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90 Cards in this Set
- Front
- Back
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What proportion of the US population is >65 years old? What proportion of the total prescription drugs are used by patients >65 years old?
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- Total population: 13%
- Prescription drugs: 33% - By 2040: 25% of population will buy 50% of prescription drugs |
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How common is iatrogenic illness in older patients?
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Nearly 1 in 3 acutely hospitalized older patients
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What is the most common iatrogenic illness? Results?
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Adverse drug reactions - leads to functional losses and increased costs
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How many OTC drugs does the average patient use?
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3.5 OTC drugs
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How many drugs is the average nursing home patient on?
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8+ drugs
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What chronic disorders do ~80% of the 70+ age group have?
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One or more of the following:
- Arthritis - Hypertension - Heart disease - Diabetes mellitus - Respiratory disease - Cancer - Stroke |
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How common are adverse drug reactions in patients >80 years old?
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24%
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How common are adverse drug reactions in patients of any age?
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14%
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How does the number of drugs used compare to the percent of people with adverse drug reactions?
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- 1-2 meds: 2% adverse reaction
- 3-5 meds: 7% - 6-10 meds: 13% - >10 meds: 17% |
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What percent of drugs are "overused" and have no indication?
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7-37% of drugs (Eg, H2 blockers)
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What drugs are "underused" and are not prescribed when indicated?
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- Pneumococcal vaccine
- Influenza vaccine |
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What is a "misused" drug?
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Drug that is indicated but prescribed in wrong dose, frequency, or duration
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How common are hospital admissions of the elderly due to inappropriate use of medications?
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10-17%
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How common are hospitalized elderly dying from a drug side effect?
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1 in 1000
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Case 1:
- Mrs. J is 89 yo woman w/ hypothyroidism (replaced with Synthroid) - Recently had hip fracture which was repaired - Weight loss, jittery feelings, and malaise What might explain her symptoms? |
* Iatrogenic Hyperthyroidism
- Caffeine (jittery), Nicotine - Withdrawal from drugs (alcohol, benzodiazepines) - Anxiety - Sympathomimetic stimulation: pheochromocytoma |
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Case 1:
- Mrs. J is 89 yo woman w/ hypothyroidism (replaced with Synthroid) - Recently had hip fracture which was repaired - Weight loss, jittery feelings, and malaise What age related physiologic change might affect the pharmacokinetics of Synthroid? |
- Changing body composition
- Reduced total body water - Decreased plasma volume - Reduced lean body mass - Increased body fat - Protein binding / reduced serum albumin |
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Which of the following pharmacokinetic changes with aging accounts for her fracture and symptoms?
a) Absorption b) Volume of distribution c) Hepatic metabolism d) Renal excretion |
Volume of distribution
- They never modified the dose, so the amount of Synthroid she was getting was too high for her decrease in volume of distribution - A chronic effect of excess thyroid hormone is OSTEOPOROSIS |
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Case 2:
- Mr. S is a 72 yo man w/ severe COPD - He is O2 dependent and takes multiple bronchodilators - Forced to use steroids to treat symptoms and cannot wean him - Use high dose Vitamin D to try to antagonize effects of steroid on bone - Wife reports he is lethargic What are some considerations for his lethargy? |
* Iatrogenesis: vitamin D → hypercalcemia
- Hypoxemia or hypercapnia - Anemia - Hypothyroidism - Pulmonary infection |
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Case 3:
- 85 yo man presents to PCP for routine exam - He is told to return in 1 year unless any problems develop - Patient mentions he had difficulty sleeping, he usually goes to bed by 9pm, takes an hour to fall asleep and wakes up at 4am; he generally takes a one hour nap each afternoon Which of the following medications should be avoided as hypnotics in older patients? a. diazepam b. flurazepam c. oxazepam d. lorazepam |
Stay away from long-acting benzos (diazepam and flurazepam) - phase 1 system (is affected by aging)
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Which drugs have no age-related decrease in hepatic clearance?
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- Ethanol
- Isoniazid - Lidocaine - Lorazepam - Nitrazepam - Oxazepam - Prazosin - Salicylate - Warfarin |
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When considering prescribing a hypnotic for this patient, which of the following medications should be avoided as a hypnotic in older patients?
a) Diazepam b) Temazepam c) Oxazepam d) Lorazepam |
Diazepam
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How is phase 2 metabolism mediated?
