Aging & Palliative Care- RAT 1

Which of the four components of kinetics are affected by aging?

- absorption

- distribution

- metabolism

- excretion

Which kinetic alteration with aging is most clinically important?

reduction of renal elimination of drugs

Impact of achlorhydria on absorption of medication

decreases absorption of nutrients (vitamin B12, calcium, iron)

Four physiologic changes of aging that affect distribution of drugs

- decrease in lean body mass

- increase in adipose tissue

- decrease in total body water

- decrease in plasma albumin concentration

Impact of decrease in lean body mass

blood levels of drugs primarily distributed in muscle increase --> risk for toxicity

Impact of increase in adipose tissue

fat soluble drugs have an increased Vd --> higher tissue concentrations and prolonged duration of action/ T 1/2

Impact of decrease in total body water

lowers Vd of water soluble drugs --> high plasma drug concentrations

Impact of decrease in albumin concentrations

can affect highly protein bound medications

Age-related changes that affect hepatic drug metabolism

liver mass and blood flow are reduced --> amount of drug delivered to liver is reduced, increased T 1/2

Result of pharmacodynamic changes of aging on drug therapy outcomes

pharmacodynamic changes tend to increase sensitivity to drug effects

Geriatric care for cardiovascular system

- increased susceptibility to orthostatic hypotension when taking drugs that affect cardiovascular system

- increased risk of developing QT prolongation

Geriatric care for central nervous system

- increased sensitivity to drugs that can access CNS

- blood brain barrier is more permeable

- decreased cholinergic, nicotinic, muscarinic receptors

- increased D2 receptors

Geriatric care for fluids and electrolytes

- decreased thirst and cardiovascular reflexes

- decreased fluid intake

- decreased ability of kidneys to concentrate urine

- electrolyte abnormalities more common

Geriatric care for glucose metabolism

- reduced insulin secretion and sensitivity (greater insulin resistance)

- older pts may not distinguish symptoms of hypoglycemia very well

Polypharmacy

taking multiple medications concurrently (>/= 4-10)

Five major categories of Beers criteria

1. potentially inappropriate medications (PIMs) to avoid in older adults

2. PIMs to avoid in older adults with specific diseases or syndromes

3. medications to be used with caution in older adults

4. clinically significant drug-drug interactions

5. medications that should be avoided or dose-adjusted based on individual kidney function

Undertreatment drug categories

- anticoagulation in patients with Afib

- malignant and nonmalignant pain

- anti hypertensive therapy

- BB treatment in HF

- statin treatment for ASCVD

Undertreatment: anticoagulation in pts with Afib

overly concerned with risk of bleeding or risk of falls if anticoagulated

Undertreatment: malignant and nonmalignant pain

- hesitant to prescribe opioids due to possible cognitive and bowel side effects

- concerns about addiction

- patients may be hesitant to use opioids

Undertreatment: antihypertensive therapy

underestimate the benefit of stroke and cardiovascular event prevention and/or fail to add second or third medication needed to attain control

Undertreatment: BB treatment in HF

concerned about complications in high risk patients despite substantial evidence of mortality benefit

Undertreatment: statin treatment for ASCVD

underestimate benefit or have concerns about adverse events

Patient/medication related factors that increase risk of ADRs in older adults

- taking more than 4 meds

- more than 14 days hospital stay

- having more than 4 active medical problems

- general medical unit admission versus geriatric ward

- alcohol use hx

- having confusion or dementia

- two to four meds added during hospital stay

Steps to minimize risk of ADRs

- evaluate comorbidities, frailty, cognitive function

- identify caregivers to take responsibility for med management

- evaluate renal function and adjust doses appropriately

- monitor drug effects

- recognize clinical signs/symptoms could be an ADR

- minimize number of meds prescribed

- adapt treatment to pts life expectancy

- realize that self medication and non adherence are common and can induce ADRs

Classes of meds that are associated with increased fall risk

- BZDs

- sedative hypnotics

- neuroleptics

- antidepressants

- antipsychotics

America's other drug problem

non adherence

Questions to assess patients for med adherence

- how do you take your medications?

- how do you organize your meds to help you remember to take them?

- how do you schedule your meal and med times?

- how do you pay for your meds?

- how do you think the meds are working for your condition?

- how many times in the last week/month have you missed your med?

Quick tool to assess for cognitive impairment

Mini-cog

Geriatric syndromes

- immobility

- isolation

- incontinence

- infection

- inanition (malnutrition)

- impaction

- impaired senses

- instability

- intellectual impairment

- impotence

- immunodeficiency

- insomna

- iatrogenesis

Two diseases in elderly that may present with atypical symptoms (delirium)

- thyroid dysfunction

- infection

Goals of palliative care

enhancing quality of life while maintaining or improving functionality

What patients qualify for hospice care?

patients with less than or equal to 6 months of life expectancy if the disease runs its typical course

Common disease states served by palliative care

- cancer

- end-stage HF

- COPD

- end-stage renal disease

- end-stage liver disease

- HIV/AIDs

- stroke or cerebral vascular accident

- Parkinsons disease

- amyotrophic lateral sclerosis (lou gehrig disease)

- Alzheimers disease and other dementias

Anxiety treatment in palliative care

- BZDs**

- SSRIs

- atypical and typical antipsychotics

Dyspnea treatment in palliative care

opioids

Delirium treatment in palliative care

antipsychotics

Pain treatment in palliative care

- opioids

- NSAIDs

- corticosteroids

- gabapentin

Terminal secretion treatment in palliative care

anticholinergics

Antidepressants that are NOT helpful for anxiety

bupropion, psychostimulatns

Med classes that can precipitate or worsen delirium in pts receiving palliative care

- anticholinergic agents

- BZDs

- opioids

- corticosteroids

- TCAs