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This Psychiatric Medication Is Involved in More Emergency Room Visits Than Any Other— And more on: Absorption, Distribution, Metabolism, Elimination. · Pearls and Prep

• 0:00
  Foreign.
• 0:05
  Welcome
• 0:05
  back,
• 0:06
  my
• 0:06
  friends,
• 0:06
  to
• 0:06
  another
• 0:07
  episode
• 0:07
  of
• 0:07
  Pearls
• 0:08
  and
• 0:08
  prep.
• 0:09
  Npz.
• 0:09
  Here,
• 0:10
  your
• 0:10
  preceptor
• 0:11
  in
• 0:11
  your
• 0:11
  pocket,
• 0:12
  your
• 0:12
  go
• 0:12
  to
• 0:12
  place
• 0:13
  for
• 0:13
  pearls
• 0:14
  that
• 0:14
  prep
• 0:14
  you
• 0:14
  to
• 0:15
  practice.
• 0:15
  Well,
• 0:16
  we
• 0:16
  have
• 0:16
  a
• 0:16
  doozy
• 0:17
  here
• 0:17
  today,
• 0:18
  let
• 0:18
  me
• 0:18
  tell
• 0:18
  you.
• 0:19
  We
• 0:19
  are
• 0:19
  going
• 0:20
  to
• 0:20
  start
• 0:20
  off
• 0:20
  with
• 0:20
  a
• 0:21
  brain
• 0:21
  tickler.
• 0:22
  It
• 0:22
  is
• 0:23
  a
• 0:23
  very
• 0:24
  interesting
• 0:24
  question
• 0:25
  I'm
• 0:25
  going
• 0:25
  to
• 0:25
  ask
• 0:25
  you.
• 0:26
  You
• 0:26
  may
• 0:26
  not
• 0:26
  know
• 0:27
  the
• 0:27
  answer.
• 0:27
  The
• 0:27
  answer
• 0:28
  may
• 0:28
  surprise
• 0:28
  you,
• 0:29
  and
• 0:29
  then
• 0:29
  we're
• 0:30
  going
• 0:30
  to
• 0:30
  go
• 0:30
  into
• 0:30
  the
• 0:30
  nitty
• 0:30
  gritty
• 0:31
  of
• 0:32
  the
• 0:32
  case.
• 0:33
  So,
• 0:34
  my
• 0:34
  friends,
• 0:35
  there
• 0:35
  was
• 0:35
  a
• 0:35
  national
• 0:36
  surveillance
• 0:36
  study
• 0:37
  between
• 0:37
  2009
• 0:38
  and
• 0:39
  2011,
• 0:40
  and
• 0:40
  it
• 0:40
  looked
• 0:40
  at
• 0:41
  emergency
• 0:41
  room
• 0:41
  visits
• 0:42
  for
• 0:42
  adverse
• 0:43
  drug
• 0:43
  events,
• 0:44
  also
• 0:44
  known
• 0:45
  as
• 0:45
  ADES,
• 0:46
  caused
• 0:47
  by
• 0:47
  psychiatric
• 0:48
  medications
• 0:48
  in
• 0:49
  American
• 0:49
  adults
• 0:50
  19
• 0:50
  years
• 0:51
  or
• 0:51
  older.
• 0:52
  Why
• 0:52
  they
• 0:52
  didn't
• 0:52
  start
• 0:52
  with
• 0:53
  18
• 0:53
  years
• 0:53
  or
• 0:53
  older,
• 0:54
  I
• 0:54
  have
• 0:54
  no
• 0:54
  idea.
• 0:54
  It's
• 0:55
  a
• 0:55
  very
• 0:55
  odd,
• 0:56
  arbitrary
• 0:56
  cut
• 0:57
  point
• 0:57
  here.
• 0:58
  Which
• 0:58
  single
• 0:59
  psychiatric
• 1:00
  medication
• 1:00
  was
• 1:01
  implicated
• 1:01
  in
• 1:01
  the
• 1:02
  highest
• 1:02
  proportion
• 1:02
  of
• 1:03
  all
• 1:03
  psychiatric
• 1:04
  medication
• 1:05
  adverse
• 1:06
  drug
• 1:06
  event
• 1:07
  ED
• 1:07
  visits?
• 1:08
  So
• 1:08
  what's
• 1:08
  the
• 1:09
  big,
• 1:09
  bad,
• 1:09
  naughty
• 1:10
  psychiatric
• 1:11
  drug
• 1:12
  that
• 1:12
  has
• 1:12
  been
• 1:13
  implicated
• 1:14
  in
• 1:14
  the
• 1:14
  highest
• 1:15
  proportion
• 1:16
  of
• 1:17
  all
• 1:17
  psychiatric
• 1:18
  medication
• 1:19
  ED
• 1:19
  visits?
• 1:20
  So
• 1:20
  you
• 1:20
  have
• 1:20
  all
• 1:21
  these
• 1:21
  psychiatric
• 1:21
  ED
• 1:22
  visits,
• 1:23
  and
• 1:23
  who's
• 1:23
  the
• 1:24
  most
• 1:24
  common
• 1:24
  culprit
• 1:26
  of
• 1:27
  these
• 1:27
  visits
• 1:28
  or
• 1:28
  what's
• 1:28
  causing
• 1:28
  this
• 1:28
  the
• 1:29
  most?
• 1:29
  Is
• 1:29
  it
• 1:29
  A,
• 1:29
  Seroquel,
• 1:31
  B,
• 1:32
  Xanax,
• 1:34
  C,
• 1:34
  Haldol,
• 1:36
  D,
• 1:36
  lithium,
• 1:38
  or
• 1:38
  E,
• 1:39
  Ambien?
• 1:41
  Okay,
• 1:41
  you
• 1:42
  can
• 1:42
  pause
• 1:42
  this
• 1:42
  if
• 1:42
  you'd
• 1:43
  like.
• 1:43
  You
• 1:44
  can
• 1:44
  think
• 1:44
  about
• 1:44
  it.
• 1:44
  You
• 1:45
  can
• 1:45
  phone
• 1:45
  a
• 1:45
  friend
• 1:47
  and
• 1:48
  maybe
• 1:48
  ask
• 1:48
  your
• 1:49
  professor,
• 1:49
  ask
• 1:49
  your
• 1:50
  peers.
• 1:50
  If
• 1:50
  you're
• 1:50
  in
• 1:50
  a
• 1:50
  zoom
• 1:51
  group,
• 1:51
  it's
• 1:51
  a
• 1:51
  great
• 1:52
  time
• 1:52
  to
• 1:52
  just
• 1:52
  pause
• 1:53
  this
• 1:53
  and
• 1:54
  think
• 1:54
  about
• 1:55
  what
• 1:55
  are
• 1:55
  the
• 1:55
  possible
• 1:55
  side
• 1:56
  effects
• 1:56
  here?
• 1:56
  What
• 1:57
  are
• 1:57
  the
• 1:57
  problems?
• 1:59
  Just
• 1:59
  think
• 1:59
  about
• 1:59
  the
• 2:00
  question,
• 2:00
  right?
• 2:00
  This
• 2:00
  is
• 2:01
  all
• 2:01
  age
• 2:01
  groups,
• 2:01
  really,
• 2:02
  19
• 2:02
  and
• 2:02
  above.
• 2:03
  So
• 2:03
  this
• 2:03
  could
• 2:03
  affect
• 2:04
  multiple
• 2:04
  different
• 2:04
  populations.
• 2:05
  My
• 2:06
  friends,
• 2:06
  the
• 2:06
  answer
• 2:07
  is.
• 2:07
  Drumroll.
• 2:09
  Ambien,
• 2:10
  yes.
• 2:11
  Might
• 2:11
  be
• 2:11
  surprising
• 2:12
  to
• 2:12
  some
• 2:12
  of
• 2:12
  you,
• 2:13
  maybe
• 2:13
  it
• 2:13
  wasn't,
• 2:14
  but
• 2:14
  Ambien
• 2:15
  alone
• 2:15
  accounted
• 2:16
  for
• 2:17
  almost
• 2:17
  12%
• 2:18
  of
• 2:18
  all
• 2:18
  adult
• 2:18
  psychiatric
• 2:19
  medication
• 2:20
  adverse
• 2:20
  drug
• 2:20
  event
• 2:21
  ED
• 2:22
  visits.
• 2:23
  It's
• 2:23
  really
• 2:23
  significantly
• 2:24
  more
• 2:24
  than
• 2:24
  any
• 2:24
  other
• 2:25
  psychiatric
• 2:26
  drug.
• 2:26
  And
• 2:27
  if
• 2:27
  you
• 2:27
  stratify
• 2:28
  this
• 2:28
  to
• 2:29
  geriatric
• 2:30
  folks
• 2:30
  65
• 2:31
  or
• 2:31
  older,
• 2:32
  it's
• 2:32
  really
• 2:32
  one
• 2:32
  in
• 2:33
  five
• 2:34
  of
• 2:34
  those
• 2:34
  visits.
• 2:36
  Ambien
• 2:37
  had
• 2:37
  its
• 2:38
  fingerprints
• 2:38
  on
• 2:38
  that
• 2:39
  visit
• 2:39
  in
• 2:39
  the
• 2:39
  form
• 2:39
  of,
• 2:40
  like,
• 2:40
  falls
• 2:41
  or
• 2:42
  accidents
• 2:42
  or
• 2:42
  things
• 2:43
  like
• 2:43
  that.
• 2:44
  Now,
• 2:44
  as
• 2:45
  a
• 2:45
  prescriber
• 2:46
  myself,
• 2:46
  I'm
• 2:47
  not
• 2:47
  a
• 2:47
  huge
• 2:47
  fan
• 2:48
  of
• 2:48
  Ambien.
• 2:48
  I
• 2:49
  rarely,
• 2:49
  if
• 2:49
  ever,
• 2:50
  prescribe
• 2:50
  it.
• 2:51
  You
• 2:51
  have
• 2:51
  really
• 2:52
  robust
• 2:52
  data
• 2:53
  out
• 2:53
  there
• 2:53
  that
• 2:53
  CBTI
• 2:55
  is
• 2:55
  kind
• 2:55
  of
• 2:55
  the
• 2:56
  gold
• 2:56
  standard
• 2:56
  to
• 2:56
  bring
• 2:57
  sleep
• 2:57
  back
• 2:57
  on
• 2:58
  board.
• 2:58
  You'd
• 2:59
  be
• 2:59
  surprised
• 2:59
  how
• 3:00
  many
• 3:00
  people
• 3:00
  will
• 3:00
  feel
• 3:01
  better
• 3:01
  or
• 3:01
  sleep
• 3:01
  better
• 3:02
  with
• 3:02
  melatonin.
• 3:03
  Just
• 3:03
  realigning
• 3:04
  their
• 3:04
  circadian
• 3:05
  rhythm.
• 3:05
  There's
• 3:06
  Ramelteon,
• 3:07
  which
• 3:07
  is
• 3:07
  a
• 3:08
  melatonin
• 3:08
  agonist.
• 3:08
  I
• 3:09
  use
• 3:09
  that
• 3:09
  a
• 3:09
  lot.
• 3:09
  I
• 3:09
  use
• 3:10
  Doxepin.
• 3:10
  That's
• 3:11
  been
• 3:11
  the
• 3:11
  new
• 3:11
  kid
• 3:11
  on
• 3:11
  the.
• 3:11
  Well,
• 3:12
  it's
• 3:12
  not
• 3:12
  the
• 3:12
  new
• 3:12
  kid
• 3:12
  on
• 3:12
  the
• 3:12
  block,
• 3:13
  but
• 3:13
  for
• 3:13
  me
• 3:13
  it
• 3:13
  is.
