4. adapted from quizlet ryanef123: Module 4: Pharmacological Considerations

What percent of older adults take over 1 medication?

90%

What percent of older adults take over 5 medications?

40%

What percent of older adults take over 10 medications?

12%

Polypharmacy is defined as ______ or more medications taken daily including OTC drugs, dietary supplements, and herbal remedies AND/OR:

- Prescribing more medications than necessary

- Inappropriate medications

- Inappropriate length of time

Five

What can lead to...

- Increased risk of adverse events

- Drug interactions

- Non-adherence

- Geriatric Syndrome

- Decreased quality of life

- Death

Polypharmacy

Polypharmacy leads to ______ syndrome

Geriatric syndrome

All of the following are part of what?

1. Cognitive impairment

2. Falls, hip fractures

3. Urinary incontinence

4. Disability

5. Delirium

Geriatric syndrome

T/F: The cost of medications can strongly affect an older adult's ability to take them as prescribed

True

Medication mismanagement ________ with age

Increases

Multiple providers increases the risk of _____?

polypharmacy

Medication mismanagement ________ with recent and/or multiple hospitalizations or emergency room visits

Increases

All of the following can contribute to what?

- >80

- Living alone

- Living in a nursing home

- >6 chronic disease states

- >9 medications and 12 doses per day

- Self medicating with OTC, herbs, recreational drugs

- Multiple healthcare providers

- Recent hospitalization

- Automated refills

- Psychiatric problems -depression

- Impaired memory, alertness

- Frailty

- Low body weight / BMI < 18.5

- Creatine clearance < 50mL/min

Medication mismanagment

T/F: All of the following are considered normal age-related physiologic changes:

- Decrease in lean muscle mass

- Decrease in water content

- Increase in fat

- Slower GI transit time

True

T/F: All of the following are considered normal age-related physiologic changes:

- Decrease in liver function

- Decrease in renal function

- Receptor sensitivity

True

Which pharmacokinetic has the most significant impact on aging adults?

A. Absorption (gut)

B. Distribution (body)

C. Metabolism (liver)

D. Excretion (kidney)

D. Excretion (kidney) (!!!!)

Which pharmacokinetic does not have a significant impact on aging adults?

A. Absorption (gut)

B. Distribution (body)

C. Metabolism (liver)

D. Excretion (kidney)

A. Absorption (gut)

The following physiologic changes and effects affect which pharmacokinetic function?

- Decreased pH

- Decrease in mucosal surface area

- Decreased motility and gut transit time

- Diminished blood flow

- Effects: may take longer, leading to a delayed peak effect in meds

Absorption (gut)

The following physiologic changes and effects affect which pharmacokinetic function?

- Less water

- Increased body fat

- Lower levels of serum proteins

- Effects: higher concentration of hydrophilic drugs, prolonged action of lipophilic drugs and more unbound drugs

Distribution (body)

The following physiologic changes and effects affect which pharmacokinetic function?

- Decreased size and function of this organ

- Decreased blood flow

- Effects: fewer enzymes in this organ

Metabolism (liver)

The following physiologic changes and effects affect which pharmacokinetic function?

- Decrease in size of this organ

- Decrease in the number of functioning nephrons

- Decreased renal blood flow

- Effects: 30-40% reduction in function, reduced clearance for this organ, increased accumulation of drugs

Excretion (kidney)

What is the mechanism of action and effect in pharmacodynamics and aging?

Receptor changes

(The number of receptors decrease and the affinity to receptor sites weakens, affecting the lock-and-key mechanisms)

How is the central nervous system effected in pharmacodynamics and aging?

- Exaggerated response to CNS drugs

- Increased sensitivity to benzodiazepines, general anesthesia, opioids

- Enticholinergics can increased dry mouth, affect sedation, and cause confusion or delirium

What are the most common anticholinergic drugs? (4)

1. Antihistamines

2. Tricyclic antidepressants

3. Antimuscarinics

4. Muscle relaxants

How is the cardiovascular system effected in pharmacodynamics and aging?

