84 Questions
Which age group is most affected by pharmacokinetic and pharmacodynamic changes?
Older persons
What is a common consequence of polypharmacy in older persons?
Increased risk of ADRs
What is the primary mechanism of action of anticholinergic drugs?
Blocking the action of acetylcholine
Which of the following conditions is NOT treated with anticholinergic drugs?
Hypertension
What is a potential consequence of prescribing anticholinergic agents to older persons?
Increased mortality
What is a common adverse effect of anticholinergic drugs in older persons?
Cognitive impairment
What is a potential interaction that can increase the risk of ADRs in older persons?
All of the above
Why should anticholinergic drugs be avoided in older persons?
They are associated with adverse effects
What is the purpose of anticholinergic burden scales?
To aid clinicians in their decision-making during a medication review
What is the significance of a score of 3 or more on the anticholinergic burden scale?
The patient is at significant risk of adverse effects
Which of the following medications has a consistent score of 3 on some anticholinergic burden scales?
Clomipramine
Why does the American Geriatrics Society recommend avoiding the use of anticholinergic medications in older persons?
Because older persons are more likely to experience adverse side-effects from anticholinergics
What is the purpose of the Anticholinergic Burden Calculator?
To aid clinicians in their decision-making during a medication review
Which of the following is a recommended alternative to sedating antihistamines?
Fexofenadine
What is the cumulative anticholinergic burden score of Tanya's medications before the medication review?
12
Which of the following medications was stopped/weaned due to drug errors identified during the medication review?
Sertraline, Tolterodine, and Aripiprazole
What is the total anticholinergic burden score of Tanya's medications after the medication review?
7
What is the main limitation of anticholinergic burden scales?
All of the above
What is the potential reason for the patient's epistaxis?
Taking DAT
What is the correct drug-drug interaction?
azathioprine and allopurinol
What is the pharmacodynamic change that results in increased responsiveness to benzodiazepines?
Changes in the neurotransmitter gamma-aminobutyric acid (GABA)-benzodiazepine receptor complex
What is the result of pathological changes in organs?
Changes in receptor binding
What is the predictor of polypharmacy?
Number of co-morbidities
What is the definition of polypharmacy?
Taking more than five medications
What is the risk associated with polypharmacy?
Both A and B
What is the purpose of the 7 Steps framework?
To center on what 'matters' to the patient
What is Tanya's level of frailty?
Moderate frailty
What is the indication of Tanya's admission?
Epistaxis and a fall
What is the primary purpose of the 'sick day rule'?
To provide guidance on medication cessation during dehydration
Which medication class can increase the likelihood of dehydration?
Diuretics
What is a potential consequence of dehydration in patients taking metformin?
Lactic acidosis
What percentage of unplanned hospital admissions due to adverse drug events are estimated to be preventable in older patients?
25%
What is a common adverse effect of anticholinergic medications in older patients?
Cognitive impairment
What is a potential interaction between NSAIDs and other medications?
Increased risk of heart failure
What is a potential consequence of prescribing α1-adrenergic receptor antagonists to older patients?
All of the above
Which medication can increase the risk of ADRs when used with clarithromycin?
Simvastatin
What is a tool used by pharmacists to determine drug-drug and drug-disease interactions?
Stockley's Interactions Checker
What is the name of the patient who was admitted to the hospital with epistaxis and was found to be taking OTC ibuprofen?
Tanya
What was the outcome of medication optimization in relation to the ACB score?
It decreased from 7 to 3
What is the estimated error rate among patients prescribed ten or more medications?
47%
What is the primary indication for Tanya's prescription of Theophylline?
Chronic obstructive pulmonary disease
What is the definition of a medication error, according to the National Coordinating Council for Medication Error Reporting and Prevention?
Any preventable event that may cause or lead to inappropriate medication use or patient harm
What is the purpose of the 7-Steps to appropriate polypharmacy?
To determine the most essential medications for a patient
What percentage of medication incidents reported resulted in actual patient harm?
16%
What is the estimated global cost associated with medication errors?
US$42 billion annually
What is the primary reason for Tanya's prescription of Aripiprazole?
To treat her depression
Why is generic prescribing recommended?
To avoid confusion and improve patient safety
What is the primary mechanism of action of Telmisartan?
To reduce blood pressure and alleviate heart failure
At which points in the medication process can errors occur?
At multiple points, including ordering, documenting, transcribing, dispensing, administering, and monitoring
What is the primary indication for Tanya's prescription of Oxybutynin?
To manage her overactive bladder
What is the purpose of the first step in the 7-Steps to appropriate polypharmacy?
To ask the patient what matters to them
What was the reason for Tanya's unnecessary medication with aripiprazole?
