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25 Cards in this Set
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About 50% of hospitalizations are the result of adverse drug effects in the elderly - In 2012, an estimated 100,000 deaths annually were caused by medication-related problems (MRPs) - MRPs can be mistaken for what is often considered a normal consequence of aging or for progression of disease - Cognitive impairment and behavioral changes are frequently the result of drug therapy - The aging process is an individualized matter = because of genetic or environmental factors or good health practices (ex exercise, healthy diet, and mental stimulation) |
MRPs can be mistaken for normal consequence of aging or for progression of disease - cognitive impairment and behavioral changes are frequently result of drug therapy |
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Physiologic Changes with Age - Cumulative effects of drugs in older adults can be due to: = Inadequate absorption (slowed GI motility, reduced fluid intake and or relative achlorhydria (lack of stomach acid) = Impaired distribution (Circulatory Dysfunction, less muscle, and more fat) = Slower metabolism (hepatic dysfunction) = Impaired excretion (renal dysfunction, constipation or poor exchange of gases in the lungs) |
Physiologic Changes with Age - four processes that drugs undergo in body 1. absorption 2. distribution 3. metabolism (Biotransformation) 4. Excretion = are all altered as body ages |
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Absorption - Gastric motility decreases - Gastric acid production diminishes, = increasing the gastric pH, = causing a more alkaline environment (affects absorption process) - Many older adults also take medication that reduces gastric acid = Examples: ranitidine (Zantac) or omeprazole (Prilosec) = Antacids are also used frequently - Calcium, Magnesium and aluminum, form insoluble and nonabsorbable complexes that are passed out of the body in the feces - some drugs affected by antacids: quinolone antibiotics, tetracycline, iron salts, ketoconazole and isoniazid = Recommended that these and certain other drugs not be taken within 2 h of taking antacids |
Absorption - decreased gastric motility (esp taking anticholinergic drugs: tricyclic antidepressants or the antispasmodics = can cause adverse effects - gastric slowing: lead to increased time for other drugs to be dissolved and absorbed - absorption by other routes of administration may be affected = aging skin atrophies, becomes thinner, potentially impairing transdermal drug absorption of patches and gels (reduced blood flow to skin) - muscle mass may be significantly decreased in some older adults (may alter drug absorption of IM and subcutaneous injections |
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Distribution Once drugs are absorbed and enter the circulation, many of them bind to proteins - Albumin: principal protein used to bind drugs As we age, the liver produces less albumin (in conditions: malnutrition, cancer, diabetes, surgery, burns and liver disease) - Allows more of the drug to be unbound (free) to reach receptor sites and therefore have a greater than expected response = Phenytoin (Dilantin) responds quite noticeably to drops in plasma albumin levels - older adults need to be monitored frequently with lab studies (esp with symptoms: sleepiness, confusion, nystagmus (involuntary back-and-forth eye movements), diplopia, and ataxia - other drugs that are highly protein bound: warfarin, aspirin, naproxen, diazepam and valproic acid (Depakote) - when used on older adult, start with lowest effective dose and increase slowly to avoid adverse effects (frequency of administration may also need to be decreased)** - drugs that are water soluble (Digoxin, ethanol, lithium, morphine, and theophylline) may become concentrated and cause adverse reactions with additive effects over time. (smaller doses would be needed to avoid potential toxicity) |
Metabolism The liver serves as a major site for drug metabolism - As we age, the mass of functional liver tissue and blood flow to the liver decreases - Ability of the liver to break down drugs declines, and drugs remain in the body longer - Repeated dosing can result in the accumulation of the drug and increases the risk for toxicity - some drugs that can produce toxic effects when poorly metabolized are: caffeine, diazepam, chlordiazpoxide, lidocaine, theophylline, meperidine, hydromorphone, warfarin, phenytoin, diphenhydramine and propranolol. |
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Metabolism - all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults - older adults have increased sensitivity to all benzodiazepines and decreased metabolism of long-acting agents = these drugs build up with repeated administration and cause SIDE EFFECTS - may be necessary to consider SSRIs, SNRIs or busipirone as alternatives for ANXIETY and SHORT-TERM use of zolpidem (Ambien) as alternative for hypnotics - Omeprazole (Prilosec) and cimetidine (Tagamet) inhibit liver enzymes from breaking down the long-acting benzodiazepines and prolong drug's duration of action - may be preferable to use other PPIs or H2- blockers (pantoprazole (Protonix) or ranitidine (Zantac) rather than omeprazole |
