Term
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Definition
| Process in which health adults become frail, with reduced physiologic reserves and increased susceptibility to disease and death |
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Term
By 2050...
Low % vs high % |
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Definition
a quarter of the US population will be over 65
Elderly people make up only 13% of the population but are 50% of med-related deaths |
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Term
Working def of polypharmacy
Avg # meds a 75 yo takes |
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Definition
Use of 6 or more meds
5 rx meds |
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Term
Define pharmacodynamics
Pharmacodynamics: what the ___ does to the ___
Two age-related pharmacodynamics changes |
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Definition
Time course and intensity of pharmacologic effect of a drug
What the drug does to the body
Change in receptor #/affinity
Change in homeostatic response |
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Term
Change in receptor number affinity in elderly:
5 med or med types that will have increased sensitivity/response
2 that have decreased response |
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Definition
Benzos
Opioids
Warfarin
Digoxin
Anticholinergic agents
Beta blockers
Beta agonists |
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Term
| 3 issues r/t change in homeostatic response in elderly |
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Definition
Decrease in baroreceptor response--can cause orthostatic hypotension
Sodium and water conservation--can cause CHF/ dehydration
Mobility and balance issues |
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Term
Describe pharmacokinetics
What the ___ does to the ___
Four pieces (acronym) |
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Definition
The action of the body on a drug over a period of time
What the body does to the drug
ADME:
Absorption, distribution, metabolism, elimination |
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Term
Describe/define absorption
Describe/define distribution |
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Definition
Bioavailability (F): fraction of a drug dose reaching systemic circulation
Volume of distribution(Vd): extent to which a drug penetrates certains portions/ tissues of the body (L/kg) |
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Term
| Define metabolism, with some examples |
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Definition
| Conversion of drug to pharmacologically active or inactive compound (cytochrome P450 enzymes in liver) |
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Term
| Define drug elimination and two related principles |
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Definition
Drug's final route of exit out of body (eg renal)
Half life (T1/2): time for half of drug amnt to be eliminated from body
Clearance (Cl): bolume of body fluid from which drug is completely removed per unit of time (eg ml/min, ml/hr) |
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Term
| 4 organ systems that are impacted by the pharmacokinetics of aging |
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Definition
GI
Body composition
Liver
Renal |
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Term
3 GI changes that occure with aging
3 resulting PK changes
1 note re: drugs impacted
2 examples |
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Definition
Increased stomach pH
Decreased GI blood flow
Slowed gastric emptying/GI transit
Decreased drug absorption
Decreased first pass metabolism
Prolonged rate of absorption
Most drug unaffected
***Decreased Fe, B12, Ca absorption with achlorhydria (low stomach acid), esp if on PPIs
***Increased risk of ulceration with ASAs, NSAIDs |
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Term
3 body composition changes that happen with aging
Two resulting PK changes, with explanation
2 examples of changes in drugs
5 examples of specific drugs for last |
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Definition
Decreased TBW, lean body mass and serum albumin
Increased body fat
Increased Vd of lipid-soluble drugs
Decreased Vd of water soluble drugs
***lipids stay in body longer, water based are excreted quicker
***Increased half life of lipid soluble benzos (eg diazepam)
***Increased free levels of albumin-bound drugs/increased free fraction
Fentanyl, rifampin, amio, theophylline, valproic acid |
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Term
Two physiologic liver changes that occur with aging
3 resulting PK changes
Example (w/ two drugs) |
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Definition
Decreased liver mass and blood flow
Decreased CYP enzymes
Decreased Phase I metabolism
? Phase II metabolism
Increased half life and decreased Cl of high first pass metablolism
Morphine and propranolol: heavy first pass elimination, so decreased clearance |
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Term
3 renal changes that happen with aging
Two resulting PK changes
General example |
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Definition
Decreased GFR, tubular secretion, renal blood flow and mass
Decreased renal elimination of meds
Increased half life of renally excreted meds
Numerous drugs; will require lower doses |
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Term
ASK ABOUT CRCL IN ELDERLY PTS?
