Geriatrics
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Questions and Answers

What is a common side effect of benzodiazepines in elderly patients?

  • Increased dopamine levels
  • Increased risk of falls and fractures (correct)
  • Reduced cognitive impairment
  • Lower risk of respiratory depression

    • Which of the following medications is associated with a higher risk of respiratory depression in elderly patients?

  • Antipsychotics
  • Barbiturates
  • Opioids (correct)
  • Antidepressants

    • What is a common cause of delirium in elderly patients?

  • Infection
  • Metabolic disturbances
  • Drugs such as sedatives and anticholinergics
  • All of the above (correct)

    • What is the most common type of dementia in elderly patients?

    <p>Alzheimer's Dementia</p> Signup and view all the answers

    What is a characteristic feature of delirium in elderly patients?

    <p>Disorganized thinking and attention</p> Signup and view all the answers

    Why are sedative hypnotics a concern in elderly patients?

    <p>They have a higher sensitivity in elderly patients</p> Signup and view all the answers

    What is a common medication-related issue in elderly patients?

    <p>All of the above</p> Signup and view all the answers

    Why is it important to screen elderly patients for cognitive impairment?

    <p>To identify cognitive impairment and its impact on daily functioning</p> Signup and view all the answers

    What is the primary goal of cholinesterase inhibitors in the treatment of Alzheimer's disease?

    <p>To slow the progression of the disease</p> Signup and view all the answers

    Which of the following is NOT a characteristic of Alzheimer's dementia?

    <p>Paying bills</p> Signup and view all the answers

    Which medication is used to treat moderate to severe dementia?

    <p>Memantine</p> Signup and view all the answers

    What is the most common psychiatric illness in the elderly?

    <p>Depression</p> Signup and view all the answers

    Which of the following is a risk factor for depression in the elderly?

    <p>Social isolation</p> Signup and view all the answers

    What is the purpose of the Geriatric Depression Scale (GDS) screening tool?

    <p>To screen for depression</p> Signup and view all the answers

    Which of the following is a common characteristic of Alzheimer's disease?

    <p>Increased daytime sleeping</p> Signup and view all the answers

    What is the primary goal of deprescribing guidelines in the elderly?

    <p>To decrease medication use</p> Signup and view all the answers

    What is the primary concern with using benzodiazepines in the elderly?

    <p>They can lead to drug dependence, tolerance, and abuse</p> Signup and view all the answers

    Which of the following is a characteristic of Selective Serotonin Reuptake Inhibitors (SSRIs) that makes them safer for elderly patients?

    <p>They have fewer adverse cardiovascular effects</p> Signup and view all the answers

    What is the main reason for concern regarding falls in the elderly?

    <p>They can result in fractures and other serious injuries</p> Signup and view all the answers

    What is the definition of orthostatic hypotension?

    <p>An excessive drop in blood pressure when changing from a lying to standing position</p> Signup and view all the answers

    What is a common consequence of falls in the elderly?

    <p>All of the above</p> Signup and view all the answers

    Which of the following is NOT a cause of orthostatic hypotension?

    <p>Hypertension</p> Signup and view all the answers

    What is the estimated percentage of falls that result in fractures?

    <p>5%</p> Signup and view all the answers

    Which of the following is a characteristic of the 'E Caps' depression checklist?

    <p>It includes symptoms such as suicidal ideation, lack of interest, and guilt</p> Signup and view all the answers

    What is an effective strategy to improve adherence in the elderly?

    <p>Link medication doses with daily routines, such as meals</p> Signup and view all the answers

    Why is drug prescribing in the elderly complex?

    <p>Due to changes in physiological, PK, and PD processes with aging, co-morbidities, and polypharmacy</p> Signup and view all the answers

    What is an important consideration when prescribing medications to the elderly?

    <p>Adjustments for age, weight, renal function, and hepatic metabolism</p> Signup and view all the answers

    What is a key principle in managing polypharmacy in the elderly?

    <p>Start Low, Go Slow</p> Signup and view all the answers

    What should prompt a review of a medication regimen in an elderly patient?

    <p>Non-specific complaints, such as dizziness or fatigue</p> Signup and view all the answers

    What is an important aspect of caring for elderly patients?