Excretion - In the older adult, kidney size, blood flow, and glomerular filtration all decrease, resulting in a decline in creatinine clearance = Illnesses such as hypertension, heart failure, and diabetes add to the age-related loss and further reduce creatinine clearance - drug by-products normally eliminated thru the kidney's can accumulate with toxic effects = Ex: digoxin poses increased risks of adverse reactions (e.g. arrhythmias) to older adults with impaired renal function. - Nephrotoxic drugs (aminoglycosides) can prove particularly dangerous to older people with reduced renal function. - acute renal failure and irreversible damage to the 8th cranial nerve (auditory and vestibular branches) are possible. |
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Seniors and Drug Development Pharmaceutical research is frequently focused on younger individuals - Older adults are often excluded from or underrepresented in clinical trials = Results may be inappropriately extrapolated to other populations with negative outcomes - some meds safe for 30 year olds but may produce unexpected results in person over 50 or 60. Ex: digoxin (Lanoxin) = older person on same dose that was appropriate 10-20 years earlier may experience side effects (loss of appetite, weakness, personality changes, nightmares, confusion, or even hallucinations) = in addition, digoxin can interact with many other drugs, sometimes slowing clearance of drug from system, which could result in cumulative effects (include possible dangerous arrhythmias) |
Potentially Inappropriate Medication Use in Older Adults - The Beers List (drugs) = Results of a survey conducted to determine the most inappropriate drugs for ambulatory nursing home residents and adults 65 or older - meds considered inappropriate if evidence in literature to substantiate risk of drug use outweighed clinical benefit when alternative therapy was available. - Published in 2003 then in 2012 in Journal of American Geriatrics Society under "Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults" - Goal: improve care for older adults by reducing their exposure to potentially inappropriate medications (PIMs) (not applicable in all circumstances e.g. patients receiving palliative hospice care) available at www.americangeriatrics.org - Health care professional treating older adults should have access to the Beers List and recognize common classes of meds that can produce problems Ex: improper antidiabetic and antithrombotic drug therapy is responsible for more than 2/3 of drug-related hospitalizations in older patients - focusing on improving management |
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Drugs to Avoid with Certain Medical Conditions - Many of meds on Beers List have anticholinergic properties and are NOT RECOMMENDED for use in older adult population - older adults sensitive to drug actions and are more likely to have adverse drug reactions to anticholinergics = resulting side effects: blurred vision, confusion, disorientation, dry mouth, dry eyes, constipation, palpitations, worsening of glaucoma, and urinary retention - Men with prostate problems are at extreme risk for acute urinary retention |
Drugs that produce significant anticholinergic effects include - Antipsychotic agents: phenothiazines, chlorpromazine, fluphenazine, thioridazine, and perphenazine. - Antidepressants such as tricyclics amitriptyline, doxepin, imipramine (Tofranil) and nortriptyline (Pamelor) - Antiparkinson agents such as benztropine (Cogentin) and trihexyphenidyl - Antispasmodics such as dicyclomine (Bentyl) and hyoscyamine (Levsin) - Antihistamines such as diphenhydramine (Benadryl) and promethazine (Phenergan) Many meds (SSRIs, some atypical antipsychotics, H2-blockers, certain cardiovascular drugs, corticosteroids, etc) that exhibit subtle anticholinergic activity that becomes more pronounced in older adults - because increase in amount of drug circulating in system is often gradual, consequences of an "overdose" may not be recognized |
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Drugs to Avoid with Certain Medical Conditions: Cognitive Impairment - more than 150,000 older adults had experienced serious mental impairment either caused or worsened by drugs - many meds can have CNS side effects: anxiety, depression, confusion, disorientation, forgetfulness, hallucinations, nightmares, or impaired mental clarity (esp in older adults) - Some Drugs can cause mental impairment (including dementia and delirium) in older adults - Anticholinergics - Antidepressants tricyclic (TCAs) - Antipsychotics (chronic and as-needed use) - Benzodiazepines - Corticosteroids - H2 receptor antagonists - Meperidine - Phenothiazines - Sedative hypnotics = after taking antipsychotics for behavioral problems of dementia unless non-pharmacologic options have failed and patients is a threat to him or herself or others. - antipsychotics are associated with INCREASED risk of Cerebrovascular accidents and mortality in persons with dementia - ALL ANTIPSYCHOTICS can cause tardive dyskinesia and/ or parkinsonism - when discontinuing may of the listed categories of drugs used chronically, Taper to Avoid Withdrawal Symptoms |
Drugs to Avoid with Certain Medical Conditions: Syncope/Falls - syncope (fainting or passing out) in seniors can be attributed to age-related physiological changes in conjunction with meds that result in decreased delivery of cerebral oxygen - many CNS drugs and antihypertensives cause dizziness or motor impairment (increase the risk of falls) - these drugs can also impair sexual functioning, reducing quality of life for some older adults |