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Hepatic metabolism:
- Mediated by cytoplasmic enzymes - Addition of water soluble moieties to drug (eg, acetylation, glucuronidation, sulfation, glycine conjugation) - Not commonly altered with age |
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Case IV
- Mrs K is an 80 yo woman living in a nursing home with dementia - She spikes a 103 degree fever and is admitted to your service What are the considerations for Mrs K's fever? |
- UTI
- Pneumonia (lower respiratory infection) - Pressure ulcer, cellulitis - C. difficile (if on antibiotics) - B symptoms of Lymphoma - Pulmonary Embolism - Immunologic (auto-immune disease: RA, SLE) |
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What happens to creatinine clearance with age?
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- Creatinine clearance drops (which drops GFR)
- Serum creatinine is staying the same (because making less creatinine) - However some people maintain creatinine clearance (no way to know what they are) |
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How do you calculate creatinine clearance? Why calculate this?
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Cockgroft Gault Equation for Creatinine Clearance
= (140-age) * weight (kg) / (72 * Scr) For women multiply by 0.85 Important to calculate when dosing a drug! |
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What are the effects of an overdose of aminoglycosides?
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- Nephrotoxicity (you can trash her kidneys)
- Ototoxicity / vestibular toxicity (dizziness) - If you under-dose though she can die due to sepsis |
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Case IV
- Mrs K is an 80 yo woman living in a nursing home with dementia - She spikes a 103 degree fever and is admitted to your service In order to dose her, you must estimate her glomerular filtration rate (GFR). Using the Cockcroft-Gault equation, which of the following is the best estimate of her GFR (ml/min)? a) 80 cc/min b) 60 cc/min c) 50 cc/min d) 40 cc/min |
= (140-age) * weight (kg) / (72 * Scr)
For women multiply by 0.85 = (140-80) * 72 / (72 *1) = 60 * 0.85 = 51 |
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Case V:
- Mr. T is a 75 yo man w/ new onset A. Fib. - Decide to cardiovert him - You use IV valium for sedation - His plane of anesthesia is deeper than you predicted - He has respiratory failure and must be intubated and placed on a ventilator What went wrong? Does this problem have a pharmacokinetic basis? |
Pharmacodynamics:
- |
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What is pharmacokinetics?
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Process of drug absorption, distribution and elimination from body
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What is pharmacodynamics?
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Target organ sensitivity to drug
- Receptors and receptor binding - Translation of receptor initiated response into biochemical reaction - Cellular response to biochemical event |
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What drugs can have increased pharmacodynamic sensitivity?
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- Benzodiazepines
- Anesthetics - Opioids - Dihydropyridines (transient in naive patients) |
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Which of the following age-related changes best explains this adverse drug reaction?
a) Behavior and lifestyle b) Pharmacodynamics c) Pharmacogenomics d) Pharmacokinetics |
Pharmacodynamics
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Case VI
- Mr. Y is a 78 yo man w/ lung cancer that metastasized to brain - Administer dexamethasone w/ good effect and he receives radiation for palliation - 2 weeks later he becomes lethargic What pharmacodynamic effect of aging might explain his picture? |
- He became hyperglycemic and elderly patients are relatively insulin resistant, so check blood sugar
- Decreased pharmacodynamic sensitivity: β adrenergic receptor - Adrenal insufficiency |
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Case VII:
- Mrs. B is an 88 yo lady with pernicious anemia, arthritis, atherosclerotic heart disease, HTN - Taking vitamin B12, ibuprofen, aspirin, nifedipine, and thiazide diuretic - She noticed insomnia so flurazepam prescribed - Gradually becomes depressed, her appetite is poor and she is non-functional - Emergent ECT is considered What would be your approach to this patient? |
Consider if some of her drugs could be responsible before acting (in this case it was the ibuprofen)
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If a patient has arthritis, what drug might they be given? What new symptom may be caused by this? What subsequent therapy will be given?
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Arthritis → NSAID → increased BP → anti-HTN med
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If a patient has depression, what drug might they be given? What new symptom may be caused by this? What subsequent therapy will be given?
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Depression → anti-cholinergic or anti-depressant → constipation → laxative use
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If a patient has agitation, what drug might they be given? What new symptom may be caused by this? What subsequent therapy will be given?
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Agitation → anti-psychotics → stiffness → anti-Parkinson treatment
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What prescribing motto can you use to avoid adverse drug events in older patients?
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Start low, go slow
Watch for key risk factors: - ≥ 6 concurrent chronic diagnoses - ≥ 12 doses of medications per day - ≥ 9 medications - 1 prior drug reaction - Low body weight or body mass index - Age 85 or older - Estimated creatinine clearance <50 mL/minute |
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What are the medications that are high risk for elderly?
