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What is key to prevention of cardiovascular disease and stroke?Control of blood pressure.Hypertension affects70% to 80% of older adults.Older adults who require anithypertensive medication should initially be prescribeda low-dose thiazide-type diuretic, angiotensin-converting enzyme inhibitor, angiotensin 2 receptor blocker, or long-acting calcium channel blocker.What should not be used as primary treatment for systolic hypertension in older adults?Beta-blockers, studies have shown that the use of beta-blockers may be worse than other agents in preventing stroke and may hasten death.What results in polypharmacy?The treatment of chronic illnesses and associated comorbidities.What can lead to greater complications and diminished mental status?The interactions of multiple medicationsWhat is not a normal part of aging?Altered mental status.Medication adherence and agingIt is often difficult to remember medications or maintain appropriate administration schedules.Patients who have decreased visionmay not be able to discriminate the dosing instructions or may not be able to see the amount of insulin drawn up in an insulin syringe.Economic factors also contribute to nonadherenceSome older adults may have to choose between the cost of their medications and the ability to purchase food or pay for utilities.Why should we start with smaller doses?Improves adherence to the medication regimen and minimizes adverse effects.Drug-receptor interactionOlder adults may have a diminished number of receptor sites, or decreased affinity of the drug to a receptor. As a result the drug does not have the same ability to produce a desired effect.Why are patients more at risk for adverse reactions?Receptors that are responsible for drug distribution may also be diminished leaving the patient at risk for more adverse reactions.What should nurses be aware of?Other physiologic changes associated with increased age.What does increase in body fat mean?The volume of distribution of drugs may be increased based on the older adult's increase in body fat relative to the percentage of the skeletal muscle.What does decline in renal function inhibitInhibits the adequate clearance of a drug. In addition, drug storage reservoirs increase with age. This physiologic change prolongs a drug's half-life, increasing the plasma drug concentrations.Absorption - GIInclude decreased gastric acidity, with an increase in the gastric pH, may lead to delayed absorption or lack of absorption of medications that require this decreased pH.Absorption - blood flowdecreased blood flow and decreased surface area to support absorption.Absorption - gastricDiminished gastric emptying also plays a role by causing the medication to be in the stomach for a longer period. This factor increases the risk of developing nausea and vomiting, thus elimination of the medication in emesis and promoting fluid volume deficit.Absorption - circulationDecreased circulation means that perenteral medications are also slowly absorbed.Absorption - muscleDecreased muscle mass and altered circulation can result in abnormal blood concentrations of medications administered intramuscularly.In all cases, a slow rate of absorptioncan result in changes in peak serum drug levels. This factor may require greater dosages to be administered to produce therapeutic results.Distribution-Diminished cardiac output. -Increased body fat. -Decreased body mass and body fluid. -Decreased serum albumin.Aging results in body mass changes:The proportion of body fat increases while lean body mass decreases. These changes may have consequences.Lipid-soluble drugsStay in the fat tissue for a longer period of time.Water-soluble drugsAntibiotics are distributed in smaller volumes due to the decrease in total body fluid volume. This increases the risk of toxicity because drug concentrations are greater.Many medications requireserum albumin to bind, transport, and distribute the medication to the target organ.In the even that the amount of serum albumin is insufficientthe amount of free drug arises, and the effect of the drug is more intense.Why do medications not get distributed adequately?Decreased circulation and diminished cardiac output.What happens at 60?The liver begins to decrease in size and mass.Decrease in the hepatic circulationlowers the rate of metabolism.What happens when the heptaic enzymes of the liver decrease?Alters the ability to remove metabolic by-products. Older adults have a reduced metabolism, medications with a long half-life will remain in the body for a greater amount of time.ExcretionThe elimination of medications is vital in the prevention of adverse drug reactions.Alterations in medication excretion include:1. Diminished renal blood flow. 2. Decreased number of functioning nephrons. 