    <p>Teamwork with the health professional team, the patient, family, and caregiver</p> Signup and view all the answers

    What is a key concept in medication safety in the elderly?

    <p>All drugs are poisons; there is none that is not a poison</p> Signup and view all the answers

    Why is follow-up important in elderly patients?

    <p>To review the medication regimen regularly and adjust as needed</p> Signup and view all the answers

    What is an essential step in improving drug therapy in the elderly?

    <p>Conducting a thorough medical history</p> Signup and view all the answers

    Why are clinical trials often inadequate for the elderly?

    <p>They often have healthy participants with few drugs and diseases</p> Signup and view all the answers

    What is the primary purpose of Beers Criteria?

    <p>To list medications NOT recommended for use in adults older than 65</p> Signup and view all the answers

    When considering medication therapy in the elderly, what is an important question to ask?

    <p>What are we treating (Disease? Symptom? Prevention? Could it be an ADR caused by a drug?)</p> Signup and view all the answers

    What is deprescribing?

    <p>The process of reducing or stopping medications</p> Signup and view all the answers

    Why is it essential to consider drug interactions when prescribing medications in the elderly?

    <p>Because the elderly are more likely to take multiple medications</p> Signup and view all the answers

    What is an important component of medication safety in the elderly?

    <p>Conducting a thorough medication review at least annually</p> Signup and view all the answers

    Why is it crucial to involve family members or caregivers in the medication management of elderly patients?

    <p>Because they can provide collateral history and support</p> Signup and view all the answers

    What is a key challenge in managing medical conditions in the elderly?

    <p>Changes in physiological and pharmacokinetic responses to medications</p> Signup and view all the answers

    What is a recommended strategy to improve medication adherence in the elderly?

    <p>Linking medication doses with daily routines</p> Signup and view all the answers

    Why is it essential to consider age, weight, and renal function when prescribing medications to the elderly?

    <p>To minimize the risk of adverse drug reactions</p> Signup and view all the answers

    What is the primary goal of a team approach to caring for the elderly?

    <p>To provide comprehensive care to patients</p> Signup and view all the answers

    What is a recommended approach to medication initiation in the elderly?

    <p>Start with a low dose and titrate upwards</p> Signup and view all the answers

    Why is it important to review medication regimens regularly in the elderly?

    <p>To reduce the risk of adverse drug reactions</p> Signup and view all the answers

    What is a key concept in medication safety in the elderly?

    <p>The risk of adverse drug reactions increases with age</p> Signup and view all the answers

    What is the importance of follow-up in elderly patients?

    <p>To monitor for adverse drug reactions and adjust therapy</p> Signup and view all the answers

    What is the main reason why caring for the elderly is considered a team sport?

    <p>It requires a comprehensive approach to care</p> Signup and view all the answers

    What is the importance of education in avoiding adverse drug reactions in the elderly?

    <p>It reduces the risk of medication errors</p> Signup and view all the answers

    Study Notes

    CNS Depressants

    • Benzodiazepines: 2-3x sensitivity, leading to more falls and fractures
    • Barbiturates: CNS depressant
    • Antipsychotics: sedation, anticholinergic effects, orthostatic hypotension, and arrhythmias; decrease dopamine receptors/neurons, levels, and increase risk of EPS effects
    • Opioids: 2-8x higher risk of respiratory depression, but decreased N/V; hallucinations and cognitive impairment may increase risk of falls and fractures
    • Antidepressants: increase risk of falls and fractures

    Pharmacodynamics in the Elderly

    • Increased sensitivity to:
      • Sedative hypnotics
      • Anticholinergics
      • Analgesics
      • Warfarin

