Geriatrics - BCPS Part I
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What are 3 physiological changes in aging patients' GI system that affects absorption of some drugs?
- GI sloooooows down =
- 1. Inc'd stomach pH (slowed acidity)
- 2. Dec'd GI blood flow
- 3. Dec'd gastric emptying
What are 4 physiological changes in aging patients' body composition that affects Vd of some drugs?
- 1. Dec'd TBW
- 2. Inc'd body fat
- 3. Dec'd or unchanged serum Albumin
- 4. Inc'd alpha1-acid glycoprotein
What tends to occur to the Vd of lipid-soluble and water-soluble drugs in the aging population?
- Inc'd Vd of lipid-sol drugs
- Dec'd Vd of water-sol drugs
What are 3 physiological changes in aging patients' liver that affects metabolism of some drugs?
- 1.Dec'd liver mass
- 2. Dec'd liver blood flow
- 3. Dec'd or unchanged CYP enzymes
What occurs to Phase I, and Phase II metabolism in aging popln?
- Phase I = dec'd or unchanged metabolism
- Phase II = no change in metabolism
What are 3 physiological changes in aging patients' renal system that affects clearance of some drugs?
- 1. Dec'd GFR
- 2. Dec'd renal blood flow
- 3. Dec'd renal mass
What are 3 vitamins that have decreased absorption in aging popln d/t increase in stomach pH?
Why are aging patients more at risk for ulceration from use of ASA and NSAID's?
Slower gastric emptying
Speaking of distribution in aging population, explain what happens when patients receive the following in comparison to younger pt's:
1. Lipid-soluble drugs (BZDs)
2. Highly albumin-bound drugs (PHT)
3. P-glycoprotein transporter
1. Lipid-soluble drugs (BZDs) - inc'd t1/2 d/t inc'd Vd
2. Highly albumin-bound drugs (PHT) - inc'd amt of free drug d/t dec'd serum Albumin
3. P-glycoprotein transporter - dec'd w/aging, less efflux = higher concentration of drug in organs like the brain
Which 3 BZD's go through phase II metabolism of aging popln n therefore less affected by age-related changes?
When using Cockcroft-Gault eqn to estimate CrCL, what weight is used in geriatrics?
IBW, but use actual body weight if less than IBW
B/c of changes in receptor # and affinity explain wut happens to geriatrics' response to the following drugs/drug classes:
- 1. BZD's - Inc'd sensitivity
- 2. Opioids - Inc'd sensitivity
- 3. Warfarin - Inc'd response
- 4. BB's - DEC'd response
What are the 6 activities of daily living (ADLs)?
- 1. Feeding
- 2. Dressing
- 3. Bathing
- 4. Toileting
- 5. Ambulating
- 6. Transferring
What are the 6 instrumental activities of daily living (IADLs)?
- 1. Cleaning
- 2. Writing/Reading
- 3. Managing meds
- 4. Shopping
- 5. Cooking
- 6. Managing $$
What are 3 common drugs/drug classes that may impair bone and muscle integrity in elderly?
- Long-term use of PPI's
- PHT (osteomalacia 2/2 dec'd P and Ca)
What are 6 common drug classes that may impair function and cause balance/dizziness/falls in the elderly?
- BZDS (those w/long t1/2 and large doses)
What are 2 common drugs/drug classes in elderly that may impair f(x) and cause extrapyramidal s(x)s?
- TYPICAL AP's
Explain what these extrapyramidal s(x)s mean:
Dystonia: Spasms, muscle contractions
Akathisia: Motor restlessness
Parkinsonism: Rigidity, bradykinesia, tremor
Tardive dyskinesia: Irregular, jerky movements
What are 2 vitamins that may aid in balance for elderly? Which 1 also aids in memory? What are the normal and deficient lab values?
Vitamin D[25 (OH)Vit D]: Normal >32; Deficient <20
Vitamin B12 (also aids in memory): Normal 200-900 pg/ml; Deficient <160 pg/ml
What are 5 common DRUGS in elderly that may affect emotional state? [HINT: 2 anti-HTN, 2 anti-cancer, 1 SC drug]
- 1. Methyldopa (alpha2-agonist)
- 2. Reserpine (anti-HTN)
- 3. Anastrozole (Arimidex)
- 4. Tamoxifen (Nolvadex)
- 5. Interferon alpha-2b
What are 3 common PHARMACOLOGICAL drug classes AND 3 common drug classes that may affect geriatrics' continence (either dec'd or inc'd)?
- 1. Anticholinergics
- 2. Alpha blockers (promote contraction)
- 3. Alpha agonists (dec'd contraction)
- 4. Alcohol
- 5. Acetylcholinesterase inhibitors (diarrhea)
- 6. Diuretics
What are 4 drug classes that are included in psychoactive medications class that should be minimized or w/drawn in elderly, if possible?
