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Geriatric Flashcards

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1
Q

Higher incidence of chronic disease leads to

A
  • More medications
  • Altered pharmacokinetics and pharmacodynamics
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2
Q

What do older adults have a higher risk and incidence of?

A
  • Adverse drug reactions
  • Can be more severe
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3
Q

What is an adverse drug events

A

Any poor outcome while utilizing medication
treatment which may or may not be directly caused by treatment

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4
Q

ADRs are the most measurable ADE, but ADE’s can also include:

A

– inappropriate prescribing
– non-compliance
– underuse of appropriate therapies
– drug-drug and drug-disease interactions

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5
Q

What is poly pharmacy typically defines as?

A

multiple drug prescriptions, usually 4 (or 5) or more

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6
Q

Polypharmacy can include:

A

– Unnecessary/duplicate medications
– Inappropriate dosing
– Drugs with negative interactions (drug-drug or
drug-diagnosis)
– Use of new drugs to treat symptoms of ADR
– Contraindicated drug

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7
Q

Inappropriate prescribing occurs when

A

utilizing drugs with poor safety profiles (more
harm than benefit), inappropriate dosage or
duration, duplication of drugs/classes

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8
Q

Risks of Polypharmacy/Over-medication

A
  • Increased risk of falls
  • Increased risk of hospital readmissions
  • Increased risk of mortality
  • Decreased quality of life
  • Increased risk of medication non-adherence
  • Increased health care utilization
  • Increased risk of adverse drug events
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9
Q

Older adults can have reduced:

A

absorption, metabolism, elimination

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10
Q

absorption in older adults

A

efficiency of gut absorption can be
impaired, movement of gut can be slower or faster

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11
Q

Metabolism in older adults

A

Liver function declines with age even in
the absence of pathology

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12
Q

Elimination in older adults

A

Kidney function declines with age even in
the absence of pathology
* Average GFR at age 20: 116 mL/min/1.73m2
* Average GFR at age 70: 75 mL/min/1.73m

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13
Q

why do older adults have delayed clearance?

A

Clearance of drugs from the body is dependent on liver and kidney

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14
Q

Other Factors Affecting Pharmacokinetics

A
  • Liver or kidney pathology slows metabolism
    and elimination of some drugs (both more
    common in elderly)
  • Enzyme induction in liver may affect drug
    activity and bioavailability
  • Presence of certain chemicals increases or
    decreases elimination (ex: vitamin C)
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15
Q

How does body composition affect pharmacokinetics

A

–decreased lean muscle mass and body water
(common in elderly and deconditioned adults) results in relative increase in serum levels of water soluble drugs at same dosage
–increased fat mass results in accumulation of
lipid soluble agents
seealotwigas

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16
Q

What drugs are older adults more sensitive to than younger adults

A

CNS-active agents (benzos, anesthetics, opioids)

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17
Q

Older adults can show decreased responsiveness to what agents?

A

Agents affecting cardiac, vascular, and pulmonary
tissue

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18
Q

Other Factors Affecting Drug Use & Effectiveness in Older Adults

A
  • Nutrition
  • Finances
  • Compliance
  • Cognitive impairment/dementia
  • Hoarding/sharing
  • Use of OTC meds
    – Laxatives
    – Alcohol
    – Caffeine
    – Herbal supplements
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19
Q

Tools to Identify Inappropriate Prescribing and Improve Prescription

A
  • Beers Criteria
  • STOPP/START
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20
Q

Drugs of primary concern

A

Benzodiazepines, antipsychotics, barbiturates, tricyclic antidepressants, strong anticholinergics , non-benzo benzodiazepine receptor agonist hypnotics, proton pump inhibitors for long term use

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21
Q

drug combinations of concerns

A
  • concurrent use of 3 or more CNS agents due to increased fall risk
  • SNRI in patients with history of falls/fracture
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22
Q

Key points about Beers Criteria

A

– Listed medications are potentially inappropriate,
NOT definitely inappropriate. Guidance and
caveats are provided.
– Criteria are specifically not applicable to patients
in hospice/palliative care, as the risk/benefit
calculation may be very different.
– The list is published as a starting point in
identifying optimal drug usage

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23
Q

What is STOPP

A

screening tool of older people’s prescriptions:
lists PIMs (things that maybe shouldn’t be used)

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24
Q

what is START

A

screening tool to alert to right treatment: lists
PPOs (potential prescribing omissions)

