Podcast
Questions and Answers
What significant change in the cardiovascular system occurs as individuals age?
What significant change in the cardiovascular system occurs as individuals age?
Which of the following is a common chronic health condition affecting older adults?
Which of the following is a common chronic health condition affecting older adults?
How does aging affect the kidney's function related to drug metabolism?
How does aging affect the kidney's function related to drug metabolism?
What is the primary concern related to polypharmacy in older adults?
What is the primary concern related to polypharmacy in older adults?
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Which pharmacokinetic process is primarily affected by aging in the hepatic system?
Which pharmacokinetic process is primarily affected by aging in the hepatic system?
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What physiological change in the gastrointestinal system contributes to altered drug absorption in older adults?
What physiological change in the gastrointestinal system contributes to altered drug absorption in older adults?
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Which demographic change is expected in the US population by 2060?
Which demographic change is expected in the US population by 2060?
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How does aging generally affect the immune system's function?
How does aging generally affect the immune system's function?
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What is a primary concern when prescribing opioids to elderly patients?
What is a primary concern when prescribing opioids to elderly patients?
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Which of the following medications is recommended for cautious use in elderly patients due to its risk factors?
Which of the following medications is recommended for cautious use in elderly patients due to its risk factors?
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What strategy should be employed when starting medications for elderly patients with Narrow Therapeutic Index drugs?
What strategy should be employed when starting medications for elderly patients with Narrow Therapeutic Index drugs?
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What is a common issue associated with under prescribing in elderly patients?
What is a common issue associated with under prescribing in elderly patients?
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Why is it important to regularly review the medications of elderly patients?
Why is it important to regularly review the medications of elderly patients?
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Which of the following agents is recommended for deprescribing in elderly patients according to the AGS BEERS criteria?
Which of the following agents is recommended for deprescribing in elderly patients according to the AGS BEERS criteria?
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What is a significant risk associated with the prolonged use of proton pump inhibitors (PPIs) in the elderly?
What is a significant risk associated with the prolonged use of proton pump inhibitors (PPIs) in the elderly?
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What factor is primarily responsible for poor medication adherence in elderly populations?
What factor is primarily responsible for poor medication adherence in elderly populations?
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What is the primary effect of decreased glomerular filtration rate (GFR) in elderly patients regarding drug clearance?
What is the primary effect of decreased glomerular filtration rate (GFR) in elderly patients regarding drug clearance?
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Which phase of hepatic metabolism shows no change with aging, making these drugs preferred for elderly patients?
Which phase of hepatic metabolism shows no change with aging, making these drugs preferred for elderly patients?
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Which of the following drug classes is associated with increased sensitivity in elderly patients?
Which of the following drug classes is associated with increased sensitivity in elderly patients?
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What is the primary concern associated with polypharmacy in elderly patients?
What is the primary concern associated with polypharmacy in elderly patients?
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Which medication is known for showing increased sedation in elderly patients?
Which medication is known for showing increased sedation in elderly patients?
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What is the consequence of the prescribing cascade in geriatric patients?
What is the consequence of the prescribing cascade in geriatric patients?
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Among the following medications, which undergoes only Phase II metabolism and is therefore safer for the elderly?
Among the following medications, which undergoes only Phase II metabolism and is therefore safer for the elderly?
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What is the common outcome of decreased hepatic blood flow related to aging?
What is the common outcome of decreased hepatic blood flow related to aging?
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Evidence suggests older adults are more likely to experience adverse drug reactions (ADRs) leading to what?
Evidence suggests older adults are more likely to experience adverse drug reactions (ADRs) leading to what?
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Which of the following drug classes shows decreased sensitivity in elderly patients?
Which of the following drug classes shows decreased sensitivity in elderly patients?
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Which class of medications is considered a potentially inappropriate medication (PIM) for older adults according to Beers' Criteria?
Which class of medications is considered a potentially inappropriate medication (PIM) for older adults according to Beers' Criteria?
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What is a significant drug-drug interaction that should be avoided in older adults?
What is a significant drug-drug interaction that should be avoided in older adults?
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Which medication should not be used first-line for treating insomnia in elderly patients?
Which medication should not be used first-line for treating insomnia in elderly patients?
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According to the START criteria, what common prescribing error in elderly patients is highlighted?
According to the START criteria, what common prescribing error in elderly patients is highlighted?
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Which of the following medications is a highly anticholinergic medication that should be avoided in the elderly?