• 3:14
  I
• 3:14
  use
• 3:14
  Doxepin
• 3:15
  a
• 3:15
  heck
• 3:15
  of
• 3:16
  a
• 3:16
  lot
• 3:17
  for
• 3:17
  its
• 3:17
  really
• 3:18
  clean,
• 3:18
  potent
• 3:19
  anti
• 3:19
  histaminergic
• 3:20
  effect.
• 3:21
  Something
• 3:21
  like
• 3:21
  a
• 3:22
  hundred
• 3:22
  times
• 3:22
  more
• 3:22
  potent
• 3:23
  Doxepin
• 3:24
  is
• 3:24
  at
• 3:24
  histamine
• 3:25
  compared
• 3:26
  to
• 3:26
  like
• 3:26
  Benadryl,
• 3:27
  which
• 3:27
  is
• 3:27
  an
• 3:27
  interesting
• 3:28
  fact.
• 3:28
  And
• 3:28
  it
• 3:28
  doesn't
• 3:29
  have
• 3:29
  all
• 3:29
  those
• 3:29
  muddy
• 3:30
  side
• 3:30
  effects
• 3:30
  that
• 3:31
  Benadryl
• 3:32
  can
• 3:32
  have
• 3:33
  with,
• 3:33
  you
• 3:33
  know,
• 3:34
  the
• 3:34
  anticholinergic
• 3:35
  side
• 3:35
  effects,
• 3:35
  et
• 3:36
  cetera,
• 3:36
  et
• 3:36
  cetera.
• 3:37
  So
• 3:37
  I
• 3:37
  avoid
• 3:38
  Ambien.
• 3:39
  We've
• 3:39
  all
• 3:39
  heard
• 3:40
  the
• 3:40
  horror
• 3:40
  stories
• 3:41
  out
• 3:41
  there,
• 3:42
  and
• 3:43
  I'm
• 3:43
  sure
• 3:43
  it
• 3:43
  can
• 3:43
  be
• 3:43
  great
• 3:43
  in
• 3:44
  the
• 3:44
  right
• 3:44
  patient
• 3:44
  at
• 3:45
  the
• 3:45
  right
• 3:45
  time.
• 3:45
  You
• 3:45
  know,
• 3:46
  all
• 3:46
  these
• 3:46
  meds
• 3:46
  are
• 3:47
  great
• 3:47
  for
• 3:47
  the
• 3:47
  right
• 3:47
  person
• 3:48
  at
• 3:48
  the
• 3:48
  right
• 3:48
  time,
• 3:49
  but
• 3:49
  you
• 3:49
  have
• 3:49
  heard
• 3:50
  horror
• 3:51
  stories
• 3:52
  that
• 3:52
  the
• 3:52
  FDA
• 3:53
  has
• 3:53
  even
• 3:53
  warned
• 3:53
  us
• 3:53
  about.
• 3:54
  You
• 3:54
  know,
• 3:54
  people
• 3:54
  driving,
• 3:55
  people
• 3:55
  having
• 3:56
  sex
• 3:56
  on
• 3:56
  Ambien
• 3:56
  and
• 3:57
  not
• 3:57
  remembering
• 3:57
  it.
• 3:58
  That's
• 3:58
  pretty
• 3:58
  scary.
• 3:59
  That's
• 3:59
  kind
• 3:59
  of
• 3:59
  the
• 3:59
  last
• 4:00
  thing
• 4:00
  I
• 4:00
  want
• 4:00
  when
• 4:00
  I
• 4:00
  prescribe
• 4:01
  a
• 4:01
  medication
• 4:01
  for
• 4:02
  my
• 4:02
  patient
• 4:02
  that
• 4:03
  they're
• 4:03
  having
• 4:03
  sex
• 4:03
  in
• 4:03
  a
• 4:04
  car
• 4:04
  on
• 4:04
  the
• 4:04
  freeway
• 4:05
  going
• 4:05
  90
• 4:05
  miles
• 4:05
  an
• 4:06
  hour
• 4:06
  and
• 4:06
  they
• 4:06
  don't
• 4:06
  even
• 4:06
  remember
• 4:07
  it.
• 4:08
  Not
• 4:08
  a
• 4:08
  very
• 4:08
  fun
• 4:08
  side
• 4:09
  effect
• 4:09
  to
• 4:09
  deal
• 4:09
  with
• 4:09
  whether
• 4:10
  you're
• 4:10
  the
• 4:10
  patient
• 4:10
  or
• 4:11
  the
• 4:11
  prescriber.
• 4:12
  Not
• 4:12
  that
• 4:12
  that
• 4:12
  happens
• 4:13
  every
• 4:13
  time.
• 4:13
  Right.
• 4:14
  But
• 4:15
  it's
• 4:15
  enough
• 4:15
  to
• 4:15
  spook
• 4:16
  me
• 4:16
  away
• 4:16
  from
• 4:16
  Ambien.
• 4:17
  And
• 4:17
  so
• 4:18
  I
• 4:18
  hit
• 4:18
  those
• 4:18
  other
• 4:19
  medications
• 4:20
  or
• 4:20
  CBTI
• 4:21
  and
• 4:21
  kind
• 4:22
  of
• 4:22
  incorporate
• 4:22
  that
• 4:23
  in
• 4:23
  my
• 4:24
  teaching,
• 4:24
  in
• 4:24
  my
• 4:24
  psycho
• 4:25
  education
• 4:25
  as
• 4:26
  well.
• 4:26
  But
• 4:27
  very
• 4:27
  interesting,
• 4:28
  right?
• 4:28
  Ambien
• 4:29
  here.
• 4:29
  So
• 4:30
  the
• 4:30
  other,
• 4:30
  now
• 4:31
  the
• 4:31
  other
• 4:31
  choices
• 4:32
  on
• 4:32
  this
• 4:33
  multiple
• 4:33
  choice
• 4:33
  question
• 4:34
  are
• 4:34
  actually
• 4:35
  they're
• 4:35
  not
• 4:36
  really
• 4:36
  innocent
• 4:36
  either.
• 4:37
  Okay.
• 4:37
  Again,
• 4:37
  these
• 4:38
  are
• 4:38
  all
• 4:38
  fantastic
• 4:39
  life
• 4:39
  saving
• 4:39
  medications
• 4:40
  in
• 4:40
  the
• 4:40
  right
• 4:40
  person
• 4:41
  at
• 4:41
  the
• 4:41
  right
• 4:41
  time.
• 4:42
  So
• 4:42
  I'm
• 4:42
  not
• 4:42
  one
• 4:43
  of
• 4:43
  those
• 4:43
  people
• 4:43
  who
• 4:44
  really
• 4:45
  poo
• 4:45
  poos
• 4:46
  any
• 4:46
  medication.
• 4:47
  There's
• 4:47
  a
• 4:47
  reason
• 4:47
  these
• 4:48
  medications
• 4:48
  exist.
• 4:49
  You
• 4:50
  all
• 4:50
  probably
• 4:50
  have
• 4:50
  a
• 4:50
  patient
• 4:51
  or
• 4:51
  maybe
• 4:51
  an
• 4:52
  uncle
• 4:53
  or
• 4:53
  a
• 4:53
  younger
• 4:54
  brother
• 4:54
  or
• 4:54
  someone
• 4:55
  who
• 4:55
  has
• 4:55
  taken
• 4:56
  these
• 4:56
  meds
• 4:57
  and
• 4:57
  they
• 4:57
  have
• 4:57
  been
• 4:57
  life
• 4:58
  changing,
• 4:58
  right?
• 4:58
  If
• 4:58
  you
• 4:59
  have
• 4:59
  schizophrenia
• 5:00
  and
• 5:00
  you're
• 5:00
  hearing
• 5:01
  voices
• 5:01
  that
• 5:01
  are
• 5:02
  taunting
• 5:02
  you
• 5:03
  or
• 5:03
  commanding
• 5:04
  you
• 5:04
  to
• 5:04
  kill
• 5:04
  yourself,
• 5:05
  Haldol
• 5:05
  could
• 5:05
  be
• 5:06
  one
• 5:06
  of
• 5:06
  the
• 5:06
  most
• 5:06
  life
• 5:07
  saving
• 5:07
  medications
• 5:08
  in
• 5:08
  the
• 5:08
  world
• 5:08
  to
• 5:09
  you
• 5:09
  might
• 5:09
  be
• 5:09
  one
• 5:10
  of
• 5:10
  the
• 5:10
  only
• 5:10
  ones
• 5:10
  you
• 5:10
  can
• 5:10
  afford,
• 5:11
  right?
• 5:11
  It's
• 5:11
  a
• 5:11
  first
• 5:12
  generation.
• 5:13
  It's
• 5:14
  not
• 5:14
  like
• 5:14
  a
• 5:14
  more
• 5:15
  expensive
• 5:15
  second
• 5:15
  generation
• 5:16
  that
• 5:16
  maybe
• 5:16
  your
• 5:16
  insurance
• 5:17
  doesn't
• 5:17
  cover.
• 5:18
  So
• 5:18
  Haldol
• 5:19
  might
• 5:20
  be
• 5:20
  the
• 5:20
  most
• 5:21
  important
• 5:22
  medication
• 5:22
  you've
• 5:22
  ever
• 5:23
  taken.
• 5:23
  Interestingly
• 5:24
  though,
• 5:24
  Haldol,
• 5:25
  on
• 5:25
  our
• 5:25
  list
• 5:25
  here,
• 5:26
  it
• 5:26
  was
• 5:26
  option
• 5:26
  C,
• 5:27
  choice
• 5:27
  C.
• 5:28
  Haldol
• 5:28
  actually
• 5:29
  has
• 5:30
  the
• 5:30
  highest
• 5:31
  rate
• 5:32
  of
• 5:32
  all
• 5:32
  the
• 5:32
  prescriptions
• 5:33
  period,
• 5:33
  that
• 5:34
  we
• 5:34
  just
• 5:34
  mentioned,
• 5:35
  actually
• 5:36
  eight
• 5:36
  times
• 5:37
  Ambien's
• 5:37
  rate
• 5:38
  leading
• 5:39
  to
• 5:39
  emergency
• 5:40
  room
• 5:40
  visits.
• 5:40
  However,
• 5:41
  it's
• 5:41
  not
• 5:41
  prescribed
• 5:42
  nearly
• 5:42
  as
• 5:42
  often
• 5:43
  as
• 5:43
  Ambien,
• 5:44
  so
• 5:44
  you
• 5:44
  don't
• 5:44
  see
• 5:45
  it
• 5:45
  in
• 5:45
  the
• 5:45
  ER
• 5:45
  as
• 5:46
  often.
• 5:46
  But
• 5:47
  if
• 5:47
  this
• 5:47
  was
• 5:47
  a
• 5:47
  multiple
• 5:48
  choice
• 5:48
  question
• 5:48
  asking
• 5:49
  you
• 5:49
  like
• 5:49
  the
• 5:49
  most
• 5:50
  serious
• 5:50
  offender
• 5:51
  per
• 5:51
  prescription
• 5:52
  proportion,
• 5:53
  Haldol
• 5:54
  would
• 5:54
  be
• 5:55
  number
• 5:55
  one.
• 5:56
  Haldol
• 5:57
  has
• 5:58
  an
• 5:58
  extremely
• 5:59
  high
• 5:59
  rate
• 5:59
  of
• 5:59
  emergency
• 6:00
  room
• 6:00
  visits
• 6:01
  due
• 6:01
  to
• 6:02
  movement
• 6:02
  disorders,
• 6:03
  eps,
• 6:04
  dystonias,
• 6:05
  acute
• 6:05
  dystonia.