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25
drugs of concern on the STOPP
– Tricyclic antidepressants, benzos, anti-psychotics – Inappropriate aspirin use – Non COX-2 specific NSAIDs – Anticholinergics
26
most commonly prescribed drug types
– Cardiovascular meds – Endocrine med
27
Most common reasons for hospitalization from adverse drug reactions
– Hypoglycemic episodes – Masked hypoglycemia – Falls – GI bleeds
28
Consequences of ADE in older adults
- decrease patient confidence and cause decreased adherence to health plan - common cause of death in elderly - Increased costs and hospitalizations associated with use of NSAIDS, proton pump inhibitors, inhaled corticosteroids, inappropriate antibiotics
29
delirium and dementia
* Importance of utilizing non-pharmacologic strategies to manage these conditions - non-drug strategies for delirium which found 11 of 14 studies demonstrated significant reductions in incidents and falls - Antipsychotics have significant dangers as a class are used too often for behavioral adults management
30
Opioid considerations
* Greatest recent increase in opioid usage occurred in adults 55 and up with overdose deaths “moderate” * In older adult patients especially, sedation can result in safety issues and increased fall risk
31
Opioid induced respiratory depression
possible serious or fatal side effect and can occur with elevated plasma levels (most commonly due to renal impairments or cytochrome P450 interference) --> This can occur AT PRESCRIBED DOSE
32
What PTs should be aware of with opioid use
should be aware of a patient’s opioid use and with the care team monitor use and side effects --> Alternative pain management strategies are crucial to minimize opioid use
33
First recommendation for chronic pain
Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain
34
Drugs that complement cryotherapy
Steroidal anti- inflammatories NSAIDS, Muscle relaxant
35
Drugs that counteract cryotherapy
- peripheral vasodilators: nitroglycerine - Cholinergic agonists: oxybutynin
36
What might cryotherapy inhibit
absorption of locally administered drug
37
drugs that complement superficial heat
NSAIDS, local anesthetics, opioids, muscle relaxers, peripheral vasodilators
38
drugs that counteract superficial heat
- cholinergic agonists: oxybutynin - Vasoconstrictors: Phenylephrine
39
What might superficial heat increase
absorption of locally administered drug
40
drugs that compliment systemic heat
Opioids, NSAIDs, muscle relaxers
41
what can systemic heat do when combined with peripheral vasodilators
can cause hypotension: clonidine, prazosin, minoxidil
42
drugs that compliment UV light therapy
Systemic and topical antibiotics, systemic and local anti-inflammatory agents
43
Drugs that counteract UV light therapy
Drugs that cause hypersensitivity to UV light (Methotrexate), drugs that cause skin rashes (Fluorouracil)
44
Other drug interactions with UV light therapy
Antibacterial drugs often increase cutaneous sensitivity to UV light: tetracycline antibiotics
45
drugs that complement TENS
opioid and non-opioid analgesics
46
drugs that counteract TENS
opioid antagonist: naloxone
47
drugs that complement functional E-stim
Skeletal muscle relaxants and anti- spasticity medications
48
drugs that counter act functional E stim
Skeletal muscle relaxants and anti- spasticity medications. Cholinergic agonists
49
Exercise can affect drugs (pharmacokinetics)
* Exercise can change physiological handling of drugs: how the body absorbs, metabolizes, and excretes * Exercise can change drug distribution within the body
50
Drugs can affect exercise (pharmacodynamics)
* The capacity to exercise may be altered * The response to exercise may be altered * Other systems may be affected when exercising with the drug
51
Several pharmacokinetic changes occur with exercise:
- redistribution of blood flow - increases in skin temperature and hydration - loss of water in plasma
52
How digoxin is altered during exercise
digoxin has been shown to bind to actively working muscles, thus decreasing serum levels
53
How warfarin level is affected by exercise
inversely related to physical activity over time with a decreased INR, possibly secondary to increased binding to serum albumin
54
how is Theophylline affected by exercise
half-life shown to increase and clearance decrease as a result of a single bout of physical activity
55
how are beta blocker affected by exercise
no “class effect,” but a single bout of increased physical activity can increase the concentration of bisoprolol, propranolol, and atenolol
56
where does most of what we know about pharmacodynamics comes from
- From clinical studies where plasma levels of drugs were not measured and dosing was not controlled – Can’t make a lot of generalizations about the effects of drugs on exercise – very specific to the action of the drug or specific to adverse effects of the drug
57
Exogenously administered hormones:
Have the greatest impact since the target may be the musculoskeletal or CV system
58
Adrenal androgens and precursor for steroids
* DHEA: Primary precursor of natural estrogens * Androstenedione (Andro): androgenic steroid produced by testes, adrenal cortex, and ovaries. * Dihydrotestosterone(DHT): a metabolite of testosterone and even more potent than testosterone ** used occasionally in "frailty" to try and build strength and revitalize deconditioned patients
59
vitamin D has been reported to...
up-regulate neuromuscular performance
60
Primary effect of beta blockers
decrease resting and exercise BP and HR, stabilize cardiac rhythms, and slow cardiac action potential and repolarization.
61
In bata-1 selective blockers this has the effect of: RPE
* Decreasing HR response and maximum exercise HR (20-30%) * Modest decrease in the maximum exercise capacity – During moderate exercise (50-60% VO2 Max), cardiac output is maintained through greater stroke volume – Slight increase in myocardial efficiency prevents dramatic drop off – VO2 Max falls off slightly in some, but not all patients – Skeletal muscle blood flow is not affected by beta1-blockers
62
non selective beta blockers cause greater...
decline in VO2 Max as skeletal muscle blood flow is reduced during exercise and there may be changes in blood glucose
63
Blood glucose lowering agents
Have the potential for hypoglycemia without exercise, but much more likely with exercise
64
Oral Hypoglycemia medications
* Metformin, sulfonylureas (such as glipizide & glyburide), thiazolidinediones (Actos, Avandia)
65
injectable blood glucose lowering medications
* Insulin: both short and long acting * GLP-1 agonists such as liraglutide(Victoza), exenatide
66
Diuretics have the potential to negatively impact exercise due to
- dehydration - this may be compounded by sweating during exercise - hydration issues more likely in older adults - Address other issues that affect hydration in your patents
67
adverse effects of diuretics
* Elevated resting and submaximal HR * Hypotension, decreased systolic and diastolic BP and decreased BP response * Dizziness, light headedness, syncope * Decreased exercise capacity and earlier fatigue
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