Term
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Definition
• Definitions vary with no established standard
• Multiple medication regimens
• Use of high-risk or unnecessary medications
• Commonly defined as use of five or more medications |
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Term
| Influencing Factors on polypharmacy |
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Definition
Demographic
• Advancing age
• Female gender
• Low educational level
Health Status Markers
• Recent hospitalization • Multimorbidity
• Depression
Health Care Characteristics
• Multiple prescribers • High healthcare
utilization
Frailty |
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Term
| Polypharmacy Consequences |
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Definition
• Geriatric syndromes
• Increased health care costs • Adverse drug events
• Drug-drug interactions
• Medication nonadherence
• Functional status decline
• Cognitive impairment
• Hospitalization
• Mortality |
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Term
| Physiologic Changes With Aging |
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Definition
• Decreased total body water
• Decreased muscle mass • Decreased organ volume • Increased body fat |
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Term
| Aging and Drug Metabolism |
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Definition
-Liver: primary source of drug metabolism
• Secondarily: • Kidney, GI tract
- Changes with aging
• Decreased liver mass + decreased function = reduced metabolism
-Medication with high first pass metabolism:
• Higher bioavailability
- Clinical significance?
• Lower medication doses = same pharmacologic effect |
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Term
| Drugs With Increased Bioavailability in the Elderly Statins |
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Definition
Statins
Atorvastatin 14%
Lovastatin 5%
Pravastatin 17-34%
Simvastatin 5% |
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Term
| Drugs With Increased Bioavailability in the Elderly Beta blockers |
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Definition
Labetalol 30-65%
Metoprolol 50-70%
Propranolol 30-70% |
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Term
| Drugs With Increased Bioavailability in the Elderly TCAs |
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Definition
Amitriptyline 30-60%
Desipramine 33-51%
Imipramine 22-77% |
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Term
| Drugs With Increased Bioavailability in the Elderly CNS drugs |
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Definition
levodopa 30-60%
morphine 20-40% |
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Term
|
Definition
• Oxidation and reduction via cytochrome (CYP) P450 enzyme system
• Inconsistent changes in elderly • Some 2C19 reductions
• No change 2D6
• Inconsistent: 1A2, 2C9, 2E1, 3A4
• Largest change in frail elderly |
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Term
|
Definition
• Examples:
• Glucuronidation • Acetylation
• Sulfation
• No major change in activity with aging |
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Term
| Phase I cardiovascular agents |
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Definition
• Atorvastatin • Simvastatin
• Propranolol |
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Term
| Phase II cardiovascular agents |
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Definition
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Term
| Phase I hypnbotic agents, sedatives |
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Definition
• Benzodiazepines • Diphenhydramine
• “Z” drugs |
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Term
| phase II hypnotic agents, sedatives |
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Definition
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Term
|
Definition
• Ibuprofen
• Meperidine
• Tramadol |
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Term
| phase II analgesic agents |
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Definition
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Term
|
Definition
• Tricyclic antidepressants
• Selective Serotonin Receptor Inhibitors |
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Term
• Barbiturates
• Carbamazepine
• Phenytoin
• Risperidone • Theophylline
phase??? |
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Definition
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Term
|
Definition
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Term
|
Definition
- Kidney: primary source of drug excretion
- Reductions with aging
• Renal mass
• Renal blood flow
• Glomerular filtration rate
• Filtration fraction • Tubular secretion
- Serum creatinine may remain “normal”
• Actual creatinine clearance (CrCl) may be reduced
• Reduced muscle mass and creatinine production |
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Term
| Most commonly used to estimate CrCl |
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Definition
Cockcroft-Gault (CG) Equation
• CrCl = [(140 – age) * weight] Serum Creatinine * 72
• Multiply by 0.85 if female |
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Term
| Cockcroft-Gault (CG) Equation controversies |
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Definition
• Weight (actual, lean body, adjusted, ideal)
• Underpredicts:
- Patients who weigh less than their IBW
• Overpredicts:
- Patients who weigh more then their IBW (i.e. obese) |
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Term
| Drugs With Altered Renal Excretion and Dose Adjustments, Antibiotics |
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Definition
• Aminoglycosides -hearing loss, ATN
• Carbapenems- Seizures
• Penicillins-CNS stimulation, seizures
• Sulfonamides - crystalluria
• Tetracycline- azotemia, renal damage
• Vancomycin- ototoxicity, nehrotoxicity |
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Term
| Drugs With Altered Renal Excretion and Dose Adjustments, antivviral agents |
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Definition
• Acyclovir, Valacyclovir • Famciclovir
-seizures, confusion, renal failure |
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Term
| Drugs With Altered Renal Excretion and Dose Adjustments,cardiovascular agents |
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Definition
• Atenolol • Digoxin
• Telmisartan
potential toxicity: • Bradycardia, hypotension • Heart block, confusion
• Renal failure |
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Term
| Drugs With Altered Renal Excretion and Dose Adjustments,, CNS agents |
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Definition
• Gabapentin • Lithium
• Pregabalin
potential toxicity: • Somnolence, confusion
• Sedation, confusion, tremors
• Confusion, blurred vision |
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Term
| Pharmacodynamic Changes and Aging |
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Definition
| altered receptor number and affinity, signal transduction, homeostatic mechanisms -> increased drug sensitivity |
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Term
| Pharmacodynamic Changes: Cardiovascular |
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Definition
• Beta-blockers
• Increased response