    Geriatric Giants

    Geriatric Giant 1: Cognitive Impairment

    • Delirium:
      • Acute disturbance in attention and disorganized thinking
      • Disorientation, perceptual disturbances, memory impairment
      • 60% of elderly hospitalized for surgery
      • Medical emergency; can cause death
      • Causes: drugs (e.g. sedatives, anticholinergics, narcotics), infection, pain, metabolic disturbances
      • Treatment: quiet, dim room, 1:1 care, hydration, reorientation, discontinuation of causative drugs
    • Dementia:
      • Newly acquired cognitive impairments that interfere with social or occupational functioning
      • Prevalence increases with advancing age
      • Types: Alzheimer's Dementia (AD), Vascular Dementia, Mixed Vascular + AD, Dementia Lewy Body (DLB), and Frontotemporal Dementia (FTD)
      • Progressive and irreversible
    • Alzheimer's Dementia:
      • Memory problems (e.g. losing items, missing appointments)
      • Difficulty performing complex tasks
      • Word finding difficulties, difficulty with names
      • Geographic disorientation (e.g. getting lost driving, familiar places)
      • Apathy and disinterest in surroundings
      • Sleep disturbances (e.g. increased daytime sleeping)
      • Disinhibiting behavior (e.g. impulsivity, socially inappropriate)
    • Alzheimer's Disease Treatment:
      • Cholinesterase inhibitors (e.g. Donepezil, Rivastigmine, Galantamine) to slow progression
      • NMDA receptor activator (e.g. Memantine) for moderate/severe dementia

    Depression

    • Most common psychiatric illness in the elderly
    • Often under-recognized and under-treated
    • Geriatric Depression Scale (GDS) screening tool
    • Common in Long Term Care patients, those with dementia, bereavement, disabilities, stroke, Parkinson's Disease, chronic illness, social isolation, poor education, poverty, alcoholism, and chronic pain
    • Mnemonic for Depression: "Sig.E Caps" - depression checklist:
      • Suicidal Ideation
      • Interest, lack of G uilt E nergy, none C oncentration, poor A ppetite(s), altered P sychomotor changes (slowed or revved up) S leep
    • Depression Treatment:
      • Non-pharmacologic: psychotherapy
      • Pharmacologic: Selective serotonin reuptake inhibitors (SSRIs) - safest in elderly, less concern for overdose and interaction with other meds

    Geriatric Giant 2: Falls in the Elderly

    • Falls are serious!
    • More than 1/3 of patients > 65 fall each year in the community
    • ½ of people who fall do so repeatedly
    • ~5% of falls result in fractures
    • ~5-10% result in other serious injuries
    • 10% of visits to the ER
    • Reason for 40% of nursing home admissions
    • Orthostatic Hypotension:
      • Excessive drop in BP when changing from lying/sitting to standing
      • Symptoms: dizziness, faints, near falls/falls
      • Causes: diarrhea/vomiting, anemia, salt-losing kidney disease, alcohol, adrenal insufficiency, stroke, Parkinson's disease, deconditioning, and prolonged bed rest, autonomic problems associated with diabetes, drugs

    Take Home Messages

    • Changes due to aging (physiological, PK, and PD), co-morbidities, and many other drugs make drug prescribing in the elderly complex
    • Caring for the elderly is a team sport! - Teamwork with the health professional team, patient, family, and caregiver
    • Education is important to avoid ADRs and IDP
    • "Start Low, Go Slow" (but keep going!)
    • Review regimen regularly
    • Non-specific complaints should prompt review to avoid prescribing cascades

    General Approach to Caring for the Elderly and the Role of the Pharmacist

    • Take a thorough history
    • Collateral history - family member, caregiver
    • Patient needs to bring in all pill bottles, blister packs, OTC meds, etc. to EVERY VISIT; complete and regular MedsChek
    • Improving prescribing:
      • "I medicate first and ask questions later."
    • Teamwork with MD: Before prescribing, think about:
      • What are we treating (Disease? Symptom? Prevention? Could it be an ADR caused by a drug?)
      • Can we use a non-drug approach?
      • Can we treat locally rather than systemically?
      • Can we remove something before adding something?
      • What interactions will there be?
      • Do we know this drug's pharmacology (e.g. renal clearance vs hepatic, P450 interactions, etc)
    • Deprescribing:
      • Apply tools/methods for patients and clinicians - help make decisions about reducing or stopping medications
    • Beers Criteria:
      • List of drugs NOT recommended for use in adults older than 65 in all settings.
      • First version in 1991, last update 2023.