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Syncope/Falls Some drugs causing or contributing to syncope or falls include: - Anticonvulsants (avoid except for treating seizures) - Antidepressants (SSRIs and TCAs) - Antipsychotics (especially chlorpromazine, thioridazine and olanzapine, which increase the risk of orthostatic hypotension) - Alpha-blockers (doxazosin, prazosin, and terazosin, which increase the risk of orthostatic hypotension and tachycardia) - Benzodiazepines - Nonbenzodiazepine hypnotics (e.g. Ambien) |
Drugs to Avoid with Certain Medical Conditions: Gastrointestinal Conditions - anyone taking NSAIDs should be cautioned about real danger of serious complications (ex: over 70,000 hospitalizations and more than 7,000 deaths from drug-induced bleeding ulcers or perforations. - particularly in older adults, may be no warning signs or pain and first symptoms of trouble may be "silent" bleed that could lead to fatal GI hemorrhage - Key to avoiding problems with NSAIDs is to use the lowest effective dose for the shortest period of time |
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COX-2 selective NSAID Celebrex has less potential for gastric problems than other nonselective NSAIDs (more data needed to confirm this) - use of PPIs and misoprostol (Cytotec) reduces but does not eliminate the risk of GI bleeding associated with NSAIDs. - to avoid problems with NSAIDs is to use LOWEST effective dose for shortest period of time - Consideration should be given to a trial of acetaminophen in place of NSAIDs |
Other GI problems - ex: indigestion, heartburn, and constipation are frequent complaints - taking of OTC remedies without adequate awareness of potential side effects or implications - Side effects of antacids: constipation (with aluminum or calcium carbonate products) diarrhea (with magnesium antacids); and acid re-bound, belching, or flatulence (with calcium carbonate). - avoid prolonged use (no longer than 2 weeks) of OTC antacids without medical supervision because of the danger of masking symptoms of GI bleeding or GI malignancy. - constipation can be worsened by anticholinergics and oral antimuscarinics (elgl oxybutynin, tolterodine) for urinary incontinence. - consider alternatives if constipation develops and avoid frequent use of strong cathartics (can lead to laxative dependence and loss of normal bowel function) = instead: increase fluids and high-fiber diet and regular bowel habits - if laxatives are necessary, use bulk laxatives (e.g psyllium), stool softeners, or sennosdes (Senokot) or PEG 3350 (Miralax) |
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Cardiovascular Disease - Studies have indicated increased risk of cardiovascular problems (thrombotic events, MI, and stroke) with the use of NSAIDs and COX-2 inhibitors (see physician to see if consideration of whether benefits outweigh potential risks. - Older adult patients with heart failure should avoid the calcium-channel blockers diltiazem and verapamil, the antidiabetic glitazones (Actos, Avandia), cilostazol (Pletal), and dornedarone (Multaq) = these agents have potential to promote fluid retention and / or exacerbate heart failure |
Patient Education on patients receiving NSAID therapy - administering the medication with food - not exceeding the dosage prescribed by the physician - not taking aspirin, alcohol, or any other drugs at the same time because they may potentiate GI or bleeding problems - the possibility of "silent" bleeding - Reducing the dosage of NSAIDs and substituting acetaminophen for pain, if possible, at least part of the time - trying exercise and heat for pain control as approved by physician |
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Polypharmacy Individuals, especially older adults, may be the victims of polypharmacy: - Excessive use of multiple drugs = OTC, herbals, or prescriptions given at one time for the treatment of a patient’s medical conditions (a patient is on multiple medications to treat multiple medical conditions may not necessarily be problematic - polypharmacy becomes problematic when negative outcomes occur. Polypharmacy may result in unecesssary and or inappropriate medication prescribing, an increase in risk of dangerous interactions with potentially serious adverse side effects, and medication nonadherence. - Health care practitioners should take opportunity to educate patients regarding medicines. (purpose, potential side effects, potential dangers and interactions between medicines) - should be monitored on an ongoing basis to determine continuing effectiveness and possible cumulative or adverse effects - medicines should be reviewed regularly to determine the feasibility of reducing dosage, possibly substituting a more effective or safe medicine or discontinuing some of the medicines. |
Patient Education for older patients should be instructed regarding - making a list of ALL medicines (with dosage) including Pain, eye drops, OTC, vitamins, herbal remedies, topical meds (should be carried in wallet or be readily available at all times) - purpose for their medication, side effects, best time to take each medication, and interaction - asking pharmacist for easy-to-hold and easy-to-open medication containers; proper storage and importance of keeping these types of containers out of children's sight and reach. - reporting side effects to physician immediately - see doctor on regular basis, every 6 months to 1 year or more often to reevaluate need for and effectiveness of drug - not stopping medicine or changing dose without consulting physician (abrupt withdrawal can be dangerous with some meds) - asking physician to prescribe a generic or less expensive alternative if cost of med is prohibitive. Sometimes social service department can assist pateitns in securing expensive meds that are imperative to patient's health. Some drug companies can help with costs - ask pharmacist to recommend a pillbox organizer or other memory aids if there is problem remembering to take meds - not taking another person's meds even fi they think it is the same as theirs - being sure all parties are informed of an issues if you use one or more physicians or pharmacies |