• 6:05
  You've
• 6:06
  probably
• 6:06
  learned
• 6:06
  about
• 6:06
  this
• 6:07
  in
• 6:07
  your
• 6:07
  coursework,
• 6:07
  right?
• 6:08
  The
• 6:08
  oculogy
• 6:09
  crisis,
• 6:10
  you
• 6:10
  know,
• 6:10
  where
• 6:11
  you
• 6:11
  where
• 6:11
  your
• 6:11
  entire
• 6:13
  airway,
• 6:14
  your
• 6:14
  eyes
• 6:14
  can
• 6:15
  kind
• 6:15
  of
• 6:16
  engage
• 6:16
  in
• 6:16
  this
• 6:17
  like
• 6:17
  muscle
• 6:17
  lock.
• 6:18
  That's
• 6:18
  a
• 6:18
  medical
• 6:19
  emergency.
• 6:19
  Your
• 6:19
  airway
• 6:20
  is
• 6:20
  implicated.
• 6:20
  You
• 6:20
  have
• 6:21
  to
• 6:21
  get
• 6:21
  immediate
• 6:21
  medical
• 6:21
  attention
• 6:22
  for
• 6:22
  that.
• 6:23
  So
• 6:23
  Haldol
• 6:24
  again
• 6:25
  has
• 6:25
  its
• 6:26
  spooky
• 6:27
  tendencies
• 6:28
  too.
• 6:28
  It
• 6:28
  can
• 6:28
  bring
• 6:28
  you
• 6:28
  to
• 6:28
  the
• 6:29
  ER
• 6:30
  if
• 6:30
  we're
• 6:30
  not
• 6:31
  careful.
• 6:31
  Lithium
• 6:32
  was
• 6:32
  on
• 6:32
  this
• 6:32
  list.
• 6:33
  Lithium
• 6:34
  is
• 6:36
  actually
• 6:38
  not
• 6:38
  as
• 6:39
  likely
• 6:39
  to
• 6:40
  bring
• 6:40
  you
• 6:40
  to
• 6:40
  the
• 6:40
  ER
• 6:41
  as
• 6:41
  Ambien
• 6:42
  is,
• 6:42
  or
• 6:42
  it's
• 6:43
  not
• 6:43
  as
• 6:43
  commonly
• 6:43
  seen
• 6:44
  in
• 6:44
  the
• 6:44
  er,
• 6:45
  but
• 6:45
  it
• 6:45
  has
• 6:45
  the
• 6:45
  highest
• 6:46
  admission
• 6:46
  rate
• 6:46
  of
• 6:47
  any
• 6:47
  psychiatric
• 6:47
  medication.
• 6:48
  And
• 6:48
  that
• 6:48
  might
• 6:49
  not
• 6:49
  come
• 6:49
  as
• 6:49
  a
• 6:49
  huge
• 6:50
  surprise
• 6:50
  to
• 6:50
  you
• 6:51
  because
• 6:51
  lithium
• 6:52
  toxicity,
• 6:53
  you
• 6:53
  know,
• 6:53
  seizures,
• 6:54
  coma,
• 6:55
  ataxia,
• 6:56
  things
• 6:57
  can
• 6:57
  get
• 6:57
  really
• 6:57
  wonky
• 6:58
  with
• 6:58
  your
• 6:58
  kidneys.
• 6:59
  So
• 7:00
  lithium,
• 7:00
  of
• 7:00
  course,
• 7:01
  is
• 7:02
  one
• 7:03
  of
• 7:03
  the
• 7:03
  most
• 7:03
  fascinating
• 7:04
  and
• 7:04
  powerful
• 7:05
  and,
• 7:05
  and
• 7:06
  incredible
• 7:07
  medications.
• 7:07
  Talk
• 7:08
  about
• 7:08
  life
• 7:08
  saving,
• 7:08
  right?
• 7:09
  What
• 7:09
  it
• 7:09
  can
• 7:09
  do
• 7:09
  for
• 7:10
  suicide,
• 7:10
  suicide
• 7:11
  attempts.
• 7:11
  It's
• 7:11
  one
• 7:12
  of
• 7:12
  the
• 7:12
  only
• 7:12
  medications
• 7:13
  out
• 7:13
  there
• 7:13
  that
• 7:13
  has
• 7:14
  been
• 7:14
  evidence
• 7:15
  has
• 7:15
  shown
• 7:15
  to
• 7:15
  actually
• 7:15
  reduce
• 7:16
  suicide
• 7:17
  attempts,
• 7:18
  so
• 7:19
  or
• 7:19
  to
• 7:19
  prevent
• 7:20
  suicide
• 7:20
  at
• 7:20
  all.
• 7:21
  It's
• 7:21
  a
• 7:21
  life
• 7:22
  saving
• 7:22
  miracle
• 7:23
  medication
• 7:23
  for
• 7:24
  some,
• 7:24
  but
• 7:24
  it
• 7:24
  is
• 7:24
  the
• 7:25
  most
• 7:25
  likely
• 7:25
  to
• 7:25
  lead
• 7:25
  to
• 7:26
  hospitalization.
• 7:27
  So
• 7:27
  this
• 7:27
  was
• 7:27
  an
• 7:28
  ED
• 7:28
  visit
• 7:28
  question,
• 7:29
  so
• 7:29
  devil's
• 7:30
  in
• 7:30
  the
• 7:30
  details.
• 7:30
  Now,
• 7:31
  Seroquel
• 7:32
  also
• 7:32
  has
• 7:33
  higher
• 7:33
  rates
• 7:34
  per
• 7:34
  prescription
• 7:35
  of
• 7:35
  getting
• 7:35
  folks
• 7:36
  to
• 7:36
  the
• 7:36
  ER
• 7:36
  than
• 7:37
  Ambien,
• 7:37
  but
• 7:37
  again,
• 7:38
  Ambien
• 7:38
  is
• 7:38
  prescribed
• 7:39
  much
• 7:39
  more
• 7:39
  often.
• 7:40
  Okay,
• 7:40
  so
• 7:41
  it's
• 7:41
  really
• 7:42
  neat
• 7:42
  to
• 7:42
  look
• 7:42
  at
• 7:42
  the
• 7:42
  overall
• 7:43
  prescription
• 7:43
  rates
• 7:44
  of
• 7:44
  these
• 7:45
  medications
• 7:46
  and
• 7:47
  not
• 7:47
  just
• 7:47
  consider,
• 7:49
  not
• 7:49
  just
• 7:49
  to
• 7:49
  consider
• 7:49
  how
• 7:50
  many
• 7:50
  of
• 7:50
  them
• 7:50
  you
• 7:50
  see
• 7:50
  in
• 7:51
  an
• 7:51
  ER
• 7:51
  as
• 7:51
  a
• 7:51
  population
• 7:53
  based
• 7:53
  question,
• 7:54
  but
• 7:54
  of
• 7:54
  course
• 7:54
  per
• 7:55
  prescription
• 7:55
  as
• 7:56
  well.
• 7:57
  Okay,
• 7:57
  so
• 7:58
  pound
• 7:58
  for
• 7:58
  pound
• 7:59
  per
• 7:59
  prescription,
• 8:00
  if
• 8:00
  you're
• 8:00
  prescribing
• 8:01
  Seroquel
• 8:02
  and
• 8:02
  Ambien
• 8:04
  one
• 8:04
  to
• 8:05
  one,
• 8:05
  you're
• 8:06
  probably
• 8:06
  gonna
• 8:07
  have
• 8:07
  more
• 8:07
  ED
• 8:07
  visits
• 8:08
  statistically
• 8:08
  at
• 8:08
  least
• 8:09
  from,
• 8:09
  from
• 8:09
  your
• 8:09
  Seroquel
• 8:10
  than
• 8:10
  your
• 8:10
  Ambien.
• 8:11
  But
• 8:11
  again,
• 8:12
  it's
• 8:12
  not
• 8:12
  one
• 8:12
  to
• 8:12
  One
• 8:13
  out
• 8:13
  there
• 8:13
  in
• 8:13
  the
• 8:13
  population.
• 8:14
  Um,
• 8:15
  it's.
• 8:15
  I
• 8:15
  don't
• 8:15
  know
• 8:15
  the
• 8:15
  exact
• 8:16
  ratio.
• 8:16
  I
• 8:17
  didn't
• 8:17
  look
• 8:17
  that
• 8:17
  up
• 8:17
  today.
• 8:18
  But
• 8:18
  clearly,
• 8:19
  Ambien
• 8:19
  is
• 8:19
  prescribed
• 8:20
  more
• 8:20
  often.
• 8:20
  That's
• 8:21
  why
• 8:21
  you
• 8:21
  see
• 8:21
  more
• 8:22
  people
• 8:24
  in
• 8:24
  the
• 8:24
  ER
• 8:25
  because
• 8:25
  of
• 8:26
  Ambien.
• 8:26
  Right?
• 8:27
  It's
• 8:27
  kind
• 8:27
  of
• 8:28
  like
• 8:28
  you
• 8:28
  see
• 8:28
  more
• 8:28
  people
• 8:29
  in
• 8:29
  the
• 8:29
  ER
• 8:30
  because
• 8:30
  of
• 8:31
  car
• 8:31
  accidents
• 8:31
  and
• 8:32
  less
• 8:32
  people
• 8:33
  in
• 8:33
  the
• 8:33
  ER
• 8:33
  because
• 8:34
  they
• 8:34
  were
• 8:34
  shot
• 8:34
  with
• 8:34
  a
• 8:34
  cannonball.
• 8:35
  It
• 8:36
  doesn't
• 8:36
  mean
• 8:36
  that
• 8:36
  cannonballs
• 8:37
  are,
• 8:37
  like,
• 8:37
  more
• 8:38
  harmless
• 8:38
  than
• 8:38
  car
• 8:38
  accidents.
• 8:39
  They
• 8:40
  actually.
• 8:40
  They're
• 8:41
  probably
• 8:41
  much
• 8:41
  more
• 8:42
  deadly
• 8:42
  than.
• 8:42
  Than
• 8:43
  car
• 8:43
  accidents,
• 8:44
  but
• 8:44
  there's
• 8:44
  just
• 8:44
  not
• 8:45
  a
• 8:45
  lot
• 8:45
  of
• 8:45
  people
• 8:45
  getting
• 8:45
  shot
• 8:46
  with
• 8:47
  a
• 8:47
  cannonball.
• 8:48
  You
• 8:48
  get
• 8:48
  my
• 8:49
  drift,
• 8:49
  right?
• 8:50
  So
• 8:50
  anyhow,
• 8:51
  I
• 8:51
  hope
• 8:51
  you
• 8:51
  appreciated
• 8:52
  that
• 8:52
  little
• 8:52
  pearl
• 8:53
  just
• 8:53
  now.
• 8:55
  I
• 8:55
  sure
• 8:56
  love
• 8:56
  it.
• 8:57
  And,
• 8:58
  yeah,
• 8:58
  it's
• 8:58
  pretty
• 8:59
  interesting,
• 8:59
  isn't
• 8:59
  it?
• 9:00
  Now
• 9:00
  we
• 9:01
  want
• 9:01
  to
• 9:01
  really
• 9:01
  get
• 9:01
  into
• 9:02
  this
• 9:02
  a
• 9:02
  little.
• 9:02
  I
• 9:02
  wanted
• 9:03
  to
• 9:03
  get
• 9:03
  into
• 9:03
  why
• 9:05
  Ambien
• 9:06
  can
• 9:06
  be
• 9:06
  tricky,
• 9:06
  particularly
• 9:07
  for
• 9:08
  elderly
• 9:08
  populations.
