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Iatrogenic Disease in Older Adults
Terms in this set (39)
What are some normal effects of aging on the body?
- Lungs: vital capacity declines
- Kidneys: filter more slowly, bladder capacity decreases
- Bones: become less dense, wear and tear causes OA
- Reproductive system: testosterone and oestrogen drop
- Heart: SV decreases
- Skin: thins, loses elasticity, fat deposits under skin drop, age spots develop
- Face: nose and earlobes lengthen, wrinkles develop (from facial expressions and sun exposure)
- Head/brain: skull thickens, head size increases, brain decreases in size (but no effect on mental function)
- Hair: thins, turns grey
- Eyesight: lenses harden
- Ears: ability to hear high frequencies drops
What do you see more of when people age?
- Loss of homeostatic reserve and lessened resilience = "frailty"
- Increased numbers of disease and conditions
- Chronicity of diseases and conditions
- Multiplicity of medications (most are long-term)
- Changing psychosocial environments (e.g. how well you can see etc, but also brain functioning changes)
What does iatrogenic mean?
Iatrogenic = producing an illness as a result of treatment
This may not be the action of a physician, but could be any health practitioner (allopathic or alternative), or even the patient.
Age alone doesn't define those who have a predisposition to iatrogenic diseases and adverse effects of treatment.
Note: many drugs have not been tested in adults, or with....?
Combinations of drugs
Case study of Mr B (aged 83):
- Frusemide would've again made him pee more
Several days later what happened?
Confusion and delirium led to a fall -> hip fracture (very bad outcome in someone older)
While he was in hospital he suffered from what issues?
- Urinary retention (the IDUC can increase infection risk -> which can then worsen delirium)
- Marked postural instability when attempting to mobilise
(as we can see, these each had various contributing factors)
Delirium is often caused by a medical condition such as what?
- Substance intoxication or withdrawal
- Or a medication side effect
Delirium has sudden onset (over hours-days) and lasts for how long?
For days to a month (often more severe at night time)
What does delirium present with?
- Memory loss
- Difficult with speech and language
- Hallucinations, delusions
- Change in ability to focus, sustain or shift attention
There are two forms of delirium:
1) Hypoactive delirium = Patients can be drowsy or lethargic, or
2) Hyperactive delirium = Can have psychomotor agitation, sleep-wake reversals, irritability, anxiety, emotional liability, and hypersensitivity to lights and sounds
What is dementia?
Progressive decline in cognition (more subtle and slow than delirium) - which leads to issues with:
- Learning and memory
- Executive function
- Perceptual motor skills
- Social cognition
Deficits become severe enough to interfere with daily function and independence (e.g. safety at home, finances, activities of daily living). What is the most common cause of dementia?
Outcome for our patient (Mr B):
- Have to take someone off drugs carefully and slowly
This is an example of iatrogenic disease = treating his symptoms led to a worse disease state
What factors caused Mr B's situation?
- "Medicalisation" of conditions and polypharmacy
- Assuming "one size fits all" for types of treatment
- Failure to explain the purpose and likely outcomes of investigations and treatments to patients and relatives/care givers
- Under and over-investigation and under and over-enthusiastic diagnostic effort (finding more things and feeling like you have to treat them)
- The employment (or lack of) appropriate rehabilitative procedures
- Poor communication between healthcare professionals
- Ignorance of normal values for common diagnostic tests in older age
In terms of polypharmacy in the elderly, here we can see some statistics:
What is polypharmacy?
Polypharmacy = the use of 5 or more medications in older people
What does this lead to as consequences?
- Adverse drug reaction (ADR) risk: increased 3-4x, 80% of the time increased in those on 6+ meds
- Falls (2x increased risk if 4+ meds)
- Medication errors (35% risk of this if 4+ meds)
- Drug-drug interactions
- Prescribing cascades
So what is a challenge in older people?
What are some risk factors for ED admissions due to ADRs in ages 65+ (38% admitted)?
- Being aged 85+ (rate is 3.5x higher)
- Women (60%)
- More likely to be admitted if on 5+ medications (2/3 of those admitted are due to unintentional overdose)
There are 4 main medication types implicated in ADR hospitalisations - what are they?
1) Warfarin (33%)
2) Insulin (14%)
3) Oral antiplatelets (13%)
4) Oral hypoglycaemics (11%)
What are the two types of adverse drug reactions (ADRs)?
1) Type A = reactions which are attributable to accentuation of a drug's known pharmacological action(s):
- Related to dose
- More predictable (listed on medications)
- Relatively common
2) Type B = reactions which are idiosyncratic:
- Unrelated to dose
- Often unpredictable and of unknown mechanism
- Governed by host factors such as genetics or allergies
- Less common but often more serious
What factors contributes to the problem of adverse drug reactions happening with age?
1) Inadequate clinical assessment and multiple disorders
2) Excessive prescribing and inadequate review of medications
3) Altered pharmacokinetics
4) Altered pharmacodynamics
5) Altered responsiveness to medications
6) Impaired compliance
In terms of inadequate clinical assessment and multiple disorders - this refers to what?
- Older people often have non-specific symptoms at presentation (falls, confusion, incontinence)
- Doctors are not skilled at getting a collateral history
- Takes time to find the underlying cause
- Older people often have multiple disorders (multimorbidity) -> which means more medications -> more drug interactions -> and so more interventions
What are some reasons that lead to (2) excessive prescribing and inadequate review of medication?