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All healthcare practitioners should follow guidelines - Educate yourself, your patients, and their families (regarding adverse side effects, cumulative effects, and interactions) Ex: have the American Geriatrics Society "Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults" readily available for quick reference - With newly prescribed drugs, note diagnoses, allergies, and other medications - Monitor long-term drug use (for effectiveness, potential for discontinuation, and physiological or mental changes. Do periodic laboratory tests as appropriate (e.g. digoxin levels) - Question any inappropriate medicine or dosage (you have moral, ethical and legal responsibility to do what is best for patient) - Document all adverse side effects, calls to the physician, and action taken |
The aging process is very individualized |
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As an individual ages, the gastric pH increases. (more alkaline environment) |
You are educating an older adult who is taking quinolone antibiotic in conjunction with an antacid. When should the patient be instructed to take the quinolone? = DO NOT TAKE within 2h of antacid |
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Cumulative effects of drugs in older adults can be due to = inadequate absorption - impaired distribution - slowed metabolism - impaired excretion |
What is an example of an antipsychotic drug that produces significant anticholinergic effects in older adults? = phenothiazines, chlorpromazine, fluphenazine, thioridazine, and perphenazine. |
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Which one of these is an appropriate medication to treat arthritis pain for older adults? - acetaminophen |
Which one of these is an appropriate medication to treat allergies in older adults? = Claritin |
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Which one of these is an appropriate pain medication for older adults after surgery? = Morphine |
When starting an older adult patient on a new drug, which is the best method of dosing = start at the lowest effective dose and increase slowly to avoid adverse effects |
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Which category of drugs is most likely to cause dizziness or motor impairment, increase the risk of falls and impact sexual functioning in older adults? = antihypertensives |
Which of these cardiac drugs is least appropriate for older adults? = Norpace (disopyramide) = antiarrhythmic agent) |
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Which one of these is an appropriate antidepressant to treat older adults with no history of seizure disorder? = Wellbutrin |
Which organ's function decreases with age, resulting in a decline of creatinine clearance? = Kidney |
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Which two categories of drug therapy are responsible for more than 2/3s (two-thirds) of drug-related hospitalization in older adult patients? = antidiabetic/antithrombotic |
Older adults are very sensitive to drug actions and are more likely to have adverse reactions to anticholinergics. What is one potential side effect of an anticholinergic? = Constipation = blurred vision, confusion, disorientation, dry mouth, dry eyes, constipation, palpitations, worsening of glaucoma, and urinary retention |
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Cristobal, 79 years of age, has early renal failure. What process might this affect? = Excretion |
Hudson, 73 years of age, has severe arthritis and takes an NSAID. What is especially concerning about the use of NSAIDs in elderly individuals? = Even fatal bleeds may not be preceded by any warning signs or symptoms |
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Lachlan, 87 years of age, has routine blood work that indicates liver impairment. What process is importantly affected by liver function? = metabolism |
Clifton, 77 years of age, takes phenytoin to control his seizures. What age-related change may alter distribution and necessitate changing his dose? = decreased production of albumin |
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Randy, 82 years of age, has relative achlorhydria. What process will this affect? = absorption |
Jadon, 67 years of age, has impaired exchange of gasses in his lungs. What process might this affect? = excretion |
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Chad is concerned about all of the medications his grandfather takes and after his grandfather is involved in a serious motor vehicle accident, decides to do some research. He finds that risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents is elevated in older individuals who take ____. = benzodiazepines |
Lela works in a nursing home and notices copies of The Beers List at nursing stations and in medication rooms. What does The Beers List list? = potentially inappropriate medications |
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In the United States, what percentage of people over the age of 60 take at least five medications? = 40% |
Deann, 79 years of age, simply doesn't drink as much water or other fluids as she used to when younger. What process might this affect? = absorption |