• 9:09
  This
• 9:09
  is
• 9:10
  kind
• 9:10
  of
• 9:10
  what
• 9:10
  I
• 9:10
  want
• 9:10
  this.
• 9:11
  The
• 9:11
  rest
• 9:11
  of
• 9:11
  this
• 9:12
  episode
• 9:12
  to
• 9:12
  focus
• 9:13
  on.
• 9:13
  Okay.
• 9:14
  The
• 9:14
  elderly
• 9:15
  population
• 9:16
  is
• 9:16
  kind
• 9:17
  of
• 9:17
  fascinating.
• 9:18
  And
• 9:18
  in
• 9:18
  order
• 9:18
  to
• 9:18
  kind
• 9:18
  of
• 9:19
  talk
• 9:19
  about
• 9:19
  this,
• 9:19
  we
• 9:19
  have
• 9:20
  to
• 9:20
  think
• 9:20
  about
• 9:20
  the
• 9:20
  difference
• 9:21
  between
• 9:21
  pharmacokinetics
• 9:22
  and
• 9:22
  pharmacodynamics.
• 9:23
  You've
• 9:24
  probably
• 9:24
  heard
• 9:24
  about
• 9:24
  this
• 9:25
  before,
• 9:25
  but
• 9:25
  pharmacokinetics
• 9:26
  are
• 9:27
  kind
• 9:27
  of
• 9:27
  what
• 9:27
  the
• 9:27
  body
• 9:28
  does
• 9:28
  to
• 9:28
  the
• 9:28
  drug.
• 9:28
  Okay.
• 9:29
  How
• 9:29
  it
• 9:29
  kind
• 9:29
  of
• 9:29
  moves
• 9:30
  through
• 9:30
  your
• 9:30
  body,
• 9:31
  how
• 9:31
  it's
• 9:31
  absorbed,
• 9:32
  how
• 9:32
  it's
• 9:32
  distributed,
• 9:33
  how
• 9:33
  it's
• 9:33
  metabolized,
• 9:34
  how
• 9:34
  it's
• 9:34
  eliminated.
• 9:35
  Okay.
• 9:36
  Versus
• 9:36
  pharmacodynamics.
• 9:37
  And
• 9:38
  that's
• 9:38
  really
• 9:38
  what
• 9:38
  the
• 9:38
  drug
• 9:39
  does
• 9:39
  to
• 9:39
  the
• 9:39
  body.
• 9:40
  Okay.
• 9:40
  Does
• 9:40
  it
• 9:41
  cause
• 9:41
  sedation,
• 9:42
  changes
• 9:42
  in
• 9:42
  mood,
• 9:43
  other
• 9:44
  side
• 9:44
  effects?
• 9:45
  Right.
• 9:45
  What
• 9:45
  the
• 9:45
  drug
• 9:46
  does
• 9:46
  to
• 9:46
  the
• 9:46
  body.
• 9:47
  So
• 9:48
  it's
• 9:48
  just
• 9:48
  kind
• 9:48
  of
• 9:48
  an
• 9:49
  interesting,
• 9:50
  Interesting
• 9:51
  dynamic
• 9:52
  that
• 9:52
  we
• 9:52
  need
• 9:52
  to
• 9:53
  think
• 9:53
  about
• 9:54
  as
• 9:54
  we
• 9:54
  go
• 9:55
  about
• 9:55
  the
• 9:56
  rest
• 9:56
  of
• 9:56
  this
• 9:56
  conversation,
• 9:57
  if
• 9:57
  you
• 9:58
  will.
• 9:58
  So
• 9:59
  now
• 10:00
  I
• 10:00
  want
• 10:00
  to
• 10:00
  talk
• 10:00
  about
• 10:01
  a
• 10:01
  mock
• 10:02
  patient.
• 10:02
  We'll
• 10:02
  call
• 10:03
  him
• 10:03
  Arthur.
• 10:03
  I
• 10:03
  looked
• 10:04
  up,
• 10:04
  like,
• 10:04
  what's
• 10:04
  the
• 10:04
  oldest
• 10:05
  name?
• 10:06
  If
• 10:06
  you're.
• 10:06
  If
• 10:06
  you're
• 10:06
  a
• 10:07
  hundred
• 10:07
  years
• 10:07
  old
• 10:07
  or
• 10:08
  older?
• 10:09
  Like,
• 10:09
  what.
• 10:09
  What's
• 10:10
  your
• 10:10
  name
• 10:10
  most
• 10:10
  likely
• 10:11
  going
• 10:11
  to
• 10:11
  be?
• 10:11
  And
• 10:11
  it's
• 10:12
  Arthur.
• 10:12
  I'm
• 10:12
  pretty
• 10:12
  sure
• 10:13
  it's
• 10:13
  Arthur.
• 10:13
  At
• 10:14
  least
• 10:14
  if
• 10:14
  you're
• 10:14
  a
• 10:14
  male.
• 10:14
  I
• 10:15
  don't
• 10:15
  know
• 10:15
  any
• 10:15
  female
• 10:15
  Arthur's.
• 10:16
  If
• 10:16
  you
• 10:16
  do,
• 10:18
  that's.
• 10:18
  You
• 10:18
  found
• 10:19
  a
• 10:19
  unicorn.
• 10:20
  So
• 10:21
  Arthur.
• 10:22
  Let's
• 10:22
  just
• 10:23
  pretend
• 10:24
  that
• 10:24
  Arthur
• 10:25
  ends
• 10:25
  up
• 10:25
  in
• 10:25
  the
• 10:25
  ER
• 10:26
  and
• 10:26
  he
• 10:27
  hit
• 10:27
  his
• 10:27
  head.
• 10:28
  He
• 10:28
  fell
• 10:28
  and
• 10:28
  hit
• 10:29
  his
• 10:29
  head.
• 10:29
  He's
• 10:30
  stable
• 10:30
  overall.
• 10:31
  But
• 10:32
  Arthur,
• 10:34
  lo
• 10:34
  and
• 10:34
  behold,
• 10:34
  was
• 10:35
  on
• 10:35
  Ambien.
• 10:35
  He
• 10:35
  was
• 10:36
  prescribed
• 10:36
  10
• 10:36
  milligrams
• 10:37
  of
• 10:37
  Ambien.
• 10:38
  Actually
• 10:38
  for
• 10:39
  sleep.
• 10:40
  And
• 10:40
  you're
• 10:40
  the
• 10:40
  ER
• 10:41
  doc,
• 10:41
  maybe,
• 10:42
  or
• 10:42
  you're
• 10:42
  consulting
• 10:43
  in
• 10:43
  a
• 10:43
  psychiatric
• 10:44
  capacity
• 10:44
  to
• 10:44
  the
• 10:44
  er.
• 10:45
  And
• 10:46
  your
• 10:46
  first
• 10:47
  look
• 10:47
  at
• 10:47
  this
• 10:48
  right
• 10:48
  is,
• 10:48
  oh,
• 10:48
  my
• 10:49
  God,
• 10:49
  Arthur's
• 10:50
  95
• 10:50
  years
• 10:51
  old
• 10:51
  and
• 10:52
  somebody
• 10:53
  gave
• 10:53
  him
• 10:54
  Ambien.
• 10:54
  Well,
• 10:54
  this
• 10:54
  is
• 10:55
  clearly
• 10:56
  not
• 10:56
  what
• 10:56
  the
• 10:56
  American
• 10:57
  Geriatric
• 10:58
  Society
• 10:59
  would
• 10:59
  recommend
• 11:00
  at
• 11:00
  all.
• 11:00
  In
• 11:00
  fact,
• 11:01
  the
• 11:02
  maximum
• 11:02
  dose
• 11:03
  that
• 11:03
  really
• 11:03
  should
• 11:04
  ever
• 11:04
  be
• 11:04
  prescribed,
• 11:05
  if
• 11:05
  at
• 11:05
  all,
• 11:06
  would
• 11:06
  be
• 11:06
  like
• 11:07
  5
• 11:07
  milligrams
• 11:07
  of
• 11:08
  Ambien.
• 11:09
  We
• 11:09
  don't
• 11:09
  want
• 11:09
  to
• 11:10
  give
• 11:10
  10
• 11:11
  milligrams
• 11:11
  of
• 11:11
  Ambien.
• 11:12
  We
• 11:12
  don't
• 11:12
  even
• 11:12
  want
• 11:12
  to
• 11:12
  give
• 11:13
  7.5
• 11:13
  milligrams
• 11:14
  of
• 11:14
  Ambien
• 11:15
  to
• 11:15
  our
• 11:16
  patient
• 11:16
  Arthur.
• 11:17
  And
• 11:17
  there's
• 11:18
  a
• 11:18
  reason
• 11:18
  that
• 11:20
  Ambien
• 11:20
  is
• 11:20
  on
• 11:20
  the
• 11:20
  beers
• 11:21
  list.
• 11:21
  There's
• 11:21
  a
• 11:21
  reason
• 11:22
  that
• 11:22
  these
• 11:23
  types
• 11:23
  of
• 11:23
  medications
• 11:24
  are
• 11:24
  ill
• 11:24
  advised
• 11:25
  in
• 11:25
  the
• 11:25
  elderly.
• 11:26
  And
• 11:26
  that's
• 11:26
  what
• 11:26
  we
• 11:26
  want
• 11:26
  to
• 11:26
  talk
• 11:27
  about.
• 11:27
  We
• 11:27
  want
• 11:27
  to
• 11:28
  talk
• 11:28
  about
• 11:28
  the
• 11:28
  pharmacokinetics
• 11:29
  and
• 11:29
  dynamics
• 11:30
  that
• 11:31
  lead
• 11:32
  to
• 11:32
  those
• 11:32
  recommendations
• 11:33
  against
• 11:34
  medications
• 11:35
  like
• 11:35
  Ambien
• 11:36
  being
• 11:37
  prescribed
• 11:38
  to
• 11:39
  folks
• 11:40
  like
• 11:40
  Arthur.
• 11:41
  Okay,
• 11:41
  now
• 11:41
  I
• 11:42
  want
• 11:42
  you
• 11:42
  again
• 11:42
  to
• 11:42
  think
• 11:43
  of
• 11:43
  the
• 11:43
  acronym
• 11:44
  adme,
• 11:45
  Absorption,
• 11:46
  Distribution,
• 11:47
  Metabolism,
• 11:47
  and
• 11:48
  Elimination.
• 11:48
  Very,
• 11:49
  four
• 11:49
  very
• 11:49
  clean
• 11:50
  simple
• 11:50
  concepts
• 11:51
  here
• 11:51
  as
• 11:52
  to
• 11:52
  why
• 11:52
  Arthur
• 11:53
  should
• 11:53
  not
• 11:54
  be
• 11:54
  given
• 11:54
  Ambien.
• 11:56
  Okay?
• 11:56
  And
• 11:56
  maybe
• 11:57
  should
• 11:57
  be
• 11:57
  pointed
• 11:57
  more
• 11:57
  towards
• 11:58
  cbti.
• 11:59
  Maybe.
• 11:59
  Doxy
• 12:00
  pin
• 12:00
  has
• 12:01
  a
• 12:01
  lot
• 12:01
  more
• 12:01
  evidence
• 12:02
  in
• 12:02
  the
• 12:02
  elderly.
• 12:02
  You
• 12:03
  still
• 12:03
  have
• 12:03
  to
• 12:03
  be
• 12:03
  careful.
• 12:04
  There's
• 12:04
  still
• 12:04
  sedation
• 12:05
  that
• 12:05
  could,
• 12:05
  could
• 12:05
  happen,
• 12:06
  Right?
• 12:06
  But
• 12:07
  Ambien
• 12:07
  is
• 12:07
  particularly
• 12:08
  problematic.
• 12:10
  Okay?