- Orthostatic hypotension (!!!)

- Decreased arterial compliance

- Baroreceptor function is blunted

What happens to the therapeutic window as people age?

It narrows

(The risk benefit ratio is different in older adults)

Define the following:

An unexpected medical problem that happens during treatment with a drug or other therapy

Adverse drug events

Adverse drug events are the most common form of?

Iatrogenic illness

(7x more adverse events)

___-___% of all hospitalizations are due to adverse drug events and ___-___% in the elderly

3-7%, 10-30%

What are the top 3 drugs linked to adverse events?

- Warfarin

- Insulin

- Digoxin

T/F: All of the following are drug groups associated with preventable adverse drug-related hospital admissions:

1. Anticoagulants

2. Antibiotics

3. Antidepressants

4. Antihistamines

5. Antiplatelet

6. Benzodiazepines

7. Cardiovascular medications

8. Diuretics

9. Hypoglycemics

10. Muscle relaxants

11. NSAIDS

12. Opioids

True

What are the 4 most common side effects in the elderly?

1. Falls/fractures

2. Orthostatic hypotension

3. Xerostomia

4. Abnormal bleeding

T/F: All of the following are common side effects in the elderly:

1. Insomnia

2. Sedation, drowsiness

3. Depression

4. Anxiety, restlessness

5. Headaches

6. Changes in appetite

7. Gastrointestinal problems

8. Liver and kidney failure

9. Muscle stiffness, weakness

10. Incontinence

11. Delirium

True

What are the 5 classes of drugs elevating fall risk?

1. Sleeping meds (Includes OTC meds - Tylenol PM, Benadryl, Unisom)

2. Anxiety meds (Benzodiazepines: Ativan, Xanax, Valium and Barbiturates: Phenobarbital)

3. Antidepressant meds

4. Pain meds (NSAIDs, Narcotics: Oxycodone, Percocet, Morphine and Medication for neuropathy: Gabapentin, Lyrica)

5. Muscle relaxants (Flexeril, Robaxin)

What type of factors are the following?

- Medical and neuropsychiatric conditions (eg, Parkinson disease, stroke, history of diabetes mellitus, and arthritis)

- Impaired vision and hearing

- Agerelated changes in neuromuscular function, gait, and postural reflexes

Intrinsic factors

What type of factors are the following?

- Medications (eg, sedatives and hypnotics, antihypertensives, diuretics, and hypoglycemic agents)

- Improper use of assistive devices for ambulation

- Environmental hazards leg, poor lighting, unstable furniture, and household clutter)

Extrinsic factors

What is the number one problem in treating illness today in aging adults?

Failure to take medication correctly

What type of issues are the following for challenges in medication adherence?

- COST

- Access to pharmacy (Transportation/Decreased mobility)

- Unpleasant side effects

- Lack of symptoms

- Inconsistent patient-provider relationship

Intentional Issues

What type of issues are the following for challenges in medication adherence?

- Complex medication schedule/regimen

- Lack of understanding about health condition

- Confusion - too many pills

- Forgetfulness – impaired memory

- Visual and hearing impairments

- Decreased dexterity

- Childproof bottles

Inadvertent Issues

What are the five moments for medication safety?

1. Starting a medication

2. Taking the medication

3. Adding a medication

4. Reviewing the medication

5. Stopping a medication

What is being described?

- Encourage patients to gather all their medications, including over the counter products like pills, creams, ointments, vitamins, and supplements

- Ask the patient to tell you why they are taking each medication, when it is taken, and how much is taken

- Consult the Beers criteria

- Consult PCP, pharmacist, and other healthcare providers

Brown bag review

What is being described?

- Established in 1991

- A consensus-based list of Potentially Inappropriate Medications (PIM) for older adults

Beers criteria

What are the five criteria included in the beers criteria?