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- Benzodiazepine anxiolytics
- Anti-depressants - NSAIDs - Analgesics - Anti-histamines - Muscle relaxants - Barbiturates - Anti-emetics - GI agents - Miscellaneous |
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What are the potential adverse effects of benzodiazepines in the elderly?
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- Prolonged sedation
- Cognitive impairment - Dependence - Increased fall risk - Addiction risk |
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What are the potential adverse effects of anti-depressants in the elderly?
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- Anti-cholinergic effects
- Orthostatic hypotension - Sedation - Cardiac arrhythmias |
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What are the potential adverse effects of NSAIDs in the elderly?
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- Serious GI toxicity (titrate to lowest effective dose and monitor for GI toxicity)
- Possible renal toxicity |
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What are the potential adverse effects of analgesics in the elderly?
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- Propoxyphene: convulsions, CNS toxicity, limited efficacy
- Pentazocine: psychotropic effects, hallucinations, seizure risk - Meperidine: confusion, convulsions, tremors, myoclonus |
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What are the potential adverse effects of anti-histamines in the elderly?
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- Anti-cholinergic
- Highly sedating - Delirium - Cognitive decrease |
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What are the potential adverse effects of muscle relaxants in the elderly?
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- Anti-cholinergic symptoms
- Limited effect |
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What are the potential adverse effects of barbiturates in the elderly?
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- Sedation
- Decreased attention (risk of falls) - Respiratory depression - Addiction risk - Hallucinations |
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What are the potential adverse effects of anti-emetics in the elderly?
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- Extrapyramidal effects
- Lower potency - Sedating |
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What is "frailty"?
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"A biological syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes"
A frail person is vulnerable, but a vulnerable is not necessarily frail |
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What is "primary frailty"?
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- Intrinsic to aging process
- A physiologic process with multi-factorial contributing causes |
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What is "secondary frailty"? Examples?
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Associated with progression or end-stage of chronic progressive diseases associated with inflammation and wasting
- HIV/AIDS - COPD - CHF - Cancer - Dementia |
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What domains are affected by frailty?
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- Balance
- Motor speed and processing - Strength and endurance - Nutrition - Mobility - Physical activity - Cognition |
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What percent of the population is >65 years?
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12.4%
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What is the phenotype of frailty?
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- Shrinking:
- Weakness - Poor endurance - Low activity |
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What is the definition of shrinking as it relates to frailty?
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- Unintentional weight loss >10#/year
- Sarcopenia |
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What is sarcopenia?
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- Low muscle mass: >2 SD below mean measured in young adults aged 18-39 yo
- Low muscle function: low gait speed (<0.8m/s in 4m walk test) |
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What is the definition of weakness as it relates to frailty?
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Grip strength: lowest 20% by gender and BMI
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What is the definition of poor endurance as it relates to frailty?
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- Exhaustion by self report
- Slowness: walking time / 15 ft - slowest 20% by gender and height |
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What is the definition of low activity as it relates to frailty?
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Caloric expenditure - lowest 20%
- Males <383 kcal/wk - Females <270 kcal/wk (this is approximately half of what you should do per day and this is done over a week) |
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How do you score "frailty"?
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1. Shrinking
2. Weakness 3. Exhaustion (poor endurance) 4. Slowness (poor endurance) 5. Low activity ≥ 3 items = frail 1-2 = hypothesized "pre-frail" 0 = robust |
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What are activities required to live in the community (instrumental ADLs)?
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- Meal prep
- Ordinary housework - Managing finances - Managing meds - Phone use - Shopping - Transportation |
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What are non-instrumental activities of daily living (ADLs) related to personal care?
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- Mobility in bed
- Transfers - Locomotion inside and outside the home - Dressing upper and lower body - Eating - Toilet use - Personal hygiene - Bathing |
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How do you calculate the frailty index score by the Rockwood Frailty Index?
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Measures accumulation of co-morbidities
# of deficits individual accumulates / total # of deficits considered = frailty index score |
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In the co-morbidity accumulation which functions are weighted the highest?
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- Highest weight on sensory loss and self-perceived health
- Next highest on loss of ADL abilities ("disability") - Next is systemic dysfunction - either diagnosed co-morbidities like PD or functional complaints |
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What is the proposed pathophysiology of how frailty affects the morbidity and mortality?
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Balance between stressor reactions of senescence or apoptosis across musculoskeletal, immunologic, and neuroendocrine systems
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What are the musculoskeletal changes that lead to frailty?
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- Decreased skeletal muscle mass
- Decreased VO2 max - Decreased strength and exercise tolerance - Diminished thermoregulation - Decreased energy expenditure and resting metabolic rate - Diminished muscle innervation - Decreased glucose uptake |
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What are the immunologic changes that lead to frailty?