• 12:11
  So
• 12:12
  we
• 12:12
  gotta
• 12:12
  think
• 12:12
  of
• 12:12
  a
• 12:12
  few
• 12:13
  things.
• 12:13
  So
• 12:14
  let's
• 12:14
  think
• 12:14
  of.
• 12:14
  Let's
• 12:15
  think
• 12:15
  about
• 12:15
  the
• 12:15
  first
• 12:15
  thing
• 12:16
  as
• 12:16
  when
• 12:17
  people
• 12:17
  get
• 12:17
  older,
• 12:18
  right,
• 12:19
  their
• 12:20
  heart
• 12:20
  pumps
• 12:20
  a
• 12:20
  little
• 12:21
  less
• 12:21
  forcefully,
• 12:22
  maybe
• 12:22
  their
• 12:22
  blood
• 12:23
  vessels
• 12:23
  get
• 12:23
  a
• 12:24
  little
• 12:24
  stiffer
• 12:24
  and
• 12:24
  narrower.
• 12:25
  So
• 12:25
  less
• 12:26
  blood
• 12:26
  is
• 12:26
  really
• 12:26
  reaching
• 12:27
  their
• 12:27
  organs
• 12:28
  every
• 12:28
  minute.
• 12:28
  And
• 12:29
  why
• 12:29
  that
• 12:29
  matters
• 12:29
  for
• 12:30
  the
• 12:30
  medications
• 12:30
  we
• 12:30
  prescribe
• 12:31
  is
• 12:32
  that
• 12:32
  blood
• 12:32
  is
• 12:33
  kind
• 12:33
  of
• 12:33
  what
• 12:33
  delivers
• 12:34
  these
• 12:34
  drugs
• 12:34
  to
• 12:34
  the
• 12:34
  liver
• 12:35
  and
• 12:35
  the
• 12:35
  kidneys
• 12:35
  to
• 12:36
  be
• 12:36
  processed
• 12:36
  and
• 12:36
  cleared.
• 12:37
  So
• 12:37
  if
• 12:37
  blood
• 12:38
  flow
• 12:39
  is
• 12:40
  slower,
• 12:40
  it's
• 12:41
  not
• 12:41
  as
• 12:41
  forceful
• 12:41
  or
• 12:42
  efficient.
• 13:37
  Your
• 13:37
  drugs
• 13:38
  get
• 13:38
  to
• 13:38
  the
• 13:38
  liver
• 13:38
  more
• 13:39
  slowly
• 13:40
  to
• 13:40
  be
• 13:40
  processed
• 13:40
  out.
• 13:40
  They
• 13:41
  get
• 13:41
  to
• 13:41
  the
• 13:41
  kidneys
• 13:41
  more
• 13:42
  slowly
• 13:42
  to
• 13:42
  be
• 13:42
  eliminated.
• 13:43
  They
• 13:43
  just
• 13:44
  get
• 13:44
  metabolized
• 13:45
  more
• 13:45
  slowly
• 13:46
  more
• 13:46
  generally.
• 13:47
  And
• 13:47
  so
• 13:47
  they
• 13:47
  stay
• 13:47
  in
• 13:48
  the
• 13:48
  body
• 13:48
  longer.
• 13:49
  Well,
• 13:50
  you
• 13:50
  know,
• 13:50
  that's.
• 13:51
  That's
• 13:51
  a
• 13:51
  little
• 13:51
  concerning
• 13:52
  because
• 13:52
  the
• 13:52
  more
• 13:53
  they
• 13:53
  stay
• 13:53
  in
• 13:53
  your
• 13:53
  body
• 13:54
  longer,
• 13:55
  well,
• 13:56
  that
• 13:56
  can
• 13:56
  very
• 13:56
  much
• 13:56
  affect
• 13:57
  the
• 13:57
  maximum
• 13:58
  levels
• 13:58
  of
• 13:59
  drug
• 13:59
  in
• 14:00
  the
• 14:00
  body
• 14:00
  at
• 14:00
  any
• 14:00
  given
• 14:01
  time,
• 14:01
  the
• 14:01
  half
• 14:01
  life
• 14:02
  of
• 14:02
  the
• 14:02
  drug.
• 14:03
  And
• 14:03
  will
• 14:04
  that
• 14:04
  really
• 14:04
  messes
• 14:05
  with
• 14:05
  your
• 14:05
  drug,
• 14:05
  timing
• 14:06
  the
• 14:06
  potency
• 14:06
  of
• 14:07
  that
• 14:07
  drug
• 14:08
  for
• 14:08
  that
• 14:08
  particular
• 14:08
  individual.
• 14:09
  And
• 14:09
  so
• 14:10
  for
• 14:10
  the
• 14:10
  elderly,
• 14:10
  this
• 14:11
  is
• 14:11
  uniquely
• 14:12
  problematic.
• 14:12
  And
• 14:13
  the,
• 14:13
  the
• 14:13
  less
• 14:14
  blood
• 14:15
  or
• 14:15
  the,
• 14:15
  the
• 14:16
  slower
• 14:16
  Blood
• 14:16
  flow
• 14:16
  is
• 14:17
  just
• 14:17
  one
• 14:17
  dynamic
• 14:18
  that
• 14:18
  actually
• 14:19
  changes
• 14:20
  the
• 14:20
  game
• 14:20
  a
• 14:21
  lot
• 14:21
  too,
• 14:21
  right?
• 14:22
  So
• 14:22
  the
• 14:23
  elderly,
• 14:23
  when
• 14:23
  we
• 14:23
  talk
• 14:24
  about
• 14:24
  absorption
• 14:24
  in
• 14:24
  this
• 14:25
  acronym,
• 14:25
  adme,
• 14:26
  the
• 14:26
  absorption
• 14:27
  piece,
• 14:28
  the
• 14:28
  elderly
• 14:29
  usually
• 14:29
  have
• 14:29
  delayed
• 14:29
  gastric
• 14:30
  emptying,
• 14:31
  okay?
• 14:32
  And
• 14:33
  that
• 14:33
  can
• 14:33
  slow
• 14:34
  the
• 14:34
  rate
• 14:34
  of
• 14:34
  absorption,
• 14:35
  right?
• 14:36
  And
• 14:36
  that
• 14:36
  can
• 14:36
  kind
• 14:36
  of
• 14:36
  shift
• 14:37
  the
• 14:37
  time
• 14:37
  to
• 14:37
  peak
• 14:38
  concentration,
• 14:38
  also
• 14:38
  known
• 14:39
  as
• 14:39
  tmax.
• 14:40
  Okay?
• 14:41
  So
• 14:41
  if
• 14:43
  your
• 14:43
  stomach
• 14:44
  is
• 14:44
  delayed
• 14:45
  in
• 14:45
  emptying
• 14:46
  the
• 14:46
  medication
• 14:47
  into
• 14:47
  the
• 14:47
  small
• 14:47
  intestine,
• 14:48
  again,
• 14:49
  you
• 14:49
  have
• 14:49
  more
• 14:50
  drug
• 14:50
  hanging
• 14:50
  out
• 14:51
  for
• 14:51
  longer
• 14:51
  periods
• 14:52
  of
• 14:52
  time.
• 14:52
  It's
• 14:52
  accumulating
• 14:53
  longer,
• 14:53
  it's
• 14:53
  not
• 14:53
  being
• 14:54
  eliminated
• 14:54
  quickly
• 14:55
  enough.
• 14:56
  So
• 14:56
  you
• 14:56
  have
• 14:56
  a
• 14:57
  higher
• 14:57
  tmax,
• 14:57
  you
• 14:58
  have
• 14:58
  a
• 14:58
  higher
• 14:58
  concentration
• 14:59
  of
• 14:59
  the
• 14:59
  medication
• 15:00
  in
• 15:00
  your
• 15:00
  bloodstream,
• 15:01
  eventually.
• 15:02
  And.
• 15:02
  And
• 15:02
  it's
• 15:02
  for
• 15:02
  a
• 15:03
  longer
• 15:03
  period
• 15:03
  of
• 15:03
  time
• 15:04
  in
• 15:04
  the
• 15:04
  elderly,
• 15:05
  okay?
• 15:05
  So
• 15:05
  the
• 15:05
  peak
• 15:06
  is
• 15:06
  actually
• 15:07
  happening
• 15:07
  later
• 15:08
  too.
• 15:08
  The
• 15:08
  peak
• 15:08
  drug
• 15:09
  level
• 15:09
  is
• 15:09
  occurring
• 15:10
  later.
• 15:10
  So
• 15:10
  for
• 15:11
  a
• 15:11
  young
• 15:11
  guy,
• 15:11
  you
• 15:12
  might
• 15:12
  Prescribe
• 15:13
  Ambien
• 15:13
  at
• 15:14
  10,
• 15:14
  and
• 15:14
  maybe
• 15:14
  the
• 15:14
  peak
• 15:15
  is
• 15:15
  around
• 15:15
  12
• 15:15
  or
• 15:15
  1
• 15:15
  in
• 15:16
  the
• 15:16
  morning.
• 15:16
  Well,
• 15:17
  because
• 15:17
  this
• 15:17
  is
• 15:17
  like,
• 15:17
  there's
• 15:18
  like
• 15:18
  a
• 15:18
  delay
• 15:18
  of
• 15:18
  game
• 15:19
  here,
• 15:19
  right?
• 15:20
  It's
• 15:20
  almost
• 15:20
  like
• 15:20
  a
• 15:20
  flight
• 15:20
  that's
• 15:21
  delayed,
• 15:22
  okay?
• 15:22
  When
• 15:22
  your
• 15:22
  flight
• 15:22
  is
• 15:23
  delayed,
• 15:23
  it's
• 15:23
  gonna
• 15:23
  get
• 15:23
  to
• 15:24
  35,000ft
• 15:25
  later
• 15:26
  on
• 15:26
  in
• 15:26
  the
• 15:26
  night.
• 15:26
  Because
• 15:27
  it's
• 15:27
  delayed,
• 15:27
  it's
• 15:28
  not
• 15:28
  getting
• 15:28
  up
• 15:28
  there
• 15:28
  fast
• 15:29
  enough.
• 15:29
  So
• 15:30
  now
• 15:30
  you
• 15:30
  were
• 15:30
  supposed
• 15:30
  to
• 15:31
  be
• 15:31
  at
• 15:31
  35,000ft
• 15:32
  at
• 15:32
  like
• 15:32
  1
• 15:32
  in
• 15:33
  the
• 15:33
  morning.
• 15:33
  Now
• 15:33
  you're
• 15:33
  going
• 15:33
  to
• 15:33
  be
• 15:34
  at
• 15:34
  35,000ft
• 15:34
  at
• 15:35
  Like
• 15:35
  4
• 15:35
  in
• 15:35
  the
• 15:35
  morning.
• 15:36
  Well,
• 15:36
  that's
• 15:36
  a
• 15:36
  problem
• 15:37
  because
• 15:38
  Arthur
• 15:38
  gets
• 15:38
  up
• 15:38
  to
• 15:39
  pee
• 15:39
  at
• 15:39
  4
• 15:39
  in
• 15:39
  the
• 15:39
  morning,
• 15:40
  and
• 15:40
  then
• 15:40
  bam,
• 15:41
  he's
• 15:41
  at
• 15:42
  the
• 15:42
  highest
• 15:44
  plasma
• 15:45
  level
• 15:45
  of
• 15:46
  his
• 15:46
  Ambien
• 15:47
  at
• 15:47
  4
• 15:47
  in
• 15:47
  the
• 15:47
  morning
• 15:48
  instead
• 15:48
  of
• 15:48
  at
• 15:49
  midnight
• 15:49
  when
• 15:49
  he
• 15:49
  should
• 15:50
  have
• 15:50
  been
• 15:50
  asleep,
• 15:50
  sound
• 15:51
  asleep,
• 15:51
  not
• 15:52
  having
• 15:52
  to
• 15:52
  pee,
• 15:53
  not
• 15:53
  having
• 15:53
  to
• 15:53
  get
• 15:54
  up
• 15:54
  to
• 15:55
  say
• 15:55
  nothing
• 15:55
  of
• 15:55
  the
• 15:56
  complex
• 15:56
  sleep
• 15:56
  behaviors
• 15:57
  he
• 15:57
  might
• 15:57
  be
• 15:57
  experiencing
• 15:58
  as
• 15:58
  his
• 15:59
  tmax
• 15:59
  is
• 15:59
  high,
• 16:00
  right?
