Special Pops Final Exam All Material

based on physiology, why do older B blockers not work well in older adults?

decreased sensitivity of B receptors

based on physiology why do older adults frequently get light headed and sometimes fall when they get out of their chairs?

decreased baroreceptor activity resulting in increased orthostatic hypotension

the vessels cant correct the decrease in BP resulting in an insufficient amount of blood reaching the brain

based on physiology, why do many older adults have vitamin B12 deficiency?

B12 absorption is decreased due to decreased gastric acid secretion and an increase in gastric pH

B12 requires a _____ environment to be absorbed

more acidic / lower pH

based on physiology why are older adults at greater risk of ulcerations from NSAIDs?

slower GI motility and emptying

based on physiology, why are older adults at greater risk of prolonged side effects for diazepam?

increased body fat which leads to an increased Vd for fat soluble drugs, resulting to an accumulation of fat soluble drugs and prolonged duration of action.

diazepam is a ____ soluble

fat

based on physiology, why are older adults at greater risk of digoxin toxicity?

decreased lean body mass and total body water resulting in decreased Vd

decreased Vd leads to increased plasma concentration of digoxin

based on physiology, why might regular insulin act as long acting insulin in older pts?

decreased renal clearance, renal mass, renal blood flow, functioning glomeruli, and glomerular filtration leads to longer half life

based on physiology, why are older adults at greater risk of ADE for drugs like Zolpidem?

increased sensitivity of BZD receptors

what is the first step in the cascade of functional decline that results in effects on organ reserves and response to drugs in older adults

progressive disability (3rd step)

why are older adults more vulnerable to ADE once functional organ reserves capacity decreases?

reduced ability to maintain homeostasis and respond to physiologic stress

which of the basic taste sensations remains intact the longest with age? and how does this effect dietary habits?

sweet food; they want to eat less healthy bc it doesnt taste the same

name one way in which decreased ability to distinguish colors affects patient counseling on medications

Decreased ability to distinguish colors may prevent patients form recognizing changes in medications that use color coding to indicate doses like warfarin and levothyroxine, which increases the risk of taking the wrong dose.

name 3 drug classes that contribute to functional decline by causing AMS

benzos

opioids

anticholinergics

name 3 drug classes that contribute to functional decline by causing muscle weakness

steroids

statins

loop diuretics

increase or decrease:

gastric pH _____ in older adults

increases

increase or decrease:

gastric ph increases in older adults, resulting in _____ absorption of drugs that require a lower pH to be absorbed

decreased

increase or decrease:

Total body water __________ in older adults,

decreases

increase or decrease:

Total body water decreases in older adults, resulting in  ________ volume of distribution (Vd) for water soluble drugs.

decreased

increase or decrease:

Total body fat ____ in older adults

increases

Total body fat increases in older adults, resulting in (increased or decreased) duration of action of fat-soluble drugs.

increased

increases or decreases:

Glomerular filtration ________ in older adults

decreases

Glomerular filtration decreases in older adults, resulting in (increased or decreased) of renally-eliminated drugs and metabolites.

decreased

increases or decreases:

Baroreceptor activity ________in older adults

decreases

Baroreceptor activity decreases in older adults, resulting in (increased or decreased) risk of orthostatic hypotension.

decreased

Name medications / classes that may cause irreversible hearing loss.

vancomycin

loop diuretics

AMGs

What happens to β-adrenergic receptors as a result of increased circulating catecholamines in older adults?

Decreased sensitivity which contributes to CV decline

Stiffening of the aorta & large arteries leads to which specific type of hypertension in older adults?

Isolated systolic hypertension

Does gastric peristalsis increase or decrease in older adults?

decrease

Does gastric acid secretion increase or decrease in older adults?

decrease

Does gastric emptying increase or decrease in older adults?

decrease

Does lean muscle mass increase or decrease in older adults?

decrease

Name recommendations for older adults that should result from their decreased respiratory muscle strength and lung tissue elasticity.

Vaccines for respiratory infections

Stop smoking

Deep breathing

Regular physical activity

which first gen antihistamines are considered inappropriate medication uses in older adults (8)

1. chlorpheniramine

2. cyproheptadine

3. dimenhydrinate

4. diphenhydramine

5. doxylamine

6. hydroxyzine

7. meclizine

8. promethazine

why are first gen antihistamines inappropriate for older adults to take? (4 reasons)

1. high anticholinergic side effects (constipation, confusion, and dry mouth)

2. reduced clearance of drug through the kidneys

3. tolerance

4. increase fall risk, delirium, and dementia

what antihistamine that is usually inappropriate for use in geriatrics can be used in the case of acute severer allergic reactions?

diphenhydramine

alternative/safer medications for geriatric patients with allergic rhinitis and associated symptoms (6)

1. irrigate nasal passages w/ purified saline solution

2. 2nd or 3rd gen antihistamines (loratadine, cetirizine, etc)

3. nasal antihistamine sprays

4. nasal corticosteroids

5. nasal mast cell stabilizers

6. eye drops

what are the 2nd and 3rd generation antihistamines that are safer in geriatric patients than 1st generation antihistamines?