1) Multiple disorders (multimorbidity)
2) Pressure on doctors to prescribe
3) Therapeutic enthusiasm and over-energetic treatment
4) Inappropriate treatment, then inadequate supervision of what is prescribed (know the common side effects, and ask the patient what they're feeling!)
In terms of altered pharmacokinetics (absorption, distribution, metabolism and excretion) in the elderly, what are the four main changes that occur?
1) Absorption is decreased (gastric atrophy impairs some absorption)
2) Increased body fat relative to mean mass:
- Leads to decreased volume of distribution for hydrophilic drugs (e.g. digoxin, lithium, ethanol)
- Increased volume of distribution for lipid soluble agents (e.g. long acting BZDs)
3) Hepatic mass and blood flow decreases with age:
- This is important if there is high first pass metabolism (e.g. with CCBs, propanolol)
- Note: blood LFTs are not helpful in predicting the extent of this in an individual patient
4) Excretion: Renal function changes with age:
- Reduced functioning nephrons
- Decreased RBF and decreased GFR (clearance of creatinine is reduced but less creatinine produced because of reduced muscle mass)
- Many drugs excreted by the kidney may be affected by this (e.g. digoxin)
In terms of (4) altered pharmacodynamics, what are the two main changes that occur with age?
1) Greater anticoagulant effect for a given dose (for heparin or warfarin in older adults)
2) Elderly tolerate CNS drugs less well (e.g. BZDs)
- New drugs are not specifically tested in the elderly
In terms of (5) altered responsiveness to medications, what does this mean?
- The therapeutic window narrows with age
- There is altered receptor and post-receptor responsiveness at end-organs (increased opiate sensitivity, decreased beta receptors)
- Normal starting doses of medications may be too high (especially if dealing with patients without much lean/fat mass on them)
In terms of (6) impaired compliance, 75% of seniors make mistakes and of these 25% are potentially serious (e.g. drug ADR, driving etc).
What are the three types of factors that lead to impaired compliance?
1) Patient factors:
- Living along and/or not coping
- Poor memory/confusion
- Tendency to judge illness by symptoms
- Reservations towards taking medications
- Vision impairments (medication print is very small)
- Dexterity impairments (issues opening containers)
2) Prescriber factors:
- Quality of explanation/instructions
- Poor instructions on prescription
- Inattention to total number of drugs
- Excessive medication times (some drugs need to be taken many times a day)
3) Medication Factors:
- Pill size (too big to swallow)
- Pill packaging (hard to open)
- Delivery method (e.g. inhalers tricky to use)
- Side effects
- Change in formulation/colour/shape (can be confusing)
- Confusion instructions (e.g. in the case of bisphosphonates - where you can't eat or drink or lie down 30 minutes after taking it)
Poor compliance is associated with poor outcomes. Compliance can be improved with intervention. What is the main thing to do?
Talk to the patient (call once a week to check things, really improves compliance)
What are some clues that help you identify a non-compliant patient?
- Lack of expected benefit
- Lack of knowledge of medications (explain it well)
- Unknown to the pharmacy (not getting drugs)
- Runs out of supplies too easily (means they are not taking them as they should)
- Drug counts (do they add up)
- Blood or urine samples
- Failure to attend appointments
Don't blame the patient for non-compliance. What is a large part of the problem?
What is the typical profile of a patient who is liable to an ADR?
- Small older female
- History of allergic illness
- Previous ADRs
- Multiple chronic illnesses
- Renal failure
- Cognitive decline
(so if you are adding more drugs to someone like this, think again)
What are some ways to reduce ADRs?
1) Get things right:
- Right diagnosis
- Right drug (or no drug) for the diagnosis
- Right dose
- Right drug name (e.g. penicillin vs penicillamine)
- Right patient (inpatient labels exist for a reason)
- Right follow up (ask about side effects and patient tolerability)
2) Choose non-pharmacological methods where possible
3) Address psychological factors early
4) Weigh up benefits vs risks
5) Start low, and go slow
6) Identify hazardous medications before you start them :
- Revised Beers criteria/STOPP-START
7) Be brave enough to cease drugs (carefully, and watch for withdrawals)
- Expect around 75-80% to have no adverse withdrawal events (watch for angina/cardiac events though - GP has a role in monitoring)
What are some measure to improve compliance?
- Minimise types of drugs where possible
- Once or twice daily with meals (easier)
- Good explanation and simple instructions
- Written instructions and drug record card
- Supervised self medicating pre-discharge
- Containers (pill boxes, blister packs) -> these require clear labelling and don't work for all drugs
- Memory aids (e.g. calendar packs)
Who has a central role in terms of inpatients, outpatients and medication management?
What does medication reconciliation involve?
- Ensure medications someone is given are the same as those they are prescribed and administered
- Avoid omission of prescribed medications + ensure previously ceased medications are not restarted
- Ward and community pharmacy is pivotal
What is NZePS?
NZ ePrescription Service = provides secure messaging channel for prescribing and dispensing prescription information electronically:
1) Prescription is generated by prescriber, transmitted to NZePS health information exchange broker -> downloaded electronically at a community pharmacy
2) Prescriber can note reason for prescribing:
- Make other comments at the time of prescribing
- Sent as part of the prescription information passed electronically to the pharmacys
3) Prescribers can request a notification when a patient's medication has not been dispensed (and pharmacists can send dispensing comments back to the prescriber)
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