General: what to do |
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Definition
| Round up to 1.0 to avoid overestimating CrCl |
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Term
| 3 drug-related issues in the elderly, with explanations |
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Definition
Adverse drug withdrawal events: s/s caused by removal of a drug
Therapeutic failure: inappropriate or inadequate drug therapy, or therapy unrelated to progression of a disease
Adverse drug event: rxn that is noxious and unintended at doses used for prophylaxis, dx or tx |
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Term
3 drugs that can cause adverse drug withdrawal events, and how to prevent
Note about therapeutic failure and a med class
Med type that can cause adverse drug rxns, with s/s assoc w/ it |
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Definition
Prednisone, BBs, benzos: titrate them down slowly
SSRIs: wait for 4-8 wks before determining that it doesn't work
Anticholinergics: urinary retention, confusion, dry mouth/eyes, blurry vision, falls, memory problems |
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Term
| Four risk factors for drug-related problems in elderly with explanations |
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Definition
Polypharmacy: more drugs than are clinically necessary and which increase risk of cognitive impairment, falls, decreased functional status and increased cost
Underuse: omission of drug therapy indicated for tx or preventions of disease or condition
Med nonadherence: not taking as prescribed
Inappropriate prescribing: drug that are not needed or where risks outweight benefits. Refer to Beers criterial |
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Term
| 3 stats re: scope of medication nonadherence |
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Definition
Pts with chronic disease take 50% of prescribed doses
Half of pts on statins d/c after 6 months of use
50% of pts d/c antihypertensives in first year |
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Term
3 drugs that can cause withdrawal syndromes
Danger of missed atenolol dose
3 drugs where resuming without titration can lead to d/c d/t ADR |
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Definition
Sertraline
Venlafaxine
Paroxetine
Atenolol: 1 missed dose can lead to rebound HTN
ACEIs
Alpha-blockers (eg terazosin)
Aricept |
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Term
Describe intentional nonadherence
4 common causes
Additional kind of nonadherence w/ description |
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Definition
Skipping doses or changing regimen to suit pt's needs
Beliefs about risks vs benefits (eg antidepressants)
Side effects
Inconvenience--try to switch from TID/QID to QD
Perceived like of benefit: esp if don't know what it's for (eg HTN)
Unintentional: d/t cognitive, literacy, mental illness, etc |
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Term
| 6 interventions to prevent medication nonadherence |
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Definition
Help pts remember
Address financial or physical barriers
Explain benefits and risks
Get pts involved
Help special populations
Communicate and educate |
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Term
| 5 ways to help pts remember to take their meds |
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Definition
Simplify dosing regimen: shoot for daily dosing if possible
Minimize the number of medications: try to get combo meds
Suggest pills boxes/reminders
Teach to relate pills to everyday activities
Enlist help of family, friends, community |
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Term
| How to address financial or physical barriers to correct med nonadherence |
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Definition
Help pts find devices (eg inhalers) that suit their physical limitations
Help pts to find free or low cost meds |
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Term
| 4 ways to explain risks and benefits of meds to cut down on med nonadherence |
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Definition
Explain benefits of adherence to the regimens
Discuss SEs in the context of med benefits; leaflets with list os side effects may cause anxiety
Use visual aids to communicate risks (eg 1 in 50K pedestrians will be hit)
Use "positive framing": if 1 in 100 pts experience an SE, 99 don't |
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Term
| 3 ways to get pts involved to cut med nonadherence |
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Definition
Use decision aids to help pts weigh risk/benefits
Tailor med regiments to pt's health goals and life expectancy
Use monitoring (eg blood pressure, peak flow, etc) to motivate and educate |
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Term
| 3 ways to help special populations to cut down on med nonadherence |
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Definition
For peds, give reward and ensure meds are palatable
For psych pts, provide frequent follow up; choose well tolerated meds and provide positive reinforcement
HTN is an asymptomatic disease, so choose well tolerated meds |
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Term
3 top ways to communicate and educate pts to cut down on nonadherence
Some other ones (to read) |
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Definition
***Provide clear, written instructions
***Have pts carry a list of current meds and bring it each time
***Put the indication on the med labels
Assess understanding of instructions
Have pts demonstrate techniques
Use visual aids to show med regimen
Provide correct amnt of info--don't overload
Provide ed materials in a variety of formats |
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Term
What is Beers criteria?
How it is used |
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Definition
A list of meds that may be inappropriate for use in older adults
High risk meds may not be reimbursed as well |
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Term
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Definition
| Potentially inappropriate medication: incorporated into healthcare policy and standards |
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Term
3 problems with PIMs
Why PIMs are often still used |
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Definition
Assoc w/ adverse drug events, hospitalization and mortality
May cause GI bleeding, falls and fracture
Limited effectiveness
Still prescribed, often as first line therapy because practitioners get used to prescribing them |
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Term
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Definition
PIMs in all older adults
PIMs in certain diseases and conditions
PIMs to use with caution |
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Term
1st anticholinergic med class to AVOID completely, w/ 3 drug examples
Rationale
2nd class of meds, w/ 3 examples, rational, and exception to avoiding |
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Definition
