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How is Beta adrenergic function different in geriatrics?
Less functional: Less sensitive to both agonists and antagonists
Should you start with a low or high dose of Beta blockers in geriatrics?
Low, but may need to go higher eventually because of reduced beta adrenergic function
How do geriatrics respond to Calcium Channel Blockers?
Increased hypotensive and HR response to CCBs
How is the BBB effected by increased age?
How are cholinergic neurons effected by increased age?
Reduced number of cholinergic neurons
How is Ach effected by increased age?
- Increased Acetylcholinesterase = Decreased Ach
- Decline in cholinergic neurons
- Avoid meds with anticholinergic SE – increase mental confusion, memory, delirium, constipation, BPH, incontinence and glaucoma
How is DA effected with age?
- Increased # of DA T2 receptors
- Decreased DA neurons in the substania nigra
What are the total effects of CNS changes in geriatrics?
- Alcohol cause more pronounced lateral sway and drowsiness
- Increased CNS response to Benzos (avoid)
- Increased analgesic response to Opioids
- More susceptible to delirium and EPS
How are fluid and electrolytes effected in geriatrics?
- Increased risk of:
- Prerenal Azotomia (especially w/ a diuretic)
How is Glucose tolerance effected by age?
- Decreased tolerance
- Prednisone may cause very high serum glucose
How is anticoagulation effected by age?
- Greater inhibition of Vitamin K dependent clotting factors with warfarin
- Consider a very small dose, like 0.5 mg
- Start at 5 mg for most
How do Geriatrics differ in their presentation of Acute MI?
- Common: Weakness, Confusion and abdominal pain
- Same as younger patients: ECG
- Less common than younger patients: Chest Pain
How do Geriatrics differ in their presentation of CHF?
- Common: Hypoxic symptoms, lethargy, restlessness and confusion
- Less common than younger patients: Dyspnea
How do Geriatrics differ in their presentation of GI bleed?
- Common: Altered mental status, syncope and hemodynamic collapse
- Less common than younger patients: Abdominal pain
How do Geriatrics differ in their presentation of Upper Respiratory Infection?
- Common: Lethargy, Confusion, anorexia, decompensated medical conditions
- Less common than younger patients: Fever Chills and productive cough
How do Geriatrics differ in their presentation of UTI?
- Common: Incontinence, confusion, abdominal pain, N/V and azotomia
- Less common than younger patients: Dysuria and fever
Inappropriate medication problems usually occur at what stage of medication use?
Ordering and monitoring stages
What groups of drugs are “potentially inappropriate medications” for all geriatrics despite condition, as per the Beers criteria?
- 1st generation antihistamines
- Alpha1 blockers
- Central Alpha agonists
- Digoxin > 0.125 mg/day
- Spironolactone > 25 mg/day
- Tertiary TCAs
- Non-benzo Hypnotics
- Estrogens w or w/o progestins
- Sliding scale insulin
- Non-COX selective NSAIDs
- Skeletal muscle relaxants
Why should 1st generation antihistamines not be used in geriatrics?
- Highly anticholinergic
- Reduced clearance
Why should Nitrofurantoin not be used in geriatrics?
Pulmonary toxicity, especially if CrCl <60
Why should Alpha 1 blockers not be used in geriatrics?
High risk of orthostatic hypotension
Why should Central Alpha Agonists be avoided in geriatrics?
High risk of CNS effects
When and Why should Digoxin > 0.125 mg/day be avoided?
- When: HF
- Why: Higher doses provide no benefit
When and Why should Spironolactone be avoided in geriatrics?
- When: HF and CrCl < 30
- Why: Risk of Hyperkalemia
Why should tertiary TCAs be avoided in geriatrics?
- Highly anticholinergic
- Causes Orthostatic Hypotension
Why should Antipsychotics be avoided in geriatrics?
Risk of: CVA, Mortality and Dementia