1. loratadine

2. cetirizine

3. levocetirizine

4. fexofenadine

geriatric pts with nasal symptoms should use ______ instead of 1st generation antihistamines

nasal antihistamine sprays like azelastine or olopatadine

nasal corticosteroids like fluticasone, budesonide, or triamcinolone

nasal mast cell stabilizers like cromolyn

geriatric pts with ocular symptoms associated with allergies should use____ instead of 1st generation antihistamines

eye drops like ocular antihistamines or decongestants

artificial tears

which drug is considered inappropriate to give to older adults for primary prevention of cardiovascular disease?

aspirin (ASA)

why is aspirin an inappropriate drug to give to geriatric patients?

increase risk for major bleeding as age increases

ASA is generally indicated for _____ in older adults with ESTABLISHED CVD

secondary prevention

alternative to ASA for primary prevention of CVD in geriatric pts

no alternative

avoid initiating aspiring for primary prevention

Consider deprescribing if on aspirin for primary prevention

is it every okay for an older adult to take aspirin

yes

which are the nonselective peripheral alpha 1 blockers that are inappropriate to use in older adults to treat hypertension

doxasozin

prazosin

terazosin

why are non-selective peripheral alpha 1 blockers not good to treat hypertension in older adults

these drugs cause high risk of orthostatic hypotension in this patient population therefore, it is not recommended for routine use

what are the central alpha-agonists not good to treat hypertension in older adults

clonodine

why is clonodine not a good choice in treatment of hypertension in older adults

high risk of adverse CNS effects which may lead to bradycardia and orthostatic hypotension therefore it is not recommended for routine use

which agents are NOT used to treat hypertension in older adults

doxazosin

prazosin

terazosin

clonidine

what drugs should be used OVER nonselective alpha 1 and central alpha agonists in the treatment of hypertension for older adults

consider nonpharm first then drug therapy

what nonpharm treatments are preferred to help treatment of HTN in older adults

DASH diet

exercise

weight loss

what pharm treatments are preferred to help treatment of HTN in older adults

regular 1st line therapy for HTN

-thiazide diuretics

-CCB

-ACEi

-ARBs

-Beta Blockers [some cases]

thiazide diuretic examples from chat

HCTZ

chlorthalidone

indapamide

metolazone

CCB examples from chat

amlodipine [most common] nifedipine

diltiazem [non-DHP]

verapamil [non-DHP]

ACEi examples from chat

lisinopril

enalapril

ramipril

benazepril

ARB examples from chat

losartan

valsartan

olmesartan

ibesartan

BB examples from chat

metoprolol

atenolol

propranolol

carvedilol

which anitdepressants are inappropriate to use in older adults

amitriptyline

paroxetine

why are amitriptyline/paroxetine not appropriate for older adults

high anticholinergic effects, sedating, causes orthostatic hypotension

which SSRI has the highest anticholinergic SE profile

paroxetine

what should be used instead of BZDP, 1st gen antihhistamines, TCAs to help with anxiety symptoms in older adults?

first we should address the cause of that is going on with the patient. are they having anxiety because of an event that has occurred?

nonpharm is first line

if pharm therapy is indicated, consider agents with safer aDE profile for older adults

which antipsychotics are considered inappropriate for older adults

aripiprazole

haloperidol

olanzapine

quetiapine

risperidone

why are these antipsychotics inappropriate for older adults

these can cause increase risk of stroke or greater rate of cognitive decline/mortality, especially in patients with dementia [dont want to make their dementia worse]

what conditions would be allowable for these antipsychotics to be given to older adults

schizophrenia

bipolar disorder

parkinson's disease psychosis

when would we consider using antipsychotics [not talking about dz allowed in]

may be appropriate if nonpharm options have failed and the patient is threatening substantial harm to self or others

what is the alternative option for antipsychotics

none :(

which BZDP are inappropriate to use in older adults

alprazolam

chlordiazepoxide

clonazepam

clorazepate

diazepam

estazolam

lorazepam

midazolam

oxazepam

temazepam

triazolam

which nonBZDP BZDP receptor agonist hypnotics are inappropriate for older adults

eszipiclone

zaleplon

zolpidem

why are BZDP inappropriate for older adults

this patient population has an increased sensitivity to BZDP and has a decreased metabolism of long acting agents