Which of the following medications is a highly anticholinergic medication that should be avoided in the elderly?
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Which of the following criteria is explicitly aimed at preventing adverse drug reactions in older patients?
Which of the following criteria is explicitly aimed at preventing adverse drug reactions in older patients?
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What is the primary goal of the ARMOR drug regimen review?
What is the primary goal of the ARMOR drug regimen review?
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Which of the following conditions would require careful assessment according to STOPP criteria in terms of medication prescription?
Which of the following conditions would require careful assessment according to STOPP criteria in terms of medication prescription?
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What percentage of patients was found to be missing appropriate medication according to the START screening tool?
What percentage of patients was found to be missing appropriate medication according to the START screening tool?
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Which of the following is a common intervention recommended for managing patients on opioids?
Which of the following is a common intervention recommended for managing patients on opioids?
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Which medication class should be monitored closely due to potential increased sensitivity in elderly patients?
Which medication class should be monitored closely due to potential increased sensitivity in elderly patients?
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According to the content, what is a key consequence of aging on renal function related to medication?
According to the content, what is a key consequence of aging on renal function related to medication?
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What screening tool should be applied when assessing older adults for potential omissions in necessary medications?
What screening tool should be applied when assessing older adults for potential omissions in necessary medications?
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What is an example of a medication commonly misprescribed or omitted in elderly patients with chronic atrial fibrillation?
What is an example of a medication commonly misprescribed or omitted in elderly patients with chronic atrial fibrillation?
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What is a significant risk when utilizing benzodiazepines for longer than four weeks in elderly patients?
What is a significant risk when utilizing benzodiazepines for longer than four weeks in elderly patients?
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Study Notes
The Aging Population
- The definition of older adults is age 65 or older.
- By 2030, all baby boomers will be over 65 and represent 1 in 5 residents.
- The US population's median age will grow from age 38 to age 43 by 2060.
- Most older adults have at least one chronic health condition.
- Arthritis is the most common at 53%.
- Older adults face higher out-of-pocket health care expenditures.
- In 2020, the average out-of-pocket cost was $6,668, a 38% increase from 2010.
- This represents 14% of their annual income, compared to 8% for all consumers.
- Medication costs comprise 11% of this amount, equating to $727 annually.
Physiology of Aging
- Cardiovascular system changes include a thicker heart wall, decreased heart rate, and increased systolic blood pressure.
- Pulmonary changes include thicker chest walls and wider central airways, resulting in decreased pulmonary flow.
- The Central Nervous System (CNS) experiences a decrease in brain size and blood-brain barrier function.
- Endocrine changes include decreased kidney size and glomerular filtration rate (GFR).
- Hepatic changes include decreased liver mass and CYP450 activity, leading to increased drug toxicity.
- The immune system experiences a general decrease in function.
- Gastrointestinal changes include decreased gastric emptying frequency and increased gastric emptying time.
- Overall body changes include decreased body water and muscle mass while body fat increases.
Challenges of Geriatric Pharmacotherapy
- Aging physiology significantly impacts drug therapy through pharmacokinetics and pharmacodynamics.
- Polypharmacy, including inappropriate prescribing and medication non-adherence, further complicates treatment.
Pharmacokinetics
- It refers to drug movement through the body, encompassing absorption, distribution, metabolism, and elimination.
- Aging affects all stages of pharmacokinetics.
Absorption
- Decreased gastrointestinal (GI) motility and blood flow can slow passive diffusion.
- However, overall bioavailability (F) for most drugs remains unchanged as increased drug transit time and absorption offset the decrease in blood flow.
- Increased GI pH may affect active transport.
- Bioavailability for some drugs like ions, vitamins, and minerals can decrease.
- Decreased hepatic blood flow can increase bioavailability of high-extraction drugs like TCAs, methylphenidate, propranolol, and nitroglycerin.
- The activation of prodrugs like enalapril can slow down.
Distribution
- Increased body fat increases the volume of distribution for highly lipophilic drugs, potentially increasing half-life.
- Decreased total body water decreases the volume of distribution for hydrophilic drugs.
- A decrease in serum albumin can increase the concentration of free drugs.
Metabolism
- Hepatic blood flow decreases with age, impacting drug clearance.
- Reduced cytochrome P450 activity decreases drug metabolism, leading to reduced clearance and increased half-life.
- Start low and go slow is a crucial principle.
Elimination
- Glomerular filtration rate (GFR) decreases with age by approximately 8 ml/min/decade.