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- Decreased: IgG, IgA, IL-2, and mitogen response
- Increased: IL-6, IL-10, CRP |
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What are the neuroendocrine changes that lead to frailty?
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- Decreased: GH, IGF-1, Vitamin D, Estrogen / Testosterone
- Increased: insulin resistance, cholecystokinin, sympathetic tone, steroid dysregulation |
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What immunologic factors decrease, leading to frailty?
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IgG, IgA, IL-2, and mitogen response
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What immunologic factors increase, leading to frailty?
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IL-6, IL-10, CRP
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What neuroendocrine factors decrease, leading to frailty?
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GH, IGF-1, Vitamin D, Estrogen / Testosterone
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What neuroendocrine factors increase, leading to frailty?
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Insulin resistance, cholecystokinin, sympathetic tone, steroid dysregulation
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What is the reliability theory of frailty?
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- Aging is the progressive accumulation of random damage to a complex system of redundant parts
- Accumulation of damage and defects over time (aging) reduces this redundancy until the system becomes a series of elements connected in series - The system’s loss of redundancy and resilience lead to vulnerability from external or internal stressors - Loss of adaptability reduces responses to stressors to the equilibrium, eventually pushing systems (organs) to failure thresholds with an increased risk of adverse outcomes  |
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What diseases can co-occur with frailty, causing secondary frailty?
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- MI
- Angina - CHF - Claudication - Arthritis - Cancer - Diabetes - Hypertension - COPD |
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What is "Symmorphosis"?
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Multi-system interplay and "co-adjustments" of different organs and functions relative to energy available for an organism
Example: exercise increases O2 requirement above baseline, with resultant changes in cardiac output, capillary density, hematocrit, muscle mitochondrial count and capacity |
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What most influences frailty?
a) Genetics b) Disease and injury c) Lifestyle d) Aging e) All of the above |
All of the above
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What happens to elderly patients with increasing dysregulation of biologic function and homeostasis?
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↑ Physiologic vulnerability → ↑ risk factors → ↑ chronic illness, organ function decline; decreased physiologic reserve → ↑ organ and system dysregulation, co-morbidities → multi-system failure
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What happens to elderly patients with decreasing function of physical function and independence?
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Isolated functional decline → progressive functional decline → dependence in multiple ADLs → disability → incapacitation
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What patients are at risk for frailty?
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- Female
- African American - Low education - Low income - Poorer health - Increased comorbid chronic disease Increased disability - Impaired cognition - Increased depressive symptoms |
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What is the relationship between frailty and disability?
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- 72% frail reported mobility difficulties
- 60% reported instrumental ADL difficulties - 46% had comorbid disease - 27% reported ADL difficulties - 22% both comorbid disease and ADL disability (27% had neither) - 6% have ADL disability |
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What are the risks for a frail person?
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- Falls
- Hospitalization - Disability - Death |
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What medical aspects do you need to assess when evaluating frailty?
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- Chronic illnesses
- Falls - Medications |
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What cognitive / psychiatric aspects do you need to assess when evaluating frailty?
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- Cognitive impairment / dementia
- Delirium - Depression - Substance abuse |
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What functional aspects do you need to assess when evaluating frailty?
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- Sensory deficits: especially vision and hearing
- Slowed gait, weakness, and decreased physical activity - ADL and IADL function - Weight loss / malnutrition |
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What social aspects do you need to assess when evaluating frailty?
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Social history
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What physical exam aspects do you need to assess when evaluating frailty?
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General exam with additional focus on:
- Neuro-cognitive: cognitive testing, depression screens - Sensory: vision, hearing - Function: strength (especially thigh muscles and grip), range of motion (shoulders, hips, and knees), walking speed |
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What labs do you need to assess when evaluating frailty?
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- CBC
- CMP - Inflammatory markers: CRP and ESR - 25-OH D3 - B12 and folate - TSH - Any testing targeting chronic disease conditions |
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How do you manage frailty?
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- Treat modifiable risk factors
- Improve core manifestations: exercise tolerance and endurance, physical activity, nutrition - Minimize risks and stressor |
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What are the opposites of frailty?
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- Robust
- Firm - Strong - Resilient - Healthy |
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What are the types of differentials to consider for any problem?
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IPINGIPI:
- Infection - Physical / trauma - Immunologic - Neoplastic - Genetic / metabolic - Iatrogenic - Psychiatric - Idiopathic |
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What are the most common problems in the elderly?
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5 I's:
- Iatrogenic - Immobility - Incompetence - Impaired homeostasis - Incontinence |