• 16:00
  So
• 16:01
  this
• 16:01
  is
• 16:01
  kind
• 16:01
  of
• 16:01
  a
• 16:01
  recipe
• 16:02
  for
• 16:02
  disaster.
• 16:03
  He's
• 16:04
  hitting
• 16:04
  his
• 16:04
  peak
• 16:05
  later.
• 16:05
  And
• 16:06
  that
• 16:06
  can
• 16:06
  also
• 16:06
  cause
• 16:07
  residual
• 16:07
  sedation
• 16:08
  in
• 16:08
  the
• 16:08
  morning
• 16:09
  again.
• 16:09
  Maybe
• 16:09
  he
• 16:09
  has
• 16:10
  to
• 16:10
  use
• 16:10
  the
• 16:10
  bathroom.
• 16:11
  Maybe
• 16:11
  Arthur
• 16:11
  drives
• 16:13
  to
• 16:14
  a
• 16:15
  garden
• 16:16
  at
• 16:16
  seven
• 16:16
  in
• 16:16
  the
• 16:16
  morning
• 16:17
  where
• 16:17
  he
• 16:17
  volunteers
• 16:18
  to
• 16:19
  plant
• 16:19
  vegetables
• 16:20
  for
• 16:21
  people,
• 16:21
  for
• 16:22
  homeless
• 16:22
  people
• 16:22
  or
• 16:23
  something,
• 16:23
  right?
• 16:23
  Maybe
• 16:23
  he's
• 16:24
  involved
• 16:24
  in
• 16:24
  his
• 16:24
  community.
• 16:24
  Maybe
• 16:25
  he
• 16:25
  has
• 16:25
  a
• 16:25
  bridge
• 16:25
  tournament
• 16:26
  at
• 16:26
  8
• 16:26
  in
• 16:27
  the
• 16:27
  morning.
• 16:27
  Or
• 16:27
  he's
• 16:27
  meeting.
• 16:28
  He's
• 16:29
  meeting
• 16:29
  a
• 16:30
  Tinder
• 16:30
  date.
• 16:31
  Older
• 16:31
  people
• 16:31
  are
• 16:32
  on
• 16:32
  Tinder.
• 16:33
  Maybe
• 16:33
  he's
• 16:33
  meeting
• 16:33
  a
• 16:33
  tinder
• 16:34
  date
• 16:34
  at
• 16:34
  9
• 16:34
  in
• 16:34
  the
• 16:35
  morning
• 16:35
  for
• 16:35
  brunch,
• 16:36
  okay.
• 16:37
  At
• 16:37
  the
• 16:37
  country
• 16:38
  club
• 16:38
  or
• 16:38
  something.
• 16:39
  And
• 16:39
  lo
• 16:39
  and
• 16:40
  behold,
• 16:40
  because
• 16:40
  of
• 16:41
  the
• 16:41
  delay
• 16:41
  in
• 16:41
  gastric
• 16:42
  emptying,
• 16:43
  he
• 16:43
  still
• 16:44
  has
• 16:44
  residual
• 16:44
  Ambien
• 16:45
  in
• 16:45
  his
• 16:45
  system,
• 16:45
  and
• 16:46
  he
• 16:46
  Crashes
• 16:46
  his
• 16:46
  Buick
• 16:48
  into
• 16:48
  a
• 16:48
  tree.
• 16:49
  Well,
• 16:49
  that's
• 16:49
  awful.
• 16:50
  He.
• 16:50
  He
• 16:50
  was
• 16:50
  supposed
• 16:51
  to
• 16:51
  be
• 16:51
  on
• 16:51
  a
• 16:51
  date.
• 16:53
  And
• 16:53
  so
• 16:53
  look
• 16:53
  what
• 16:53
  you
• 16:53
  did.
• 16:54
  Look
• 16:54
  what
• 16:55
  you
• 16:55
  did.
• 16:56
  All
• 16:56
  right,
• 16:57
  so
• 16:57
  you
• 16:57
  get
• 16:57
  my
• 16:58
  point,
• 16:58
  right?
• 16:58
  The
• 16:58
  delayed
• 16:59
  gastric
• 17:00
  emptying
• 17:01
  impacts
• 17:01
  the
• 17:01
  absorption
• 17:02
  of
• 17:02
  the
• 17:02
  medication.
• 17:03
  It's
• 17:03
  kind
• 17:04
  of
• 17:04
  a
• 17:04
  delayed
• 17:05
  flight
• 17:05
  or.
• 17:06
  Right.
• 17:06
  And
• 17:06
  so
• 17:06
  that's.
• 17:07
  That's
• 17:07
  a
• 17:07
  problem.
• 17:07
  The
• 17:07
  peak
• 17:08
  will
• 17:08
  be
• 17:08
  later
• 17:09
  and
• 17:09
  bad.
• 17:10
  So
• 17:10
  now
• 17:10
  the
• 17:11
  D
• 17:11
  part
• 17:11
  we
• 17:11
  talked
• 17:12
  about,
• 17:12
  a
• 17:12
  D,
• 17:12
  M
• 17:12
  E
• 17:12
  D
• 17:13
  is
• 17:13
  distribution,
• 17:14
  also
• 17:14
  known
• 17:15
  as
• 17:15
  the
• 17:15
  fat
• 17:15
  trap.
• 17:16
  Okay?
• 17:16
  This
• 17:17
  is
• 17:17
  where
• 17:17
  things
• 17:17
  get
• 17:17
  clinically
• 17:18
  important
• 17:18
  now
• 17:18
  with
• 17:18
  aging.
• 17:19
  Lean
• 17:20
  body
• 17:20
  mass
• 17:20
  and
• 17:21
  total
• 17:21
  body
• 17:21
  water
• 17:21
  decrease
• 17:22
  and
• 17:22
  body
• 17:23
  fat,
• 17:23
  as,
• 17:23
  you
• 17:23
  know,
• 17:23
  increases.
• 17:24
  You
• 17:24
  don't
• 17:25
  need
• 17:25
  to
• 17:25
  open
• 17:25
  up
• 17:25
  a
• 17:25
  textbook
• 17:26
  for
• 17:26
  that.
• 17:27
  For
• 17:27
  people
• 17:27
  like
• 17:27
  me,
• 17:27
  I
• 17:28
  just
• 17:28
  need
• 17:28
  to
• 17:28
  take
• 17:28
  off
• 17:28
  my
• 17:29
  shirt,
• 17:29
  right?
• 17:29
  And
• 17:30
  when
• 17:30
  you
• 17:30
  get
• 17:30
  into
• 17:30
  your
• 17:30
  40s
• 17:31
  or
• 17:31
  50s,
• 17:32
  you
• 17:32
  start
• 17:32
  to
• 17:33
  understand,
• 17:33
  like,
• 17:34
  you're
• 17:34
  not
• 17:34
  lean
• 17:35
  anymore.
• 17:35
  You
• 17:36
  just
• 17:36
  gradually
• 17:37
  tend
• 17:37
  to
• 17:37
  get
• 17:37
  fatter
• 17:38
  every
• 17:38
  year.
• 17:39
  As
• 17:39
  a
• 17:39
  general
• 17:40
  rule,
• 17:40
  and
• 17:40
  this
• 17:41
  is
• 17:41
  my
• 17:41
  own
• 17:41
  personal
• 17:42
  experience
• 17:43
  speaking,
• 17:45
  it's
• 17:45
  from
• 17:45
  a
• 17:45
  place
• 17:45
  of
• 17:46
  vulnerability
• 17:46
  and
• 17:47
  fear
• 17:47
  that
• 17:47
  I'm
• 17:47
  talking
• 17:48
  to
• 17:48
  right
• 17:48
  now.
• 17:49
  But
• 17:49
  body
• 17:49
  fat
• 17:50
  does
• 17:50
  increase.
• 17:50
  And
• 17:50
  this
• 17:51
  is
• 17:51
  one
• 17:51
  of
• 17:51
  those.
• 17:51
  Those
• 17:51
  beautiful
• 17:52
  pearls
• 17:52
  that
• 17:52
  I
• 17:52
  don't
• 17:53
  need
• 17:53
  a
• 17:53
  mnemonic
• 17:53
  for.
• 17:54
  For
• 17:54
  any
• 17:54
  of
• 17:54
  you.
• 17:54
  Right.
• 17:55
  Because
• 17:55
  we
• 17:55
  all
• 17:55
  know
• 17:55
  this
• 17:55
  intuitively.
• 17:56
  It's
• 17:57
  a
• 17:57
  sad
• 17:57
  reality
• 17:58
  of
• 17:58
  getting
• 17:58
  older.
• 17:59
  We
• 17:59
  get
• 17:59
  fatter,
• 18:00
  even
• 18:00
  if
• 18:01
  we're
• 18:01
  doing
• 18:01
  everything
• 18:02
  perfectly
• 18:02
  right.
• 18:03
  I
• 18:03
  could
• 18:03
  swim
• 18:04
  as
• 18:05
  many
• 18:05
  laps
• 18:05
  as
• 18:05
  Michael
• 18:06
  Phelps
• 18:07
  in
• 18:07
  the
• 18:07
  gym
• 18:09
  in
• 18:09
  my
• 18:09
  pool.
• 18:09
  I
• 18:10
  could
• 18:10
  swim
• 18:10
  like
• 18:10
  a
• 18:10
  thousand
• 18:11
  laps.
• 18:11
  I
• 18:11
  could
• 18:11
  deadlift
• 18:12
  £300
• 18:13
  every
• 18:13
  day
• 18:13
  for
• 18:13
  the
• 18:14
  rest
• 18:14
  of
• 18:14
  my
• 18:14
  life
• 18:14
  and
• 18:14
  only
• 18:15
  eat
• 18:15
  spinach.
• 18:16
  And
• 18:16
  I
• 18:16
  will
• 18:16
  get
• 18:17
  fatter.
• 18:17
  I.
• 18:17
  Okay,
• 18:18
  the
• 18:18
  problem
• 18:18
  is
• 18:19
  a
• 18:19
  lot
• 18:19
  of
• 18:19
  the
• 18:19
  medications
• 18:20
  that
• 18:20
  we
• 18:20
  prescribe
• 18:20
  are
• 18:21
  lipophilic,
• 18:21
  meaning
• 18:22
  they
• 18:22
  love
• 18:22
  fat.
• 18:23
  And
• 18:23
  so
• 18:25
  they
• 18:26
  distribute
• 18:26
  into
• 18:27
  this
• 18:27
  expanded
• 18:28
  compartment
• 18:28
  of
• 18:28
  fat.
• 18:29
  And
• 18:29
  because
• 18:30
  there's
• 18:30
  more
• 18:30
  of
• 18:30
  it,
• 18:32
  that
• 18:32
  kind
• 18:32
  of
• 18:32
  releases
• 18:33
  the
• 18:33
  drug.
• 18:33
  Slowlier,
• 18:34
  slower,
• 18:35
  slow.