continued use can lead to dependence

all BZDP lead to increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes

when may BZDP be appropriate for older adults

for seizure disorders, rapid eye movement sleep behavior disorders, BZDP/ethanol withdrawal, severe GAD, periprocedural anesthesia

why are nonBZDP inappropriate in older adults

similar to BZDP as they cause delirium, falls, fractures, and increased ER visits/ hospitalizations

these have minimal improvement in sleep latency and duration

should we be taking BZDP for insomnia

bro no

what would be an alternative option for treatment of insomnia INSTEAD OF BZDP, Z drugs, 1st gen antihistamines, TCAs? what would we do first?

1st look for health conditions or anything that would cause sleep disruption [is patient anxious, have bills to pay so can sleep, unsafe neighborhood, medical conditions keeping them from sleep]

what kind of nonpharm therapy is considered 1st line for treatment of insomnia instead of inappropriate drug therapy

cognitive behavioral therapy for insomnia including sleep restrictions, stimulus control therapy, cognitive therapy, relaxation, sleep hygiene

T/F: good sleep hygiene alone is most effective for treating chronic insomnia

FALSE--alone is not effective

what medications may be used and are considered safe to give older adults to treat insomnia

low dose doxepin

ramelteon [short term use]

which medications have insufficient evidence and are not recommended to use for the treatment of insomnia in older adults

trazodone

meltaonin

what kind of diabetic medication is inappropriate for older adults

insulin sliding scale and SU

why is sliding scale insulin inappropriate for older adults

causes higher risk of hypoglycemia without improvement in hyperglycemia management

avoid short or rapid acting insulin if used without basal or long acting

what could be an alternative to sliding scale insulin for this patient population

adding basal insuline allows for safe d/c of sliding scale

what are the SUs that are inappropriate to give to older adults

glimepiride

glipizide

glyburide

why are SUs inappropriate for this patient population

these have higher risk of CV events, all cause mortality, and can cause hypoglycemia

this drug class can increase the risk of CV death and ischemic stroke

do long or short acting SUs have a higher risk of prolonged hypoglycemia -- aka making these even more of a reason not to use in older adults

long-acting agents like glyburide and glimepiride

which SU is considering short acting

glipizide

when would be the only option it is "okay" to use SUs in this patient population to treat DM

when there are substantial barriers to the use of safer and more effective agents

what are some alternative agents to SUs

metofrmin

SGLT2 inhibitors

GLP1

DPP4 inhibitors

SGLT2 examples from chat

dapagliflozin

empagliflozin

canagliflozin

DPP4 inhibitor examples from chat

sitigliptin

saxagliptin

which PPIs are inappropriate to use in older patients

all of them:

dexlansoprazole

esomeprazole

lansoprazole

omeprazole

pantoprazole

rabeprazole

why are PPIs inappropriate to use in this patient population

there is a risk of c. diff infections, pneumonia, FI malignancies, bone loss, and fractures if these patients take this medication

[due to even more decreased acid in the body bc of the PPI and also at the body ages it naturally has decreased acid]

geriatric pts should not take PPIs unless…

if the patient is at high risk for erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory conditions, etc.

what would be nonpharm alternatives for PPIs for older adults to try

lifestyle

dietary

weight management

not eating within 2-3 hours of bedtime

elevate head of bed

what would be pharm alternatives for PPIs for older adults to try in the event nonpharm isn't good enougth

for nocturnal symptoms, patients can try nighttime H2 receptor antagonists

if they are on BID PPI, it is suggested to reduce to QD if they can't completely d/c

what are Non-COX 2 selective NSAIDs that are inappropriate to use in older adults

aspirin >325

diclofenac

etodolac

ibuprofen

indomethacin

ketorolac

meloxicam

naproxen

piroxicam

why are Non-COX 2 selective NSAIDs inappropriate

they have an increased risk of GI bleeding or PUD [especially in high risk groups like those taking steroids, anticoags, or antiplatelets]

using PPIs or misoprostol may reduce this risk

what happens with longer use of NSAIDs

upper GI ulcer, gross bleeding, or perforation may occur if treated with this drug class for an extended period of time

longer use = more likely to cause problems

when would it be "okay" to use NSAIDs in geriatric pts

if alternatives are not effective and patients can take the PPI

what is significant about indomethacin and ketorolac

oldest drug in class

have an increased risk of GI bleeding/PUD/AKI