oral hypoglycemic agents: avoid sulfolyurea chlorpropamide, renal, hypoglycmia.
-Antidepressants(some anticholinergic and sedative). all may cause hyponatremia.
-Anxiolytics. avoid long acting, avoid falls.
-Antipsychotics-as needed only
-Antiepileptic drugs - phenytoin
-Cardiac meds - decrease digoxin.
-Anticoagulant and ANtiplatelet Meds-3x more likely to bleed from heaprin, hyperkalemia, thrombocytopenia
-Analgesia-Tylenol appears safe.
Anithistamines anticholinergic and CNS effects
-Diuretics-HCTZ is hyponatremia, hypokalemia, and delirium

Front 16

Key principles of prescribing in older adults? 8

Back 16

1. Know the diagnosis
2. Conduct med review regularly
3. Do not prescribe when in doubt
4. Empower pts and caregivers by education
5. Know well the drugs you prescribe
6. Start low, go slow
7. Be neither the firs tnor the last to use a new drug.
8. Write legibly

Front 17

In what ways can you encourage compliance among older adult pts? (6)

Back 17

1. Educate pt and/or caregiver
2. SImplify drug regimin
3. Provide clear dosing instructions
4 Encourage use of pillboxes
5. consider cost when prescribing
6. monitor for compliance

Front 18

What are some example of dosing circumstances that pose challenges in prescribing for the older adult?

Back 18

Not enough dosing options. No support RCTs for lolder adults. Start low but dont be subtherapeutic. Titrate up to reach levels

Front 19

ADEs would be ranked?

Back 19

number 5 cause of death in US

Front 20

How might the beers list be used or how has it been used

Back 20

list of medications that are generally considered inappropriate when given to elderly people. Widely used over the past 10 years for studying prescribing patterns w/in populations, educating clinicians, and evaluating healthy outcomes, cost, and utilization data.

Front 21

What are some weaknesses of the Beer's list?

Back 21

with the continuous arrival of new drugs on the market, icnreased knowledge about older drugs, and removal of older drugs, and removal of older drugs from the market, these criteria must be updated on a regular basis to remain useful. Lack of studies done on older pts.

Front 22

Elderly account for __% of total annual Rx Spending in the US

Back 22

42%. $43 billion of $102 billion.

Front 23

It is now ____ that poses a threat to our nation's health and economic well-being

Back 23

Chronic diseases

Front 24

look at High Severity in Beers list Table 1 and 2.*

Back 24

look at High Severity in Beers list Table 1 and 2.

Front 25

Order these from greatest to least prevalent:

Stroke, Cancer, OP, AD, HTN, arthritis

Back 25

HTN, Arthritis, Osteoporosis, Cancer, Stroke, AD

Front 26

___ are probably the single most important health care technology in preventing illness, disability, and death in the geriatric population.

Back 26

Medications

Front 27

An undesireable event experienced by a patient
-Involves or is suspected to involve drug therapy
-Actually or potentially interferes with a desired patient outcome

Back 27

Medication Related Problems

Front 28

What is the Highest cost of MRP?

Back 28

Ambulatory cared, followed by nursing and hospitals

Front 29

What are the 8 categories of MRPs? Which is number 1?

Back 29

1. Untreated indication(winner)
2. Drug use without indication
3. Failure to receive drugs
4. Drug interaction(potential/actual).
5. Adverse drug reaction
6. Correct drug, dose too low.
7. Correct drug, dose too high
8. Improper drug selection

Front 30

What are some risks for MRPs?

Back 30

• Multiple chronic diseases
• Multiple prescribers
• Multiple medications
• Types of medications prescribed
• Under-representation in clinical trials, particularly
those over age 75
• Shortage of trained professionals in geriatric
pharmacotherapy

Front 31

These are all examples of which MRP?

• Depression in the nursing home
Lebowitz BD. JAMA 1997.
• Osteoporosis in the nursing home
Bellantino S. JAGS 2001.
• Atrial Fibrillation/Anticoagulation
Bungard TJ. Arch Intern Med 2000.
• Hypertension
DiBari M. J HTN 1999.
• MI primary/secondary prevention
DiBari M. J HTN 1999.
• Opioids: fear of addiction
AGS Guidelines. JAGS 1998.
ective 11, 13

Back 31

Untreated indication(enough info to indicate a condition but they are not being treated)

Front 32

This MRP is really common with transitional care

Back 32

Drug Use without indication

Front 33

a. What is estimated % of noncompliacne and what is noncompliance associated with?

Back 33

26-59% assoicated with Higher socioeconomic status, Greater number of prescribed medications, higher psychological stress

Front 34

These are all reasons for what MRPs?

• Lack of understanding or misinterpretation of
directions.
• Sensory impairments
• Drug regimen interferes with daily activities.
• Drug regimen is too complex.*
• Lack of understanding why the medication is
important or the goals of therapy.
• Doesn’t believe the medication will work or is
even necessary. (or too expensive)
• Numerous providers.

Back 34

noncompliance

Front 35

Place:
Confusion, sedation, falls(2)
Hyerkalemia(2)
Hypotension
Electrolyte imbalance
Arrythmia

Back 35

Front 36

% of hospitilization of elderly due to ADR(%) and Non-compliance(%)

Back 36

28%
17%
11%

Front 37

% ADEs predictable

Back 37

95%

Front 38

% serious. life-threatening. Fatal

Back 38

ADEs

Front 39

Female gender and small body size RF for...

Back 39

ADRs

Front 40

Any symptom in an elderly pt should be considered __ until proved otherwise

Back 40

drug side effect

Front 41

Prevent ADE by ALWAYS considering this as possible consequence of current drug tx

Back 41

S/S

Front 42

Symptoms of MRP(10)

Back 42

• Confusion
•Depression
• Delirium
• Insomnia
• Parkinson’s-like
symptoms
• Incontinence
• Weakness or lethargy
• Loss of appetite
• Falls
• Changes in speech

Front 43

What drug would:
1. Start low then adjust up until ADRs, then go down?
2. Start low, get to goal
3. Start low, stay low

Back 43

1. Beta-blockers
2. Warfarin
3. THiazide

Front 44

Beers List

Back 44

 Pentazocine (Talwin)  Flurazepam
(Dalmane)
 TCAs  Long half-life
psychotropics
 Digoxin > 0.125mg QD  Methyldopa (Aldomet)
 Dicyclomine (Bentyl)  All barbiturates except
phenobarbital

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