1. Medications to be avoided in most older patients

2. Medications to be avoided with certain conditions

3. Medications that should be used with caution because the risks outweigh the benefits

4. Consider medication interactions

5. Change dosing based on kidney function

Drug interactions with other drugs, food, supplements, or medical conditions can cause what three possible side effects?

- Decrease action of drug(s)

- Increase action of drug(s)

- Cause adverse effects

The following is describing NSAIDs interaction with which type of medication?

- Increase blood thinning effects, posing a risk of dangerous bleeding

Anticoagulants

What anticoagulant should warfarin users avoid?

NSAIDs

The following is describing NSAIDs interaction with which type of medication?

- May reduce the effectiveness, potentially elevating blood pressure levels

Blood Pressure Medications

The following is describing NSAIDs interaction with which type of medication?

- Decreases lithium clearance, leading to heightened serum concentrations and toxicity

Lithium Clearance

NSAIDs (increase/decrease) lithium clearance

decrease, leading to a heightened serum concentration and toxicity

The following is describing NSAIDs interaction with which type of medication?

- Displacement from protein binding sites, concerning at high doses used for chemotherapy

Methotrexate Interaction

The following is describing NSAIDs interaction with which type of medication?

- Associated with an increased risk of gastrointestinal bleeding

Corticosteroids

T/F: Lipid Solubility and Protein Binding contribute to widespread distribution in the elderly. May result in excessive drug levels and potential toxicity, especially with impaired renal function.

True

Pseudoephedrine causing blood vessel _______. It is commonly found in nasal decongestants

Constriction

__________ can enhance the duration of local anesthetics. Consider adjusting local anesthetic doses when patients are using decongestants.

Vasoconstrictors

Vasoconstrictors can _______ blood pressure. Caution in patients with hypertension or cardiovascular conditions.

Elevate

__________ is a sedative antihistamine, causing drowsiness. Used in nighttime pain relief formulas, cough and cold remedies, and sleep aids.

Diphenhydramine

What has the following interaction with analgesics?

- Increases sedative effect

- Adjust pain management strategies

Diphenhydramine in Antihistamines

What has the following anticholinergic effects?

- Causes dry mouth and blurred vision.

- Consideration in patients with xerostomia or visual impairments.

Diphenhydramine in Antihistamines

T/F: Diphenhydramine in Antihistamines can cause dizziness and have a heightened risk of falls and injuries, especially in the elderly

True

What effect does grapefruit have when combined with statins (like simvastatin)?

Increased drug potency

What effect does grapefruit have when combined with calcium channel blockers (like amlodipine)?

Higher blood levels of the Ca Channel Blocker drug

Which drugs can have adverse effects with grapefruits?

- Statins

- Calcium channel blockers

What food counteracts the anticlotting action leading to decreased blood-thinning activity and an increased risk of blood clot formation with warfarin?

Cranberries

What food causes irregular heartbeats and heart palpitations with ace inhibitors (like lisinopril)?

Banana

What type of food decreases absorption and decreases effectiveness of the antibiotic (like tetracycline)?

Dairy products (calcium)

Food _______ absorption of penicillin vk

Decreases

Alcohol _______ liver toxicity with acetaminophen

Increases

What is the recommended limit for carpules of local anesthetic in older adults?

2-3 carpules

Which patient condition DOES NOT require caution when prescribing NSAIDs?

A. Hypertension

B. Renal disease

C. Gastrointestinal bleeding

D. Liver disease

D. Liver disease

What percentage of older adults report chronic pain?

76%

How does alcohol tolerance and sensitivity change in older adults?

tolerance decreases, sensitivity increases

When tailoring acetaminophen dosage for older adults, when should the dose be reduced by 50%?

A. In frail older adults.

B. In cases of polypharmacy or hepatic insufficiency.

C. In individuals with a history of alcohol abuse.

D. All of the above.

D. All of the above

which drugs can have adverse effects with cranberries?

warfarin

which drugs can have adverse effects with bananas?

ace inhibitors (lisinopril)

which drugs can have adverse effects with dairy products/calcium?

antibiotics (tetracycline)

which drugs can have adverse effects with alcohol?

acetaminophen

The following adverse effect is seen between which food-drug interaction?