• 18:36
  I
• 18:36
  can't
• 18:36
  believe
• 18:36
  I
• 18:36
  just
• 18:36
  said
• 18:36
  slowlier,
• 18:37
  slower.
• 18:38
  And
• 18:39
  it
• 18:39
  really
• 18:39
  prolongs
• 18:40
  the
• 18:40
  duration
• 18:40
  of
• 18:40
  action
• 18:41
  beyond
• 18:41
  what
• 18:42
  the
• 18:42
  half
• 18:42
  life
• 18:42
  alone
• 18:43
  would
• 18:43
  predict.
• 18:44
  Well,
• 18:44
  that's
• 18:44
  really
• 18:44
  important
• 18:44
  because
• 18:45
  half
• 18:46
  lives
• 18:46
  govern
• 18:46
  a
• 18:47
  lot
• 18:47
  of
• 18:47
  what
• 18:47
  we
• 18:47
  do.
• 18:47
  But
• 18:48
  if
• 18:48
  we're
• 18:48
  staring
• 18:48
  at
• 18:48
  Arthur,
• 18:49
  and
• 18:50
  let's
• 18:50
  just
• 18:50
  say
• 18:50
  even
• 18:50
  Arthur's
• 18:51
  looks
• 18:51
  like
• 18:52
  he's
• 18:52
  in
• 18:52
  decent
• 18:52
  shape
• 18:52
  for
• 18:53
  a
• 18:53
  95
• 18:53
  year
• 18:53
  old.
• 18:54
  Well,
• 18:54
  he
• 18:54
  probably
• 18:54
  has
• 18:55
  more
• 18:55
  fat
• 18:55
  distribution
• 18:56
  than
• 18:56
  Arthur
• 18:57
  had
• 18:57
  when
• 18:57
  he
• 18:57
  was
• 18:58
  19.
• 18:58
  Okay?
• 18:59
  And
• 18:59
  so
• 19:00
  it's
• 19:00
  going
• 19:00
  to
• 19:01
  delay
• 19:02
  the
• 19:02
  release
• 19:02
  of
• 19:03
  this
• 19:03
  medication
• 19:03
  or
• 19:03
  the
• 19:04
  distribution
• 19:04
  of
• 19:04
  this
• 19:04
  medication
• 19:06
  and
• 19:06
  also
• 19:06
  the
• 19:07
  clearance
• 19:07
  of
• 19:07
  the
• 19:07
  medication.
• 19:08
  And
• 19:08
  so
• 19:09
  bam,
• 19:09
  we
• 19:09
  have,
• 19:09
  again,
• 19:11
  higher
• 19:11
  levels,
• 19:12
  higher
• 19:12
  peak
• 19:12
  levels,
• 19:13
  slower
• 19:13
  elimination.
• 19:14
  And
• 19:14
  this
• 19:15
  is
• 19:15
  just
• 19:15
  getting
• 19:15
  kind
• 19:15
  of
• 19:16
  built
• 19:16
  up
• 19:16
  in
• 19:16
  his
• 19:16
  system,
• 19:17
  unknowingly,
• 19:18
  it
• 19:18
  is
• 19:18
  not
• 19:19
  following
• 19:19
  the
• 19:19
  same
• 19:20
  half
• 19:20
  life
• 19:20
  rules
• 19:21
  as
• 19:21
  a
• 19:21
  19
• 19:21
  or
• 19:22
  20
• 19:22
  year
• 19:22
  old.
• 19:22
  That's
• 19:23
  a
• 19:23
  problem.
• 19:24
  Now,
• 19:24
  adme,
• 19:25
  we're
• 19:25
  on
• 19:25
  the
• 19:25
  M
• 19:25
  part
• 19:26
  metabolism.
• 19:27
  This
• 19:27
  is
• 19:27
  kind
• 19:27
  of
• 19:28
  more
• 19:28
  straightforward.
• 19:28
  You've
• 19:29
  probably
• 19:29
  heard
• 19:29
  about
• 19:29
  this
• 19:29
  many
• 19:30
  times.
• 19:30
  But
• 19:30
  this
• 19:31
  sort.
• 19:31
  This
• 19:31
  continues
• 19:32
  to
• 19:32
  compound
• 19:33
  our
• 19:34
  Ambien
• 19:34
  problem.
• 19:35
  The
• 19:35
  liver
• 19:35
  slows
• 19:36
  down
• 19:36
  the
• 19:36
  metabolism,
• 19:37
  right?
• 19:37
  It
• 19:38
  slows
• 19:38
  down
• 19:38
  when
• 19:38
  you're
• 19:39
  older.
• 19:40
  Ambien
• 19:40
  is
• 19:41
  metabolized
• 19:42
  primarily
• 19:43
  through
• 19:44
  CYP3A4.
• 19:45
  Okay.
• 19:47
  There's
• 19:47
  some
• 19:47
  contributions
• 19:48
  from
• 19:48
  1A2
• 19:49
  and
• 19:49
  2C9.
• 19:51
  But
• 19:51
  when
• 19:51
  you
• 19:51
  age,
• 19:52
  hepatic
• 19:52
  blood
• 19:53
  flow
• 19:53
  decreases.
• 19:53
  We
• 19:54
  talked
• 19:54
  about
• 19:54
  the
• 19:54
  blood
• 19:54
  flow,
• 19:55
  right?
• 19:55
  The
• 19:55
  heart's
• 19:55
  just
• 19:55
  not
• 19:56
  pumping
• 19:56
  as
• 19:56
  easily.
• 19:57
  There's
• 19:57
  stiffness
• 19:58
  in
• 19:58
  the
• 19:58
  arteries.
• 19:59
  So
• 19:59
  hepatic
• 20:00
  blood
• 20:00
  flow
• 20:00
  decreases
• 20:02
  by
• 20:02
  25
• 20:02
  to
• 20:03
  40%.
• 20:04
  Your
• 20:04
  liver
• 20:04
  volume
• 20:05
  shrinks.
• 20:05
  Okay.
• 20:06
  And
• 20:06
  that
• 20:07
  reduces
• 20:07
  the
• 20:08
  rate
• 20:08
  at
• 20:08
  which
• 20:08
  drugs
• 20:08
  are
• 20:08
  even
• 20:09
  delivered
• 20:09
  to
• 20:09
  or
• 20:10
  processed
• 20:10
  by
• 20:11
  the
• 20:11
  liver.
• 20:11
  Well,
• 20:12
  that's
• 20:12
  a
• 20:12
  problem,
• 20:12
  right?
• 20:13
  It's
• 20:13
  almost
• 20:14
  like
• 20:15
  when
• 20:16
  at
• 20:16
  age
• 20:16
  19,
• 20:16
  you,
• 20:17
  you
• 20:17
  order
• 20:17
  pizza
• 20:18
  and
• 20:19
  they
• 20:19
  answer
• 20:19
  on
• 20:20
  the
• 20:20
  first
• 20:20
  ring
• 20:20
  and
• 20:21
  they
• 20:21
  deliver
• 20:21
  it
• 20:22
  to
• 20:22
  your
• 20:22
  door
• 20:22
  in
• 20:22
  20
• 20:23
  minutes.
• 20:23
  Okay.
• 20:24
  And
• 20:24
  it's
• 20:24
  almost
• 20:25
  like
• 20:25
  when
• 20:25
  you're
• 20:25
  a
• 20:26
  95,
• 20:27
  it
• 20:27
  rings
• 20:28
  seven
• 20:28
  times,
• 20:29
  it
• 20:29
  goes
• 20:29
  to
• 20:29
  an
• 20:29
  answering
• 20:30
  machine,
• 20:31
  you
• 20:31
  leave
• 20:31
  a
• 20:32
  message,
• 20:32
  they
• 20:32
  call
• 20:32
  you
• 20:33
  back
• 20:33
  four
• 20:33
  hours
• 20:34
  later,
• 20:35
  and
• 20:35
  then
• 20:35
  they
• 20:35
  finally
• 20:36
  take
• 20:36
  your
• 20:36
  order
• 20:37
  and
• 20:37
  get
• 20:37
  to
• 20:37
  your
• 20:37
  house
• 20:38
  to
• 20:38
  deliver
• 20:39
  the
• 20:39
  pizza
• 20:39
  at
• 20:40
  4
• 20:40
  in
• 20:40
  the
• 20:40
  morning
• 20:40
  when
• 20:41
  you're
• 20:41
  ready
• 20:41
  to
• 20:41
  fall
• 20:41
  from
• 20:42
  taking
• 20:42
  Ambien.
• 20:43
  So
• 20:43
  it's
• 20:43
  a,
• 20:43
  it's
• 20:44
  a
• 20:44
  really.
• 20:46
  It's
• 20:46
  probably
• 20:46
  getting,
• 20:47
  I
• 20:47
  mean,
• 20:47
  if
• 20:47
  I
• 20:48
  should
• 20:48
  probably
• 20:48
  retitle
• 20:49
  the
• 20:49
  name
• 20:49
  of
• 20:49
  this
• 20:49
  episode
• 20:50
  to
• 20:50
  Getting
• 20:50
  Old
• 20:50
  Really
• 20:51
  Sucks
• 20:52
  rather
• 20:52
  than
• 20:53
  like
• 20:53
  whatever
• 20:53
  it's
• 20:53
  going
• 20:53
  to
• 20:54
  be
• 20:54
  Ambien
• 20:54
  and
• 20:54
  Arthur
• 20:55
  or
• 20:55
  something.
• 20:56
  It
• 20:56
  sucks,
• 20:57
  right?
• 20:57
  So
• 20:57
  your
• 20:57
  liver
• 20:58
  is
• 20:58
  not
• 20:58
  processing
• 20:59
  this
• 20:59
  as
• 20:59
  quickly.
• 21:00
  That's
• 21:01
  difficult.
• 21:02
  Okay.
• 21:04
  And
• 21:04
  so
• 21:04
  elimination
• 21:06
  is
• 21:06
  the
• 21:06
  E.
• 21:07
  Right.
• 21:07
  We
• 21:07
  talked
• 21:07
  about
• 21:07
  Adme.
• 21:08
  Elimination
• 21:09
  is
• 21:09
  the
• 21:09
  kidney
• 21:09
  bottleneck.
• 21:10
  So
• 21:11
  a
• 21:11
  lot
• 21:11
  of
• 21:11
  these
• 21:12
  medications
• 21:12
  are
• 21:12
  eliminated
• 21:13
  renally,
• 21:13
  as
• 21:14
  you
• 21:14
  know.
• 21:14
  And
• 21:15
  the
• 21:15
  decline
• 21:15
  in
• 21:15
  your
• 21:16
  glomerular
• 21:16
  filtration
• 21:17
  rate
• 21:17
  is
• 21:18
  real.
• 21:18
  There's
• 21:19
  an
• 21:19
  age
• 21:19
  related
• 21:19
  decline
• 21:20
  after
• 21:20
  the
• 21:20
  age
• 21:20
  of
• 21:21
  40
• 21:21
  where
• 21:22
  there's
• 21:22
  reduced
• 21:22
  renal
• 21:23
  blood
• 21:23
  flow.
• 21:23
  Same
• 21:23
  thing
• 21:23
  we
• 21:24
  talked
• 21:24
  about
• 21:24
  with
• 21:24
  the
• 21:24
  liver.
• 21:25
  And
• 21:25
  so
• 21:25
  the
• 21:25
  clearance
• 21:26
  of
• 21:26
  these
• 21:26
  medications
• 21:27
  is
• 21:27
  not
• 21:27
  as
• 21:28
  rapid,
• 21:28
  meaning
• 21:29
  they
• 21:29
  accumulate
• 21:29
  longer
• 21:31
  to
• 21:31
  more
• 21:31
  max
• 21:32
  concentrations
• 21:33
  in
• 21:33
  your
• 21:33
  blood.
