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Some stats on Geriatrics
- 13% of Ontario popln-> 40% of drugs
- More than 50% use OTCs
Risk of ADRs increased with >4 meds, and dramatically when >9 meds or >12 doses/day
What are the fou categories of drug utilization problems in the elderly?
- Altered physiology
- polypharmacy+ Drug interactions
- Medication adherence
How is lung function changed in the elderly?
- Stiffening of lugns: Decreased muscle strength (thus decreased endurance), increased rigidity of chest wall
- function: same lung volume, but decreased vital capacity, and increased residual volume
- decreased alveolar surface
- increased mucus production, but decreased cilia activity/number (higher rates of infection)
- decreased effeciency in monitoring/control of breathing
How is the mortality rate in elderly if they have: penumonia/sepsis, UTI, Appendicitis
- 3X mortality
- 5-10 mortality
- 15-20X mortality
due to decrease in thymus hormones, decreased antibody response and decreased antigen response.
- 1/3rd of those above 85 have cognitive impairment.
- attention to perform tasks is preserved, but semantic knowledge and word retrieval decline
- linguistic abilities are intact (can still speak many languages)
comprehension, math, and vocubulary is at the same level as an adult, but the speed of processing/rxn time are decreased
Memory of elderly patients
- decreased encoding (could be decrease in senses or short-term memory)
- storage is the same
- recognition doesn't decline, but recall does
Absorption in geriatrics
- no significant changes (unless reduced stomach acid)
- rate may be slower, but same extent.
What are the key areas that change distribution in elderly?
- Protein binding (albumin decreases or stays the same; alpha-1-acid glycoprotein increases or stays the same)
- Volume of distribution (fat increases, body water decreases)
- blood flow
What are 3 common acidic drugs; 3 common basic drugs?
warfarin, phenytoin, naproxen
lidocaine, imipramine, propranolol
What are some drugs that should not be used in hepatic compromised patients?
What happens to hepatic Blood flow?
What happens to mass of liver?
- theophylline, warfarin, diazepam, phenytoin
- Blood flow decreases by 40%
- Mass decreases by 30% (decreased capacity)
What factors are important in liver function, in order?
Genotype, lifestyle, cardiac output, hender/hormones, age
(note how age isn't that important for liver funcitoning)
What happens to renal elimination in the elderly? Which drugs is this important for specifically?
Decreased RBF, GFR, and tubular secretion; decreased in CrCl by 40% from age 40-> 80, especially in those with co-morbidities
- important for digoxin, fluoroquinolones (reduced dose)
- glyburide (causes hypoglycemia), nitrofurantoin (requires CrCl~60), metformin (causes diabetic ketoacidosis), aminoglycosides
What are some mechanisms that could explain the increased response from drugs seen in the elderly?
- Changes in receptor numbers
- changes in receptor affinity
- post-receptor alterations
- age-related impairment in homeostasis
What are some drugs that show increased sensitivity in elders?
- Diazepam (2-3X more sensitivity)
generally: Sedative hypnotics, anticholinergics, analgesic, warfarin
What is Delirium?
- Decreased attention+ disorganized thinking
- common post surgery (60% post-op)
- caused by drugs (sedatives, anticholinergics, narcotics), infection, pain, metabolic disturbance
Treatment: quiet, dim room, hydration, reorientation, d/c drugs with probable cause
Dementia (and AD)
- newly acquired cogntiive impairment, interfering with social/occupational function
- progressive and irreversible
- Treatment for AD:
- cholinesterase inhibitors (donepzil, rivastigmine, galantamine)
- NMDA (memantine)-for moderate to severe dementia
- most common psychiatric illness in elderly (especially in LTC patients)
- Geriatric depression scale-> can be used to screen, but not diagnostic.
- Treated using SSRIs (not-anti cholinergics and dont have CV effects; especially good for co-morbid dementia)
What is SIG E CAPS
- Mnemonic for depression:
- Suicide ideation
- Appetite (increased or decreased)
- Psychomotor (increased or decreased)
Stats on falls in elderly
- more than 1/3 of patients >65 fall each year (1/2 over 80; 1/2 in LTC)
- only about 5% result in fractures; about 5-10% result in other srs injuries
falls are the reason for 10% of ER visits; 40% of nursing home admissions
What is orthostatic hypotension defined as
drop in BP from sitting to standing that is more than 20/10 mmHg
What are the various types of incontinence?
- Urge: sudden urges to pee
- Stress: leakage due to cough, laugh, sneeze
- Mixed: urge+stress
- Overflow: over-extended bladder leading to leakage
- Functional: inability to toilet
What are some acute, reversible, causes of urinary incontinence? [ DRIP]
- Restricted mobility, retention
- Infection, inflammation, impaction (from constipation)
- Polyuria, pharmaceuticals
Treatment of various types of incontinence
- overflow: intermittent catheterization; alpha-blockers (in males)
- urge: regular timed toileting (q2 hours when awake), decreased oral fluids, add beside urinals, anticholinergics (oxybutynin, tolterodine)
functional: bedside urinals, frequent/regular toileting
Stress: kegel exercises, smoking cessation (eliminates cough), weight loss if obese, (pharms are: estrogen, TCA, pseudoepherine or phenylpropanolamine)
Primary and secondary causes of osteoporosis in elderly. Treatment of osteoporosis?
- primary: loss of osteoblasts (loss of estrogen in women)
- secondary: hyperthyroid, hyperparathyroid, steroid use
Treatment: bisphosphanates (not for patients with CrCl less than 30)+ Vit D+ calcium (etidronate, alendronate, risedronate, zoledronic acid)
What are the current vaccination recommendations for elderly?
- Tetanus-diphtheria (every 10 years)
- Pneumovax (all individuals over 65, every 5 years)
- Zostavax- prevents herpes zoster in those who got chicken pox (shingles)
preventable errors from overtreatment (too many of the wrong drugs)
Risk factors for ADRs in adults
- # of meds
- PK/PD changes
- multiple prescribers/pharmacies
- unreliable drug history
Drug-drug interactions increase with
age, # of drugs, # of physicians, # of comorbidities
What is a prescribing cascade?
- Adverse drug rxn misinterpreted as a new condition, leading to another drug-> another ADR
- (thus, non-specific complaints should prompt review, rather than quick prescription)
Inappropriate Drug Prescribing Measurement Methods
- explicit: START/STOPP, BEERS criteria
- implicit: medication appropriateness index
- list of drugs not recommended for use in adults over 65 in all settings
- (does not substitute for professional judgement+individualized care; also does not address needs of palliative/hospice patients)
- Screening tool of Older Persons Potentially Inappropriate Prescriptions
- Screening Tool to Alert Doctors to the Right Treatment
validity established through delphi consensus ( 18 geriatric experts from Ireland/UK)
What does START/STOPP criteria help to reduce?
- Unnecessary drugs
- drug-drug and drug-disease interaction
- incorrect dose, frequency, duration
- under-prescribing for common conditions such as CVD, diabetes, osteoporosis
What are the 3 most common drugs that cause ER visits due to ADR?
- Warfarin (17%)
- Digoxin (13%)
- Insulin (3%)
- 33 of all ER visits due to ADR
Some very common DDI
- Warfarin + (NSAID/sulfonamide/antibiotics/phenytoin)
- ACE-I+ (potassium supplements/spironolactone)
- Digoxin + (Amiodaroe/verapamil)
- Theophyllin (Quinolone antibiotics)
- PPI + (calcium B12, Fe)
- Quinolones + (Divalent cations)
- Atorvastatin + macrolides