3. Diminished glomerular filtration rate. 4. Diminished tubular secretion.Dosages with an increased half-lifeShould be lower.What is an important indicator of the renal systemCrCl is an important indicator of the ability of the renal system to eliminate the medication and prevent adverse drug effects.In most older adultsThe serum creatinine remains within the normal range due to decreasing creatinine levels in association with a decrease in muscle mass.What is the most reliable measure for evaluation of renal function?Glomerular filtration rate.What is the alternative to the 24- hour CrCl and glomerular filtration rate?Cockroft-Gault method, this method estimates the CrCl.With a decreased CrClIt is necessary to reduce the dosage of the medication.Beers CriteriaIt provides clinicians with the names of the medications that are potentially inappropriate for use in older adults, listing drugs to be avoided and giving adjustments in dosages related to chronic kidney disease and diminished kidney function.How often is Beer Criteria updated?Every 3 years.Who determines new criteria?An interdisciplinary panel of experts.Two new parts in 2019:1. Drugs for which dose adjustment is required based on kidney function. 2. Drug-drug interactions.First-Generation antihistamines (Anticholinergics)Diaphenhydramine and Meclizine. Highly anticholinergic; clearance reduced with advanced. Avoid.Antispasmodics (anticholinergics)Atropine and Scopolamine. Highly anticholinergic; uncertain effectiveness. Avoid.AntithromboticsDipyridamole. May cause orthostatic hypotension; more effective alternatives available. Avoid.Anti-infectiveNitrofurantoin. Potential pulmonary toxicity, hepatotoxicity, and peripheral neuropathy; more effective alternative available. Avoid in individuals with creatinine clearance less than 30 mL/min or for long-term suppression of bacteria.Peripheral Alpha-1 blockers (cardiovascular)Prazosin and Doxazosin. High risk of orthostatic hypotension. Avoid use as an antihypertensive.Central Alpha-1 blockers (cardiovascular)Clonidine. High risk of adverse CNS effects; may cause bradycardia and orthostatic hypotension. Avoid as first-line antihypertensive.Antiarrhythmic (cardiovascular)Digoxin. Atrial fibrillation: should not be used as first-line agent. Heart failure: Conflicting evidence; Decreased renal clearance may lead to toxicity. Avoid as first-line for atrial fibrillation. Avoid doses > 0.125mg daily.Antiarrythmic (cardiovascular)Amiodarone. Effective, ut has higher rate of toxicity than other antiarrhymics for a-fib. Avoid as first-line therapy for a-fib, unless patient has heart failure or substantial left ventricular hypertrophy.Antidepressants (CNS)Amitriptyline and Paroxetine. Highly anticholinergic, sedating and cause orthostatic hypotension. Avoid.Antipsychotics (CNS)All first and second generation. Increased risk of cerebrovascular accident and greater rate of cognitive decline and mortality in patients with dementia. Avoid for behaviors problems of dementia and delirium unless high risk of harm to self or others. Avoid except for schizophrenia, bipolar disorder, or use and an antiemetic during chemo.Barbiturates (CNS)Phenobarbital. Greater risk of overdose at low dosages; higher rate of physical dependence. Avoid.Benzodiazepines (CNS)Alprazolam, Lorazepam, Chlordiazepoxide, Clonazepam and Diazepam. Older adults have increased sensitivity to these drugs. Increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults. Avoid.Nonbenzodizepines, benzodiazepine receptor agonist hypnotics (CNS)Zolpidem. Similar to benzodiazepines. Avoid.Endocrine related agentsInsulin, sliding scale. Refers to sliding scale treatment with short- or rapid-acting in absence of basal insulin; higher risk of hypoglycemia. Avoid.Sulfonlureas, long-durationGlyburide. HIgher risk of severe prolonged hypoglycemia in older adults. Aoid.Gastrointestinal AgentsMetoclopramide. Can cause extrapyramidal effects including tardive dyskinesia. Avoid, unless used for gastroparesis and duration not to exeed 12 weeks.Non-Steroidal Anti-inflammatory (NSAIDs)Asprin, Diclofenac, Ibuprofen, Naproxen and Ketorolac. Increased risk of GI bleeding or peptic ulcers in high risk groups (>75 yo taking parenteral corticosteroids, anticoagulants, or antiplatelet agents). Avoid chronic use unless other alternative not effective and patient can take gastroprotective agent.Skeletal muscle relaxantsCyclobenzaprine and Methocarbamol. Some anticholinergic effects, sedation, and increased risk of fractures. Avoid.