Pharm E4- Geriatrics

What age is considered geriatric?

≥ 65

What are basic ADLs?

Bathing, dressing, toileting, maintaining continence, grooming, feeding, transferring

What are intermediate ADLs?

Grocery shopping, driving, using public transport, using a phone, chores, home repairs, preparing meals, laundry, taking meds, handling finances

What are advanced ADLs?

Fulfilling societal, community & family roles; participating in recreational & occupational tasks

What is polypharmacy?

The use of ≥ 5 regular meds

What are reasons for polypharmacy?

Longer life expectancy, increased chronic diseases, evidence based clinical practice guidelines (EB CPG)

What are consequences of polypharmacy?

ADRs (+ might not realize they’re experiencing ADR), decreased compliance, & falls → sedation, hypotension, lightheaded, dec alertness, confusion, dec muscle stability

What might cause decreased compliance?

Complex dosing schedule, multiple meds, cost, lack of support, memory, visual impairment, dysphasia, decreased venous access for IV dose, & willingness to adhere

What is considered end of life?

< 6 months to live

When treating a pt > 65 y/o near end of life, what should you prioritize in the treatment plan?

Palliative treatment, improving QOL

What age related renal changes are seen in elderly patients?

Decreased: renal mass, blood flow to afferent artery, GFR, ability to maintain acid-base balance

*CrCl & serum cr are misleading!

Which patients have impaired gastric emptying (slower absorption)?

Diabetics

What drug reaction can be seen in an osteoporosis patient taking BSS + calcium?

Chelation → educate pt to separate meds

How does drug distribution change in the elderly?

Dec lean muscle mass & inc fat → increased volume distribution of lipidphilic meds

Dec body water → decreased volume distribution of hydrophilic meds

How is protein binding affected in the elderly?

Dec serum albumin → poor nutrition, no protein stores, affects weak acids

Inc a-acid glycoprotein

increased free fraction of protein bound drug available to tissue

Phenytoin used to treat seizures is 90% albumin bound. What might happen if given to a geriatric patient?

Increased free fraction d/t hypoalbuminemia → falls, ataxia, sedation, etc

Why is increased serum Cr not proportional to decreased CrCl in elderly patients?

SCr is falsely low bc lack muscle to produce Cr; leads to overestimates & overdoses

How is renal drug clearance affected in geriatrics?

Reduced function, prolonged half lives, increased risk of toxic concentrations

*affected by hydration → many are dehydrated & labs will change, always get a 2nd set of labs

Which equation is more specific for CrCl in elderly?

MDRD

How is first pass metabolism and bioavailability affected?

Decreased function of phase I reactants (CYP450) → more drug gets through

Minimal changes in phase II reactions

Decreased metabolism d/t impaired liver blood flow → more drug

What are examples of impaired homeostatic responses in eldery/

CO, postural hypotension, temperature regulation, fasting BG

Which BZDs are better to use in elderly because they are more water soluble, lack active metabolites, and dont stick around as long?

Lorazepam, oxazepam, temazepam, triazolam

How are sedative hypnotics affected in elderly?

50-150% inc in half lives (esp w/ BZDs d/t inc adipose tissue), inc accumulation of active metabolites, inc risk for ataxia, falls, AMS

How do opioids affect elderly?

Accumulation of active metabolites, susceptible to respiratory depressive effects

Why would a dementia patient taking opioids, muscle relaxants, and drinks alcohol be an issue?

Synergistic effects, can’t tell if dementia is getting worse or if they are SEs d/t meds

Why should lithium be avoided in elderly?

Highly dependent on kidneys for elimination → decreased clearance d/t reduced renal function

What drugs can increase the accumulation of lithium?

Diuretics

Which antidepressants are safe in elderly?

SSRIs

Why should anticholinergics be avoided in elderly?

AMS, falls

What is there an increased risk of w/ antihypertensives?

Orthostatic hypotension

*+ elyte imbalances if diuretics

What is there a high prevalence of with antiarrhythmics in elderly patients?

Electrolyte imbalances → more prone to arrhythmias d/t poor hemodynamic reserve

*extended half lifespan of quinidine, procainamide, & lidocaine

What risk is associated with warfarin & GKO?

Bleeding risk, stroke, death

What agent contains ASA but many elderly patients do not realize, making it easy to overdose?

BC powders/goody’s

How long can noncontrolled substances be prescribed for?

1 year (elderly tend to save meds & share → risk ADRs)

Why might inhalation & eye drop dosage forms be an issue for elderly?

Lose dexterity causing them to have improper technique

Which arthritis meds are most expensive?

Newer NSAIDs

How can you ensure the patient understood what you said about their meds?

Teach back method, have them repeat what you said

Are there major changes seen with absorption in elderly?

No, main issue is drug interactionsW

What assessment focuses on elderly w/ complex problems, emphasizing function status & QOL (functional, medical, psychosocial) & uses an interdisciplinary team?

Comprehensive geriatric assessment (CGA)

When completing the nutrition section of the CGA, what should be asked?

Detailed recall of food, drinks, vitamins, supplements taken in the last 24 hrs