- This can affect renal elimination of drugs and their metabolites.
Pharmacodynamics
- It refers to the body's biological response to drugs.
- Elderly patients experience significant changes in their responses to medication.
Effects of Aging on Pharmacodynamics
- Hospitalization rates due to adverse drug reactions (ADRs) are four times higher in elderly than in younger patients at 17%.
- Elderly patients are more sensitive to anticholinergic drug effects and experience increased sedation, increasing the risk of falls.
- Sensitivities may increase for drugs like digoxin, warfarin, alpha-blockers, diuretics, vasodilators, anticholinergics, alcohol, opioids, benzodiazepines, and antipsychotics.
- Sensitivities may decrease for drugs like beta-blockers, beta-agonists, and calcium channel blockers (CCBs) impacting cardiac conduction.
Challenges of Geriatric Pharmacotherapy
- Polypharmacy is defined as the use of five or more medications, affecting 35.8% of US adults.
- 13% of elderly patients on five or more drugs experience ADRs requiring medical attention.
- Polypharmacy is associated with increased risks of hospitalization, functional and cognitive impairment, delirium, falls, frailty, mortality, and nonadherence.
- Prescribing cascades occur when an ADR is misinterpreted as a new medical condition, leading to additional prescriptions.
- The focus should shift from quantity to quality of medications, utilizing STOPP/START criteria.
- Under-prescribing needs to be avoided, including analgesics, antidepressants, beta-blockers, antihypertensives, and Alzheimer's treatments.
- Overdosage is a concern, especially with narrow therapeutic index (NTI) drugs.
- Dosing adjustments, starting low and going slow are recommended.
- Interactions should be monitored, especially via CYP450 pathways.
- Inadequate monitoring can lead to missed therapeutic goals and ADRs.
- Monitoring labs periodically and reviewing drug necessity are essential.
- Patient adherence is critical, and communication, drug cost, and regimen complexity can affect compliance.
Tools for Appropriate Medication Selection and Utilization
- The American Geriatrics Society (AGS) Beers Criteria guidelines are designed to optimize medication selection and utilization in older adults.
- The STOPP criteria identify potentially inappropriate medications in older adults.
- The START criteria highlight medications that should be considered for initiation in older adults with specific conditions.
Inappropriate Drugs
- ADRs due to inappropriate drugs account for 3% of emergency department (ED) visits, with warfarin, digoxin, and insulin being common culprits.
- 20% of elderly patients use one inappropriate drug, leading to unsuitable drug selection, dose, frequency, or duration, therapy duplication, drug interactions, or continued medications for resolved conditions.
- The AGS Beers criteria identifies high-risk medications and provides recommendations for avoidance or cautious use in older adults.
AGS Beers Criteria Significant 2023 Updates
- Aspirin should be avoided for primary prevention in older adults over 60 years; consider deprescribing.
- Warfarin should be avoided unless direct oral anticoagulants (DOACs) are not suitable. Prioritize multimodal pain strategies and non-pharmacologic approaches.
- Rivaroxaban is discouraged for long-term nonvalvular atrial fibrillation or venous thromboembolism (VTE) treatment; Apixaban or dabigatran are preferred.
- Sulfonylureas for diabetes should be avoided unless other agents fail. Glipizide offers the best safety profile if necessary.
- Estrogens should be used cautiously, considering risks versus benefits. Consider deprescribing.
- Proton pump inhibitors (PPIs) should be avoided for scheduled use over eight weeks due to risks of Clostridium difficile infection, pneumonia, gastrointestinal malignancy, bone loss, and fractures.
- Opioids may increase delirium risk; prioritize multimodal pain strategies and non-pharmacologic approaches.
- Anticholinergics should be avoided due to adverse central nervous system effects and contributions to falls and fractures.
- Skeletal muscle relaxants are poorly tolerated for musculoskeletal (MSK) complaints. Consider alternatives due to anticholinergic effects, sedation, and fracture risks.
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors increase urogenital infection and euglycemic ketoacidosis risks; use with caution.
STOPP/START Criteria
- STOPP criteria alert physicians to potentially inappropriate medications (PIMs) in older adults.
- START screens patients for errors of omission, identifying medications that should be prescribed but aren't.
- Applying STOPP/START criteria within 72 hours of hospital admission reduced adverse drug reactions (ARR=9.3%; NNT=11) and reduced length of stay by 3 days.
- STOPP criteria include consideration of medication indication, beyond-duration use, and duplicate medication classes.