A mix-up with her daughter's prescription
Why is medication reconciliation important?
To reduce the potential for errors at interfaces of care
What is the primary indication for Tanya's prescription of Brimica genuair?
To treat her chronic obstructive pulmonary disease
What is the importance of confirming an accurate list of medication?
To avoid confusion and reduce the potential for errors
What is the primary mechanism of action of Bisoprolol?
To reduce blood pressure and alleviate heart failure
What is the primary indication for Tanya's prescription of Duloxetine?
To manage her depression
What is the primary purpose of the 7-Steps to appropriate polypharmacy in relation to the patient?
To establish person-centred goals and prioritize the patient's needs
What is the primary reason for not stopping essential drug therapy without specialist input?
To ensure the patient does not experience rapid symptomatic decline
What is the main goal of reviewing the indication of other medications?
To determine if therapeutic goals are being achieved
What is the benefit of reducing the dose of a medication?
It reduces the burden of medication on the patient
What is the primary goal of informing relevant healthcare and social care professionals of changes in treatments?
To optimize patients' treatment to achieve their preferred outcomes
What is the estimated savings in medication costs for every pound invested in the review process?
£2.38
What is an important factor to consider when assessing the effectiveness of a medication?
The patient's perception of the medication's effectiveness
What is the definition of inappropriate polypharmacy according to the National Institute on Aging?
The use of excessive or unnecessary medications
What is a common adverse drug reaction (ADR) in older adults?
Delirium
What should be considered when deciding to change a medication for cost reasons?
The medication's effectiveness, safety, and adherence
What is the primary focus of the King's Fund's paper on polypharmacy and medicines optimization?
Optimizing medication use to achieve better patient outcomes
What is an important step in implementing the plan agreed upon with the patient?
Liaising with caregivers and providing clear instructions
According to the Scottish Government Polypharmacy Model of Care Group, what is a critical aspect of appropriate polypharmacy?
Prescribing medications according to best evidence
What is the estimated reduction in medication prescribed to residents in care homes participating in the Northumbria NHS Trust's medication review project?
17%
What should be discussed with the patient when agreeing on the plan?
The outcomes of the review in terms of medication changes
What is the primary benefit of reducing the number of medications prescribed to patients?
Improving patient outcomes
Why is it important to identify medications that are deemed essential to the patient?
To understand the patient's perspective on their medication
What is the primary goal of the medication review process?
To identify opportunities for medication optimization
What is the definition of appropriate polypharmacy according to the King's Fund?
Prescribing medications according to best evidence
What is the primary focus of the Scottish Polypharmacy Model of Care Group?
Optimizing medication use to achieve better patient outcomes
What is the estimated time saved by nurses in administering medications after participating in the Northumbria NHS Trust's medication review project?
1 hour
What is a key characteristic of appropriate polypharmacy?
Drugs are prescribed for specific therapeutic objectives agreed with the patient.
In which situation does inappropriate polypharmacy occur?
When a patient is taking multiple medications with no evidence-based indication.
What is a consequence of inappropriate polypharmacy?
Patients are at an unacceptably high risk of adverse drug reactions.
What is a requirement for appropriate polypharmacy?
Patients must be motivated and able to take all medicines as intended.
What is an important consideration in optimizing drug therapy for appropriate polypharmacy?
Minimizing the risk of adverse drug reactions.
What is a key difference between appropriate and inappropriate polypharmacy?
The therapeutic objectives of the medications.
Study Notes
Pharmacokinetic and Pharmacodynamic Changes in Older Adults
- With advanced age, regulatory processes that ensure functional integration between cells and organs are impaired, leading to changes in pharmacokinetics and pharmacodynamics.
Pharmacokinetic Changes
- Affect how the body handles drugs, including absorption, distribution, metabolism, and elimination.
- Impaired liver and kidney function, decreased muscle mass, and altered body composition contribute to pharmacokinetic changes.
Pharmacodynamic Changes
- Affect drug actions on the body, including changes in receptor binding, postreceptor effects, and adaptive homeostatic responses.
- Increased permeability of the blood-brain barrier, decreased responsiveness to beta-agonists, and increased sensitivity to anti-hypertensives are examples of pharmacodynamic changes.
Anticholinergic Drugs
- Associated with adverse effects in older persons, including cognitive impairment, confusion, delirium, and increased mortality.
- Avoid prescribing anticholinergic drugs in older persons, and recommend alternative medications where possible.
- Anticholinergic burden scales, such as the Anticholinergic Cognitive Burden (ACB) scale, can help clinicians assess the risk of adverse effects.
Medication Errors and Polypharmacy
- The rate of medication errors increases with the number of medicines prescribed, with 47% of patients taking ten or more medications experiencing a prescribing or monitoring error.