• 21:33
  Okay.
• 21:34
  So
• 21:34
  you
• 21:34
  have
• 21:35
  slower
• 21:35
  hepatic
• 21:35
  metabolism,
• 21:36
  slower
• 21:37
  renal
• 21:37
  elimination
• 21:38
  of
• 21:38
  metabolites.
• 21:39
  So
• 21:39
  you
• 21:39
  have
• 21:39
  increased
• 21:40
  drug
• 21:41
  exposure,
• 21:41
  to
• 21:42
  say
• 21:42
  nothing,
• 21:42
  of
• 21:42
  course,
• 21:43
  of
• 21:43
  the
• 21:43
  fact
• 21:44
  that
• 21:44
  you
• 21:44
  have
• 21:44
  more
• 21:44
  fat
• 21:45
  distribution
• 21:47
  and
• 21:47
  that
• 21:48
  you're
• 21:48
  just
• 21:48
  absorbing
• 21:49
  more
• 21:49
  of
• 21:49
  this
• 21:50
  because
• 21:50
  you're
• 21:50
  not
• 21:50
  emptying
• 21:51
  gastrically
• 21:52
  as,
• 21:52
  as
• 21:53
  quickly
• 21:53
  as
• 21:53
  you
• 21:53
  were
• 21:53
  before.
• 21:54
  Now,
• 21:54
  the
• 21:54
  pharmacodynamic
• 21:55
  piece
• 21:56
  to
• 21:56
  this
• 21:56
  is
• 21:56
  that
• 21:56
  your
• 21:56
  brain
• 21:57
  also
• 21:57
  tends
• 21:57
  to
• 21:57
  get
• 21:57
  more
• 21:58
  sensitive
• 21:59
  to
• 22:00
  sedative
• 22:00
  hypnotics
• 22:02
  at
• 22:02
  the
• 22:02
  same
• 22:02
  concentrations
• 22:03
  as
• 22:04
  someone
• 22:05
  who
• 22:05
  may
• 22:05
  not
• 22:05
  be
• 22:05
  as
• 22:06
  sensitive
• 22:06
  to
• 22:06
  it,
• 22:06
  who's
• 22:07
  30,
• 22:07
  40
• 22:07
  years
• 22:08
  younger.
• 22:08
  Okay.
• 22:09
  And
• 22:10
  so
• 22:10
  older
• 22:11
  adults
• 22:11
  definitely
• 22:11
  do
• 22:12
  show
• 22:12
  that
• 22:12
  increased
• 22:12
  sedative
• 22:13
  effect
• 22:13
  from
• 22:13
  benzodiazepines
• 22:14
  or
• 22:14
  Z
• 22:15
  drugs
• 22:15
  at
• 22:16
  equivalent
• 22:16
  plasma
• 22:17
  levels.
• 22:18
  Excuse
• 22:19
  me.
• 22:20
  Compared
• 22:20
  to
• 22:20
  younger
• 22:21
  adults.
• 22:22
  So,
• 22:23
  of
• 22:24
  course
• 22:24
  that's
• 22:24
  a
• 22:24
  problem.
• 22:25
  Right.
• 22:26
  There's
• 22:26
  maybe
• 22:27
  an
• 22:27
  increased
• 22:27
  gamma
• 22:28
  A
• 22:28
  receptor
• 22:28
  sensitivity
• 22:29
  going
• 22:29
  on
• 22:30
  here,
• 22:31
  and
• 22:31
  the
• 22:31
  homeostasis
• 22:32
  is
• 22:33
  not
• 22:33
  as
• 22:33
  easily
• 22:33
  to
• 22:33
  com.
• 22:34
  To
• 22:35
  compensate.
• 22:37
  So
• 22:39
  what
• 22:39
  are
• 22:40
  the
• 22:40
  takeaways
• 22:40
  from
• 22:41
  Arthur
• 22:42
  and
• 22:42
  his
• 22:43
  Ambien?
• 22:44
  The
• 22:44
  big
• 22:45
  takeaways,
• 22:45
  of
• 22:45
  course,
• 22:46
  are
• 22:46
  to
• 22:46
  appreciate
• 22:47
  the
• 22:47
  pharmacokinetic
• 22:49
  and
• 22:49
  pharmacodynamic
• 22:50
  differences
• 22:50
  in
• 22:50
  the
• 22:51
  elderly,
• 22:52
  particularly
• 22:52
  with
• 22:52
  medications
• 22:53
  like
• 22:53
  Ambien.
• 22:54
  But
• 22:54
  there
• 22:54
  sure
• 22:54
  are
• 22:54
  many
• 22:54
  other
• 22:55
  medications.
• 22:56
  And
• 22:56
  remember
• 22:57
  that
• 22:57
  the
• 22:57
  same
• 22:58
  dose
• 22:59
  is
• 22:59
  not
• 22:59
  the
• 22:59
  same
• 23:00
  depending
• 23:00
  on
• 23:00
  who
• 23:00
  your
• 23:01
  patient
• 23:01
  is
• 23:01
  in
• 23:01
  front
• 23:01
  of
• 23:01
  you.
• 23:02
  There
• 23:02
  are
• 23:03
  many
• 23:03
  different
• 23:03
  filters
• 23:04
  by
• 23:04
  which
• 23:04
  you
• 23:05
  have
• 23:05
  to
• 23:05
  put
• 23:05
  your
• 23:06
  prescribing
• 23:07
  mentality
• 23:07
  through
• 23:08
  before
• 23:09
  you
• 23:09
  understand
• 23:09
  what's
• 23:10
  really
• 23:10
  happening
• 23:10
  to
• 23:11
  your
• 23:11
  patient.
• 23:12
  Right.
• 23:13
  There's
• 23:13
  how
• 23:13
  they're
• 23:13
  going
• 23:13
  to
• 23:14
  metabolize
• 23:14
  it.
• 23:15
  Right.
• 23:15
  There's
• 23:15
  their.
• 23:16
  Their
• 23:16
  liver
• 23:16
  and
• 23:16
  kidney
• 23:17
  profile,
• 23:18
  their
• 23:18
  body
• 23:18
  fat
• 23:19
  distribution,
• 23:19
  their
• 23:20
  age.
• 23:21
  Right.
• 23:21
  Their.
• 23:21
  Their
• 23:22
  unique
• 23:22
  sensitivity
• 23:23
  to
• 23:23
  the
• 23:23
  medications
• 23:24
  you
• 23:24
  prescribe.
• 23:24
  So
• 23:25
  starting
• 23:25
  low
• 23:25
  and
• 23:25
  going
• 23:26
  slow
• 23:26
  is
• 23:27
  not
• 23:27
  just
• 23:27
  a
• 23:27
  platitude.
• 23:28
  It's
• 23:28
  a
• 23:28
  direct
• 23:28
  consequence
• 23:30
  of
• 23:31
  really,
• 23:31
  the
• 23:31
  ADME
• 23:32
  framework
• 23:33
  we
• 23:33
  shared
• 23:33
  and
• 23:33
  why
• 23:34
  we
• 23:34
  do
• 23:34
  it.
• 23:34
  But
• 23:35
  avoiding
• 23:35
  Ambien
• 23:36
  entirely
• 23:36
  in
• 23:36
  these
• 23:36
  populations
• 23:37
  would
• 23:37
  probably
• 23:37
  be
• 23:38
  a
• 23:38
  wise
• 23:38
  move
• 23:38
  if
• 23:39
  you
• 23:39
  wanted
• 23:39
  to
• 23:40
  kind
• 23:40
  of
• 23:40
  reduce
• 23:40
  morbidity
• 23:41
  and
• 23:41
  mortality,
• 23:43
  gravitate
• 23:43
  more
• 23:44
  towards
• 23:44
  CBTI
• 23:45
  or
• 23:45
  other
• 23:45
  pharmacology,
• 23:48
  pharmacological
• 23:49
  options
• 23:49
  that
• 23:50
  maybe
• 23:51
  are
• 23:51
  less.
• 23:53
  Less
• 23:53
  dangerous.
• 23:55
  Remember
• 23:56
  that
• 23:56
  the
• 23:56
  elderly
• 23:56
  have
• 23:57
  higher
• 23:57
  peaks,
• 23:57
  longer
• 23:57
  duration,
• 23:58
  they
• 23:58
  have
• 23:58
  greater
• 23:59
  total
• 23:59
  exposure
• 24:00
  to
• 24:00
  these
• 24:00
  medications,
• 24:01
  and
• 24:01
  it
• 24:01
  might
• 24:01
  be
• 24:02
  hitting
• 24:02
  a
• 24:02
  more
• 24:02
  sensitive
• 24:03
  brain.
• 24:05
  And
• 24:05
  that's
• 24:06
  really,
• 24:06
  I
• 24:07
  think,
• 24:07
  a
• 24:07
  lot
• 24:08
  for
• 24:08
  you
• 24:08
  to
• 24:08
  digest
• 24:09
  today,
• 24:09
  my
• 24:09
  friends,
• 24:09
  but
• 24:10
  it's
• 24:10
  been
• 24:10
  a
• 24:10
  real
• 24:11
  pleasure.
• 24:11
  I've
• 24:11
  enjoyed
• 24:12
  every
• 24:12
  second
• 24:12
  of
• 24:12
  this.
• 24:13
  It's
• 24:14
  always
• 24:14
  fun
• 24:14
  to
• 24:14
  learn,
• 24:15
  again,
• 24:16
  not
• 24:16
  to
• 24:16
  beat
• 24:16
  up
• 24:16
  on
• 24:16
  Ambien.
• 24:17
  Like
• 24:17
  I
• 24:17
  said,
• 24:17
  there's
• 24:18
  probably
• 24:18
  plenty
• 24:18
  folks
• 24:18
  out
• 24:19
  there.
• 24:19
  It's
• 24:19
  really
• 24:19
  helpful
• 24:20
  for.
• 24:21
  But
• 24:21
  in
• 24:22
  the
• 24:22
  right,
• 24:22
  every
• 24:23
  med
• 24:23
  is
• 24:23
  kind
• 24:24
  of
• 24:24
  good
• 24:24
  for
• 24:24
  the
• 24:24
  right
• 24:24
  person
• 24:25
  and
• 24:25
  not
• 24:25
  good
• 24:25
  for
• 24:25
  another
• 24:26
  person.
• 24:26
  Right.
• 24:27
  And
• 24:27
  that's
• 24:27
  our
• 24:27
  job
• 24:27
  as
• 24:28
  clinicians,
• 24:28
  is
• 24:29
  to
• 24:29
  figure
• 24:29
  out
• 24:29
  who's
• 24:30
  the
• 24:30
  best
• 24:30
  fit
• 24:30
  for
• 24:30
  this
• 24:30
  and
• 24:31
  why.
• 24:32
  And
• 24:33
  we
• 24:33
  will,
• 24:33
  and
• 24:33
  we
• 24:33
  will
• 24:33
  continue
• 24:34
  to
• 24:34
  do
• 24:34
  great
• 24:34
  things.
• 24:35
  Thank
• 24:35
  you
• 24:35
  all
• 24:35
  for
• 24:36
  tuning
• 24:36
  in.
• 24:36
  This
• 24:36
  was
• 24:36
  a
• 24:36
  fun
• 24:36
  one.
• 24:37
  We'll
• 24:37
  catch
• 24:37
  you
• 24:37
  next
• 24:37
  time
• 24:38
  here
• 24:38
  on
• 24:38
  Pearls
• 24:39
  and
• 24:39
  Prep.