Geriatrics

Question 1

Geriatric Population

Answer 1

The fastest growing segment in the US population is people 65 years of age and older; population older than 85 years of age is growing even faster

• By 2030 approximately 1/5 will be older than 65 years of age
• Older adults account for 1/3 of prescription drug use, whereas it is only 13% in the general population
• Polypharmacy common in older adult population
• Emergency visits for ADRs more common in older adults than in younger adults
• Functional status changes often make medication management difficult

Question 2

Physical Changes Associated with Aging

Answer 2

Mental Changes
- Increased susceptibility to delirium and cognitive side effects of drugs
Sensory Changes
- Sight: 1/3 of older adults have visual impairment
- Hearing: 1/3 of older adults have hearing impairment
- Smell & Taste: diminished smell & taste may impair nutrition; compounded by medications
- Peripheral sensation contributes to fall risk: compounded by medication
Musculoskeletal changes

Question 3

Geriatrics: Pharmacokinetic Changes

Answer 3

Absorption: not dramatically different in older adults compared with younger adults
Distribution: increased fat stores, decreased total body water & serum albumin
Metabolism: decreased hepatic blood flow, decreased cytochrome (CYP) 450 system function
Excretion: decreased renal mass & glomerular filtration rate & tubular secretion; serum creatinine an unreliable marker of renal function

Question 4

Geriatrics: Pharmacodynamic Changes

Answer 4

• Reduced homeostatic mechanisms
• Altered receptor sensitivity
• Increased sensitivity to drugs

Question 5

Geriatrics: Pharmacotherapeutics

Answer 5

High risk for ADRs

• Nonadherence: intentional and unintentional
• Unsafe practices
• High prevalence of use of OTC and herbal therapies
• Polypharmacy
• – Risk of drug-drug interactions
• – Prevalence of comobidities
• – Using one drug to treat side effects of another

Question 6

General Principles for Prescribing for Older Adults

Answer 6

• Before prescribing, collect a “complete” drug history; revisit at least every 6 months
• Avoid a drug if benefit is only marginal
• Evaluate drug list for duplications
• Review drug list for ADRs, and query patient
• Prescribe nonpharmacological treatments, whenever possible
• Ensure patient symptom is not part of normal aging
• Make risk predictions
• Start low and go slow

Question 7

Geriatrics: Self-Management Practices

Answer 7

• Need to maintain a medication list, including allergies and ADRs
• Brown bag to each visit
• Drug information sheet
• Use of pill box
• Reconciling medications with all care transitions

Question 8

Geriatrics: Functional Assessment

Answer 8

• Ability to manage ADLs & cognitive status strong indictors of ability to manage medications
• Social support important to assess
• ADL assessment: Katz ADLs, Lawton instrumental ADL
• Assessment of vision and hearing
• Cognitive Status Assessments: Geriatric Depression Scale, Mini-Mental State Examination, or Mini-Cog
• Medication management ability assessment, medication-assisted treatment

Question 9

Geriatrics: Improving Adherence

Answer 9

• Assess potential causes of unintentional nonadherence
• Ensure functional status allows for appropriate medication use
• Perform home assessment of frail older adults
• Collaborate with pharmacist to check for drug-drug/drug-food interactions or duplications

Question 10

Geriatrics: Inappropriate Prescribing

Answer 10

Avoid drugs that:

• Have narrow therapeutic ranges
• Have slow elimination rates
• Totally depend on kidney excretion
• Have have drug-drug interactions
• Have high ADR profiles

Beer’s Criteria
Start/stop tools

Question 11

Geriatrics: Beer’s Update

Answer 11

In 2019, Beer’s list dropped some medications that increase fall risk and issues in older adults

• these medications are still of concern, however
• there medications cause issues in ALL patients
• they are not geriatric-specific alerts

Question 12

Geriatrics: Private Homes and Independent Living- Prescribing Considerations

Answer 12

Social Support 
Communication with caregiver
Caregiving limitations 
Home care for homebound patients 
- Skilled 
-  Unskilled
---Reasonable caregiver expectations

Question 13

Geriatrics: Assisted Living- Prescribing Considerations

Answer 13

• Home-like, not medical environment
• Variable regulatory standards
• Variable nursing support
• Medication administration issues
• Cognitive impairment common
• Caregiver knowledge limited
• Written medication orders for OTC, prescription, and herbal products required

Question 14

Geriatrics: SNF- Prescribing Considerations

Answer 14

Oversight by pharmacist and RN in facility

All medications must be linked with diagnosis

Queries by pharmacists common

Numerous quality improvement opportunities related to medication use