- 1. Sedative-hypnotics
- 2. Anxiolytics
- 3. AP's
- 4. Antidepressants
What dose of Vitamin D is recommended in older adults w/high risk of falls?
800IU/day Vitamin D
Hyponatremia is a risk factor for ________ in the elderly. This may be worsening with use of what 3 drug classes?
Hyponatremia is a risk factor for FALLS
- 1. Diuretics
- 2. SSRI's
- 3. ACE inhibitors
Vitamin B12 absorption may be impaired in elderly by administration of what 3 drugs/drug classes?
- 1. PPI's
- 2. H2-blockers
- 3. K supplementation
According to AGS and ADA, what should geriatric patients A1C goal be? [HINT: What 3 factors should be considered?]
A1C goal should be individualized
For frail, older adult, those w/<5yrs life expectancy, others with risk outweighing benefits of intensive glycemic control - A1C<8%
According to 2013 ACC/AHA Cholesterol guidelines, what are recommendations for statins in elderly?
Age 75 and older: Mod-intensity statins
LDL>190: High-intensity statin, although benefits less clear in age>75 and mod-intensity may be considered
What are the moderate-intensity statins? What are the high-intensity statins?
- Moderate: (Florida ppl love sunshine n rain, plz)
- Fluva XL 80mg or Fluva 40mg BID
- Prava 40-80mg
- Lova 40mg
- Simva 20-40mg
- Atorva 10-20mg
- Rosuva 5-10mg
- Pita 2-4mg
- Atorva 40-80mg
- Rosuva 20-40mg
What are 6 drug-related reversible causes of mental status changes in elderly?
- 1. Anticholinergics
- 2. Opioids
- 3. Corticosteroids
- 4. BZDS
- 5. Sedative-hypnotics
- 6. Antiparkinson meds
Regarding Folstein MMSE for AD, if patient is left untreated, score can decrease by how much per year?
Dec's by 3-4 points per year
Regarding Folstein MMSE for AD, what are the scores for mild, moderate, and severe stages of AD, out of 30?
- Mild: 20-24
- Mod: 10-19
- Severe: <10
Give 2 examples each of cognitive loss AND f(x)al loss in each of the 3 stages of AD.
Mild: 20-24; Short-term memory loss, word-finding probs // Loss of IADLs like managing meds, may get lost in familiar places
Mod: 10-19; Disorientation to time and place, inability to engage in activities and convo // Needs assistance w/ ADLs like bathing and dressing
Severe: <10; Loss of speech and ambulation, incontinence of bowel and bladder // dependent on basic ADLs like feeding, req's ATC care
Name the 3 cholinesterase inhibitors (brand and generic), their available formulations, generic availability, and name which one is better tolerated than the others.
Donepezil (Aricept tabs, Aricept ODT) - both generic, better tolerated than others
Rivastigmine (Exelon caps, Exelon patch, Exelon oral solution) - caps are generic, patch and soln are brand
Galantamine (Razadyne tabs, Razadyne ER, Razadyne oral soln) - all generic
What are the available strengths of each dosage form of Aricept? What is the starting AND maintenance dose?
- 5, 10, 23mg tabs
- 5, 10 ODT
- Start: 5mg daily
- Maint: 10mg daily, may inc to 23mg daily
What are the available strengths of each dosage form of Exelon? What is the starting AND maintenance dose?
- 1.5, 3, 4.5, 6mg caps
- 2mg/ml oral soln
- 4.6mg, 9.5, 13.3mg per 24hr patch
- Start 1.5mg BID or 4.6mg/24hr patch
- Maint: 3-6mg BID or 9.5-13.3mg/24hr patch
What are the available strengths of each dosage form of Razadyne? What is the starting AND maintenance dose?
- 4, 8, 12mg tabs
- 8, 16, 24mg ER caps
- 4mg/ml oral soln
- Start: 4mg BID
- Maint: 8-12mg BID OR 8-24mg ER daily
As of August 2014, regular NAMENDA tabs were d'ced. What are the available dosage forms and strengths? What is starting and maintenance dose? What is conversion of memantine 10mg BID to?
7, 14, 21, 28mg ER tabs (Namenda XR)
10mg BID => Namenda XR 28mg daily
- Start 7mg ER daily
- Maint: 28mg ER daily
When considering d/cing a cholinesterase inhibitor, is tapering necessary? Any rebound adverse efx?
Tapering rec'd if pt is at a higer dose
1st 2 weeks, pt will have rebound agitation
In a 2014 VA cooperative trial in pts w/mild-mod AD, what was given to pts that slowed functional decline and dec'd caregiver time? (drug and dose)
Vitamin E 2000IU/day
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