- Increases the potency of statins in the blood

grapefruit and statins

The following adverse effect is seen between which food-drug interaction?

- Higher blood levels of the Ca channel blocker drug

grapefruit and CCBs

The following adverse effect is seen between which food-drug interaction?

- Counteracts the anticlotting action leading to decreased blood-thinning activity and an increased risk of blood clot formation

cranberries and warfarin

The following adverse effect is seen between which food-drug interaction?

- Irregular heartbeats and heart palpations

bananas and ACE inhibitors (lisinopril)

The following adverse effect is seen between which food-drug interaction?

- Decreases absorption and decreases effectiveness of the antibiotic

dairy products/calcium and antibiotics (tetracycline)

The following adverse effect is seen between which food-drug interaction?

- Decreased absorption

food and penVK

The following adverse effect is seen between which food-drug interaction?

- Increased liver toxicity

alcohol and acetaminophen

T/F: Multivitamins, antacids, and mineral supplements containing: Calcium, magnesium, zinc, aluminum, potassium, iron, and other minerals interact with many antibiotics in the gut and decrease the absorption in a way that reduces the level of the antibiotic in the body and makes the treatment ineffective.

True (!!!!)

When the following supplements are taken with antibiotics, such as tetracycline, doxycycline, or cipro, what is the adverse side effect?

- Calcium Magnesium

- Zinc

- Potassium

- Iron

- Aluminum

Decreases absorption, making the antibiotics ineffective

When melatonin is taken with opioids, what is the adverse side effect?

Drowsiness

Which common herbal agents should not be given with warfarin because it can increase bleeding and potentiate the effect of the anticoagulants?

- Garlic

- Ginger

- Gingko

- Green tea

What herbal agent is the following?

- BLEEDING AND CLOTTING RISK

- Decrease the effect of Warfarin and increase the risk of blood clots

Ginseng

What may increase drowsiness and dizziness especially when combined with muscle relaxants, sleep or anxiety meds, opioids and antidepressants?

valerian

Fish oil Omega-3 fatty acids (increase/decrease) bleeding

Increase

What is the dose/number of cartidges of 1:50,00 epi for an adult patient with significant cardiovascular disease?

0.04mg/ 1.1 carts

What is the dose/number of cartidges of 1:100,00 epi for an adult patient with significant cardiovascular disease?

0.04mg/ 2.2 carts

What is the dose/number of cartidges of 1:200,00 epi for an adult patient with significant cardiovascular disease?

0.04mg/ 4.4 carts

All of the following are optimal considerations for local anesthetics EXCEPT:

A) Option of no anesthesia

B) Caution with long-lasting agents

C) Vasoconstrictors generally OK

D) Careful technique, aspiration

E) Always more than 2-3 carpules per visit

F) Awareness of lip/tongue chewing

E) Always more than 2-3 carpules per visit (should be NO more than 2-3 carps/visit)

What is the first choice for managing tooth pain with analgesics in older adults?

Acetaminophen

Acetaminophen dosing should be reduced by about ____% in certain older adults who are at higher risk of toxicity

50%

(Ex: In frail older adults, polypharmacy - use multiple medications-, history of hepatic insufficiency, and alcohol abuse)

NSAIDs can be used for managing tooth pain in older adults as long as they have no history of what? (4)

- GI bleeding

- Peptic ulcers

- Congestive heart failure

- Renal disease

Which NSAID can be used with patients at risk for cardiovascular disease?

Naproxen

Which NSAID can be used with patients at risk for GI bleeding?

Celebrex

Which condition is the MOST important reason to use NSAIDs with extreme caution in older adults?

Gastrointestinal bleeding or ulcers

Approximately what percentage of elderly patients may have asymptomatic GI ulcers and/or bleeding?

60%