- Medication errors can occur at any stage of the medication process, including ordering, documenting, transcribing, dispensing, and administering.
- Polypharmacy is a major risk factor for adverse drug reactions, with 25% of unplanned hospital admissions in older adults being preventable.
Adverse Drug Reactions (ADRs)
- Commonly cause adverse clinical outcomes in older people, with 8.6 million unplanned hospital admissions in Europe annually.
- ADRs can be caused by drug-drug and drug-disease interactions, as well as polypharmacy.
- Older people are at increased risk of ADRs due to physiological changes associated with aging, including decreased counterregulatory mechanisms.
Pharmacodynamic Changes and Age
- Changes in drug-receptor interactions, adaptive homeostatic responses, and pathological changes in organs can affect drug actions on the body.
- Examples include increased sensitivity to benzodiazepines, decreased response to beta-agonists, and increased susceptibility to postural hypotension.
Polypharmacy and its Risks
- Defined as taking five or more medications, with excessive polypharmacy being ten or more medications.
- Predictors of polypharmacy include the number of co-morbidities and the number of prescribers involved.
- Risks associated with polypharmacy include cognitive impairment, falls, immobility, incontinence, multi-morbidity, and reduced quality of life.### Patient Information
- Tanya is an 82-year-old patient with multiple medical conditions.
- She has Chronic Obstructive Pulmonary Disease (COPD), Stage III, with a forced expired volume (FEV) of 1-38% and is on long-term oxygen therapy (LTOT).
- Other medical conditions include overactive bladder, vaginal prolapse, congestive cardiac failure (CCF), depression, vitamin D deficiency, intermittent hemodialysis (IHD), angina, and hypercholesterolemia.
Medications
- Folic acid (5 mg daily) - B group vitamin, vitamin B9
- Desunin (colecalciferol) (1600 units daily) - Vitamin D
- Duloxetine (60 mg daily) - Antidepressant
- Atorvastatin/ezetimibe (10/40 mg) - Cholesterol
- Duoplavin (clopidogrel 75/aspirin 75 mg) - Antiplatelet medication, cardio-protective
- Pantoprazole (40 mg) - Stomach tablet to reduce acid
- Oxybutynin (10 mg daily) - Treats urge incontinence/urinary frequency
- Aripiprazole (15 mg daily) - Antipsychotic medication
- Telmisartan (40 mg daily) - Blood pressure/heart failure
- Theophylline (200 mg twice a day) - Treats COPD
- Sertraline (Lustral) (100 mg daily) - Antidepressant
- Bisoprolol (1.25 mg daily) - Antihypertensive/heart failure/angina
- Bumetanide (2 mg) - Diuretic used in heart failure
- Detrusitol (tolterodine) (4 mg daily) - Urge incontinence/urinary frequency
- Ventolin (salbutamol) "200" Diskus T inhalation (every 3.5 hrs) - Bronchodilator
- Brimica genuair 340/12 (aclidinium/Formoterol) (one puff twice a day) - Inhaler for COPD
- Ibuprofen (over-the-counter) - Pain relief
7 Steps to Appropriate Polypharmacy
- Step 1: What matters to the patient?
- Identify patient's goals and priorities
- Establish person-centered goals
- Step 2: Is the medicine essential?
- Review medications for essentiality
- Ensure patient understands importance of essential medications
- Step 3: Is it unnecessary or harmful?
- Review medications for therapeutic goals and risk vs. benefit
- Consider deprescribing unnecessary medications
- Step 4: Is it cost-effective?
- Review medications for cost-effectiveness
- Explore opportunities for cost minimization
- Step 5: Effectiveness
- Review therapeutic objectives and medication effectiveness
- Discuss and decide on adding, intensifying, or stopping medications
- Step 6: Safety/harm
- Identify safety risks and adverse drug reactions (ADRs)
- Monitor for drug-disease interactions, drug-drug interactions, and high-risk drugs
- Step 7: Agree plan with patient and communicate
- Agree and communicate plan with patient and/or caregiver
- Ensure patient understands outcome of review and administration instructions
Appropriate and Inappropriate Polypharmacy
- Appropriate polypharmacy: prescribing for an individual with complex conditions, optimized medication use, and evidence-based therapeutic objectives
- Inappropriate polypharmacy: prescribing multiple medications inappropriately, or where intended benefits are not realized
- The Scottish Polypharmacy Model of Care Group defines five stages for appropriate polypharmacy:
- Prescribing (and risk assessment)
- Medication review
- Dispensing and administration
- Communication and patient engagement
- Medication reconciliation (at care transitions)
This quiz covers the changes in pharmacokinetics and pharmacodynamics that occur with advanced age, affecting the body's handling of drugs and their actions on the body.
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