- Examples of STOPP criteria:
- Verapamil or diltiazem in NYHA Class III-IV heart failure
- Beta-blockers with calcium channel blockers (risk of heart block)
- Loop diuretics for dependent edema without heart failure, liver, or renal disease
- ACE inhibitors or ARBs with hyperkalemia
- Aspirin >160 mg daily
- Anticoagulants with aspirin in atrial fibrillation
- Ticlopidine
- Tricyclic antidepressants (dementia, glaucoma, urinary retention, etc.)
- Benzodiazepines for more than 4 weeks
- First-generation antihistamines
- Nonselective beta-blockers in asthma
- Benzodiazepines in respiratory failure
- START criteria highlight common errors of omission, such as:
- Statins in atherosclerotic disease
- Anticoagulation in chronic atrial fibrillation
- Antiplatelet drugs in arterial disease
ARMOR
- ARMOR is a drug regimen review process that includes:
- Assessment using Beers, STOPP, and START criteria
- Review of drug-disease interactions, drug-drug interactions, adverse drug reactions (ADRs), and functional status
- Minimization of medications with no evidence for use, where risk outweighs benefit, or that have a high negative impact on function
- Optimization of medications to address duplication/redundancy, renal dose adjustment, liver function, hypoglycemic medications, anticoagulants, seizure medications, antidepressants, and beta-blockers
- Reassessment of heart rate, blood pressure, fasting plasma glucose, functional/cognitive status, clinical status, and compliance
Medication Reconciliation
- Medication reconciliation identifies an accurate medication list, including dose, frequency, and route.
- Should be performed upon transfer of a patient.
- Ensures an accurate medication list follows the patient from hospital to clinic or clinic to hospital.
- Include prescription medications (Rx), topical medications, over-the-counter (OTC) medications, and supplements.
- Monitor medication lists for changes in patients, such as serum creatinine increase and cost.
Medication Review Questions
- Valid and current indication
- Appropriate dose
- Prevention of acute deterioration
- Actual or potential ADRs or drug interactions
- Drug efficacy in the specific patient
- Appropriate dosage form and schedule
- Cost-effectiveness
Medication Brown Bag Review
- ISMP recommends a "brown bag" checkup, where a primary care provider or pharmacist reviews all medications, including Rx, OTC, topical, herbal/natural, and supplements.
- This can be billed as a visit using Z79.X code.
Considerations for Prescribing in Older Adults
- Hepatic and renal functions decline with age, requiring avoidance or reduced dosage of many medications.
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Potentially inappropriate medications (PIMs) for older adults:
- First-generation antihistamines
- First- and second-generation antipsychotics
- Tricyclic antidepressants (except doxepin 125 mcg)
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Drug-drug interactions to avoid in older adults:
- Multiple anticholinergics
- Opioids with benzodiazepines/gabapentinoids
- Three or more CNS medications
- Multiple renin-angiotensin system (RAS) inhibitors
- RAS inhibitors with potassium-sparing diuretics
- ACE inhibitors/ARBs/loop diuretics with lithium
- Peripheral alpha-1 blockers and loop diuretics
- Warfarin with amiodarone, ciprofloxacin, macrolides (except azithromycin), trimethoprim/sulfamethoxazole (TMP-SMZ), or selective serotonin reuptake inhibitors (SSRIs)
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Highly anticholinergic medications include:
- First-generation antihistamines
- Tricyclic antidepressants (except doxepin < 6 mg)
- Antimuscarinics used for urinary incontinence
- Certain antispasmodics
- Certain antipsychotics
- Benztropine and trihexyphenidyl
- Cyclobenzaprine and orphenadrine
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Don't do the following:
- Use antipsychotics first-line for dementia.
- Add medications to push A1c below 7.5%.
- Use benzodiazepines or other sedative-hypnotics first-line for insomnia, agitation, or delirium.
- Use antibiotics for asymptomatic bacteriuria.
- Prescribe appetite stimulants or supplements for anorexia or cachexia without periodic reassessment.
- Conduct a drug regimen review before prescribing any medication.
Assessment
- The medication class recommended by the Beers Criteria to be avoided in the elderly is anticholinergics.
- The START criteria address prescribing errors in the elderly that are due to underprescribing.
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Description
This quiz explores key aspects of the aging population, including demographic changes and health challenges faced by older adults. It also covers the physiological changes that occur in various systems of the body as people age. Test your knowledge on these important topics related to gerontology.