• Increased risk of orthostatic hypotension • Decreased arterial compliance
• Decreased baroreceptor reflex
• Medications
• TCAs, antipsychotics, diuretics, ACEIs • Direct vasodilators, opioids |
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Term
| Pharmacodynamic Changes: Fluid and Electrolyte |
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Definition
Reductions with aging: Glomerular filtration rate
• Thirst response
• Urine concentration
• Aldosterone response to hyperkalemia
• Response to antidiuretic hormone
-------->
• Reduced coping with sudden changes in fluid status or electrolytes |
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Term
| • Increased adverse drug event risks in elderly |
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Definition
• Medications that cause electrolyte disturbances and preexisting electrolyte disorder
• Acute illness affecting fluid and electrolyte status
• Use of multiple medications that can cause electrolyte disturbances |
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Term
| Pharmacodynamic Changes: CNS |
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Definition
changes w aging: number of neurons and receptors, metabolism of neurotransmitters ---->
Decrease in reserve or compensatory ability |
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Term
| Gamma-aminobutyric acid (GABA) neurotransmitter system changes |
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Definition
• Increased sensitivity to benzodiazepines
• Toxicities • Ataxia
• Sedation
• Cognitive impairment |
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Term
| Acetylcholine neurotransmitter system changes |
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Definition
-Reduced
• Cholinergic neurons
• Choline uptake from periphery
• Choline acetyltransferase
• Nicotinic and muscarinic receptors
-Increased
• Acetylcholinesterase |
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Term
| Dopamine neurotransmitter system changes |
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Definition
| • Increased dopamine type 2 receptors • Predisposes patients to delirium |
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Term
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Definition
| • Reduction in dopamine type 2 receptors • Increased risk of extrapyramidal side effects |
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Term
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Definition
• Voluntary prescription drug insurance coverage
-All Medicare patients are eligible
• Hundreds of privately-insured subsidized plans are offered
• Late enrollment penalty
-Applied if not purchased when first eligible for Medicare |
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Term
|
Definition
1. Medicare Prescription Drug Plan (PDP)
• Drug coverage is added separately to original Medicare Part A/B
2. Medicare Advantage Plan (Part C)
• Similar to an HMO
• AKA“MA-PDs”
• Medicare Part A, B, D are bundled together |
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Term
| Costs Associated With PDPs |
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Definition
• Premium
• Monthly fee that varies by plan
• Yearly deductible
• Out-of-pocket costs before PDP begins payment of covered drugs
• Copayments, coinsurance
• Payment for medication after deductible is met
• Copayment: set amounts for specific drug tiers
• Coinsurance: pay percentage of drug cost (i.e. 25%)
• Costs in the coverage gap
• Begins when the patient and drug plan have spent a certain amount on covered drugs
• Temporary limit on drug plan coverage of medications
• Amount changes annually
• Patient responsible for higher percentage of cost on brand and generic medications |
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Term
|
Definition
• State run health insurance program for low income and disabled individuals
• Must enroll in a PDP
• PDP pays first then Medicaid covers remainder
• Participants responsible for small co-payment • Nursing home patients pay $0 |
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Term
| Managed Care Plans (Part C) |
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Definition
• Medicare Advantage Plan
• Private companies that contract with Medicare to provide Part A, B, and D coverage
• Examples include:
• Health Maintenance Organizations (HMOs) • Preferred Provider Organizations (PPOs)
• Cover all Medicare services
• Most plans offer extra coverage
• Rules
• Medicare pays insurance company fixed monthly amount
• Plans can charge different out-of-pocket costs • Set different rules on how to get services |
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Term
|
Definition
• CMS and state pay health plan a prospective capitation payment per month per patient
• Same payment regardless of services
• Goal: reduce cost and increase quality
-Reduce excess and expensive services |
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Term
|
Definition
• Voluntary prescription drug insurance coverage
-All Medicare patients are eligible
• Hundreds of privately-insured subsidized plans are offered
• Late enrollment penalty
-Applied if not purchased when first eligible for Medicare |
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Term
|
Definition
1. Medicare Prescription Drug Plan (PDP)
• Drug coverage is added separately to original Medicare Part A/B
2. Medicare Advantage Plan (Part C)
• Similar to an HMO
• AKA“MA-PDs”
• Medicare Part A, B, D are bundled together |
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Term
| Costs Associated With PDPs |
|
Definition
• Premium
• Monthly fee that varies by plan
• Yearly deductible
• Out-of-pocket costs before PDP begins payment of covered drugs
• Copayments, coinsurance
• Payment for medication after deductible is met
• Copayment: set amounts for specific drug tiers
• Coinsurance: pay percentage of drug cost (i.e. 25%)
• Costs in the coverage gap
• Begins when the patient and drug plan have spent a certain amount on covered drugs
• Temporary limit on drug plan coverage of medications
• Amount changes annually
• Patient responsible for higher percentage of cost on brand and generic medications |
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Term
|
Definition
• State run health insurance program for low income and disabled individuals
• Must enroll in a PDP
• PDP pays first then Medicaid covers remainder
• Participants responsible for small co-payment • Nursing home patients pay $0 |
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Term
| Managed Care Plans (Part C) |
|
Definition
• Medicare Advantage Plan
• Private companies that contract with Medicare to provide Part A, B, and D coverage
• Examples include:
• Health Maintenance Organizations (HMOs) • Preferred Provider Organizations (PPOs)
• Cover all Medicare services
• Most plans offer extra coverage
• Rules
• Medicare pays insurance company fixed monthly amount
• Plans can charge different out-of-pocket costs • Set different rules on how to get services |
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Term
|
Definition
• CMS and state pay health plan a prospective capitation payment per month per patient
• Same payment regardless of services
• Goal: reduce cost and increase quality
-Reduce excess and expensive services |
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