    Pharmacokinetic Changes with Age

    • The action of drugs in the body over time includes processes of absorption, distribution, metabolism, and elimination
    • Age-related changes in absorption:
      • Gastric pH increases
      • Splanchnic blood flow decreases
      • Delayed gastric emptying
      • Intestinal transit slows down
      • GI absorptive surface decreases
    • However, the extent of drug absorption is generally unchanged, but may be slower in the elderly

    Pharmacokinetic Changes with Age: Distribution

    • Three key areas that change with age and affect drug distribution:
      1. Protein Binding
        • Albumin binds to acidic drugs (e.g., Naproxen, Phenytoin, Warfarin)
        • Alpha-1-acid glycoprotein binds to basic drugs (e.g., Lidocaine, Propranolol, Quinidine, Imipramine)
      2. Volume of Distribution
      3. Blood Flow
    • Changes in body composition with age:
      • Decrease in total body water (from 61% at age 25 to 53% at age 70)
      • Increase in fat percentage (from 14% at age 25 to 30% at age 70)
      • Decrease in cell solids and bone mineral

    Predisposing Risk Factors for Falls

    • Previous falls
    • Depression
    • Balance impairment
    • Decreased muscle strength
    • Medications
    • Gait impairment and walking difficulty
    • Visual impairment
    • Arthritis
    • Cognitive impairment
    • Pain
    • Age >80
    • Female
    • Low BMI
    • Urinary incontinence
    • Diabetes

    Geriatric Giant: Urinary Incontinence

    • Definition: Involuntary loss of urine in sufficient amount or frequency to constitute a social or health problem
    • Types:
      • Urge incontinence: leakage due to urgency
      • Stress incontinence: leakage due to cough, laugh, or sneeze
      • Mixed incontinence: combination of urge and stress incontinence
      • Overflow incontinence: leakage due to overextended bladder
      • Functional incontinence: leakage due to inability to toilet

    Acute, Reversible Causes of Urinary Incontinence (DRIP)

    • D: Delirium
    • R: Restricted mobility, retention
    • I: Infection, inflammation, impaction (fecal)
    • P: Polyuria, pharmaceuticals

    Drugs Associated with Urinary Incontinence

    • Alpha blockers (e.g., terazosin)
    • Anticholinergics (e.g., amitriptyline)
    • Antipsychotics/neuroleptics (e.g., methotrimeprazine, chlorpromazine)
    • Calcium-channel blockers (e.g., diltiazem)
    • Antihistamines (e.g., diphenhydramine)
    • Diuretics (e.g., furosemide)
    • Drugs for Alzheimer's disease (e.g., donepezil)
    • Ethanol
    • Lithium
    • Metoclopramide
    • Narcotics
    • Phenytoin
    • Sedatives/hypnotics (e.g., lorazepam)
    • Skeletal muscle relaxants (e.g., Can)

    Beers Criteria and STOPP/START Criteria

    • Purpose: Improve medication safety in older adults by increasing awareness of inappropriate medication use
    • Encourage healthcare providers to stop and consider carefully the risks, consider non-drug alternatives
    • Guide clinicians in making decisions about safe medication use in older adults
    • Broad application to electronic health records

    Medication Appropriateness Index (MAI) – Toolkit Online

    • Measures the appropriateness of prescribing for elderly patients using 10 criteria for each medication prescribed
    • Criteria include:
      • Indication
      • Is drug effective?
      • Is dose correct?
      • Are directions correct?
      • Are directions practical?
      • Drug-drug interactions
      • Drug-disease interactions
      • Is there duplication with other drugs?
      • Is duration of therapy acceptable?
      • Economics

    Strategies to Improve Adherence

    • Provide education to patients, family, and caregivers
    • Link medication doses with daily routines, such as meals
    • Use memory aids and administration aids
    • Team approach with MD: recommendations to assist in reducing the number of meds taken and/or frequency of doses

    Take Home Messages

    • Changes due to aging, co-morbidities, and multiple drugs make drug prescribing in the elderly complex
    • Adjustments for age, weight, renal function, hepatic metabolism, and low serum albumin are necessary
    • Education is important to avoid ADRs and IDP
    • "Start Low, Go Slow" (but keep going!)
    • Review regimen regularly
    • Non-specific complaints should prompt review to avoid prescribing cascades

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    Description

    This quiz covers the effects and risks of CNS depressants, including benzodiazepines, barbiturates, antipsychotics, opioids, and antidepressants. Learn about the potential risks of falls, fractures, respiratory depression, and cognitive impairment.

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