First generation antihistamines
Diphenhydramine, promethazine, hydroxyzine
Anticholindergic SEs: confusion, constipation, falls
GI antispasmodics
Belladonna alkaloids, dicyclomine, scopolamine
Anticholinergic SEs and uncertain efficacy
Exception: palliative care to decrease secretions |
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Term
Anti-infective to avoid
Circumstances in which to avoid |
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Definition
Nitrofurantoin (Macrobid)
Avoid for long-term UTI prophylaxis or if CrCl <60 |
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Term
Cardiovascular drug class to AVOID
3 examples
Rationale
When to avoid
Alternative to Hytrin for BPH |
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Definition
Alpha 1 blockers
Doxazosin
Terazosin
Prazosin
High risk for orthostatic HTN
Avoid as first-line antihypertensive
Flomax |
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Term
CNS med class to absolutely avoid in all circumstances
2 examples
Rationales |
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Definition
Tertiary TCAs
Amitriptyline
Imipramine
Highly antichoinergic; sedation, orthostatic hypotension, prolonged QT |
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Term
Class of CNS drugs to avoid for prolonged use (>90 days)
3 examples
Rationale
Alternatives to use |
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Definition
Nonbenzodiazepine hypnotics
Zolpidem (Ambien)
Eszopiclone (Lunesta)
Zaleplon (Sonata)
Very hard to get off of; causes delirium, falls; minimal improvement in sleep latency and duration
Slee hygiene, melatonin |
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Term
CNS med class to avoid in elderly for tx of insomnia, agitation and delirium
4 first kind
3 second kind
3 rationale |
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Definition
Long and short acting benzos
Short: Xanax, Ativan, Serax, Restoril
Long: Librium, Klonopin, Valium
1) Increased sensitivity to benzos
2) Slow metabolism of long acting agents
3) Increased risk of cognitive impairment, delirium, falls and fractures |
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Term
Major pain med type to avoid in elderly
3 examples
Rationale |
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Definition
Skeletal muscle relaxants
Robaxin, Soma, flexeril
Anticholinergic side effects, sedation, risk of fracture |
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Term
Second kind of pain med not to use in elderly, with exception
3 examples
Rationale
Two examples |
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Definition
Non COX-2 selective NSAIDs
ASA >325 mg/day
Ibuprofen
Naproxen
Increased risk of GI bleeds
Avoid unless no alternatives available
If must take, take with GI protective agent like PPI |
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Term
4 meds or med types that elderly should avoid taking for heart failure
Rationale |
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Definition
NSAIDs/COX-2 inhibitors
Non-DHP CCB (verapamil, diltiazem)
Pioglitazone
Rosiglitazone
Cause fluid retention that exacerbates heart failure |
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Term
4 meds or med types to avoid taking for syncope in elderly
Rationale |
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Definition
AChE-I: donepazil, galantamine, rivastigmine
Tertiary TCA
Olanzapine
Peripheral alpha blockers (doxazosin, terazosin, prazosin)
Orthostatic hypotension, bradycardia |
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Term
4 meds or med blockers to avoid for dementia and cognitive impairment in elderly
Alternative for one
Rationale |
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Definition
Anticholinergic agents
H2 blockers
Benzos
Zolpidem
Use PPI instead of H2 blockers
CNS adverse effects |
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Term
5 meds or med classes to avoid for using in elderly with hx of falls or fractures
Rationale |
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Definition
Antipsychotics
Benzos
Non-benzo hyponotics (Ambien, eszopiclone, zalepion)
TCA
SSRI
Ataxia, impaired psychomotor fx, syncope and additional falls |
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Term
4 med or med types to avoid in pts w/ chronic constipation
Rationale |
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Definition
Antimuscarinics (PO) for urinary incontinence: oxybutinin, tolterodine)
Non-DHP CCB (verapamil, diltiazem)
Anticholinergics and antispasmodics
1st generation antihistamines
May worsen constipation |
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Term
2 med or med types to avoid in elderly pts w/ CKD 4 or 5
Rationale |
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Definition
NSAIDs
Triamterene alone or in combo
May increase risk of kidney disease |
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Term
Drug-drug combo risks:
ACEI+K
BB+AChE-I
Diurectic+diuretic
Benzos, sedatives, hypnotics, GI antispasmodics, skeletal muscle relaxants and 1st gen histamines |
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Definition
Hyperkalemia
Bradycardia
Lytes disturbance, dehydration, hypotension
Sedation, confusion, falls, cognitive impairment |
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Term
| 4 principles of optimal pharmacotherapy in geriatrics |
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Definition
Correct drug
Correct dose
Txs appropriate condition
Appropriate for pt |
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Term
Way to start a med for an elderly pt
3 principles behind it |
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Definition
Start low, go slow
Initiate meds at lower doses
Titrate up slower than younger pts
Smaller max doses |
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Term
Prescribing tips for geri pts:
First thing to avoid
Something to consider
Second thing to avoid, with three specifics |
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Definition
Avoid a pill for every ill--ensure dx prior to prescribing
Consider non-pharm therapy first
Avoid changing multiple meds at the same time:
***Starting two agents at the same time
***Changing doses for multiple meds simultaneously
***Reach therapeutic doses before switching agents |
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Term
6 principles of elderly prescribing
Determine
Consider
Avoid
Use
Use
Adjust |
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Definition
Determine therapeutic endpoints and plan for assessment
Consider risk vs. benefit
Avoid prescribing drug to tx side effect of another
Use 1 med to tx two conditions
Use simplest dose regiment possible
Adjust doses for renal and hepatic involement |
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Term
| 3 ways to avoid polypharmacy |
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Definition
Review meds regularly, when new meds start, or doses change
Keep accurate/current med records incl OTCs, herbals, supps
Pt to bring ALL meds to appts for med review by pharmacists |
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