Care of elderly Flashcards
what is dementia?
dementia is a progressive and largely irreversible syndrome that is characterised by a widespread impairment of mental function.
Why do anticholinergic drugs cause so many side effects?
Acts on nictoinic and muscarinic receptors. 5 muscarinic subtypes M1-M5 are widespread in teh body
M2 and M3- urinary retention
M1, M3 and M4 - dry mouth
M1, M2, M3 - constipation
All subtypes are present in the brain - cognitin and memory impairment
Why are anticholinergics of concern in dementia?
All muscarinic receptors are present in the brain - important in cognition, memory and learning.
BBB may be disrupted in dementia and so increased suseceptibility to anticholinergic side effects
What is the anticholinergic burden scale?
Scoring system for anticholinergic effect of common;y used medicines 0-3
0= no activity
3= high activity
What are the common side effects associated with cholinesterase inhibitors?
Nausea, vomiting and diarrhoea - usually transient Weight loss Muscle weakness Syncope Urinary retention
Cholinesterase inhibitors are CI in who?
Glaucoma, sick sinus syndrome, unexplained syncope, severe hepatic/renal impairment, uncontrolled COPD
What is memantine?
NMDA receptor antagonist - blocks action of glutamate
Why might phenytoin cause ataxia, slurred speech, confusion etc.
Has narrow therapeutic window - TDM monitoring needed
Define postural hypotension
Fall of 20mmHg in SBP or 10mmHg in DBP on assuming upright position.
How can we manage postural hypotension?
Medication review
Increase fluid input, TEDS
Medication - fludrocortisone
A 68 year old patient taking amiodarone describes herself as slowing down, and claims she has gained weight. What might be the cause and what tests would you want to do?
Amiodarone-induced hypothyroidism.
Test TSH, T3, T4 levels
Why is prescribing more difficult in older people?
Mutliple pathology
Polypharmacy
Difficulties with adherence
Alternated drug handling - more susceptible to adverse events, interactions etc.
What is the difference between adherence and compliance?
Compliance = the extent to which the patients behavior matches the prescribers recommendations Adherence = the extent to which the patients behavior matches agreed recomendations from the prescriber
Outline some unintentional causes of nonadherence that might be seen in the elderly
Physical difficulty with packing or devices due to poor vision and dexterity Poor swallow Confusion/memory problems Poor communication/lack of information Polypharmacy and complicated regimens
Outline possible intentional causes of nonadherence that might be seen in the elderly
Deliberate adjustments e.g. no taking water tablet because they are going out
Lack of confidence in the medicines ‘they dont work’
Side effects or concerns about these
Polypharmacy/complicated regimen
Poor communication/lack of information
What are some issues with multi compliance aids?
Patient needs to understand how to use it
Can take away their independence and reduce understanding of medicines
Issues of stability of medicines outside their original packaging
MCAs are associated with a high incidence of potentially inappropriate medications.
Outline some of the reasons for inappropriate prescribing in elderly
Over enthusiasm - the desire to respond to patients symptoms with a drug
Failure to recognize an adverse effect - elderly patients are more susceptible to adverse events
Patients of relative refusing to take a drug
Failure to individualize treatment
Inadequate review - failure to optimise doses or discontinue unnecessary drugs
Underprescribing because they are old e.g. antidepressants
The cholinesterase inhibitors have no demonstrated differences in efficacy, but what might influence your choice?
Donezepil is the only one that is once daily
Rivastigmine is available as a patch
What should be prescribed/offerred alongside an NSAID in elderly patients?
PPI
In elderly patients taking maintenance corticoidsteroid therapy what should we consider prescribing?
Bisphosphonate
When should NSAIDs be stopped?
Patients with history of peptic ulcer disease
Heart failure - risk of exacerbation
With warfarin - risk of bleeding
Renal impairment
Why should prochloperazine or metoclopramide be prescribed to patients with parkinsons?
Risk of exacerbating parkinsons
At what eGFR should metformin not be prescribed?
eGFR <50ml
Give five drugs that have been identified as having a significant associated with falls in elderly patients
Antihypertensives Diuretics Beta-blockers Antidepressants Benzos Antipsychotics Sedatives Opioids
Describe the signs and symptoms of AD
Memory loss, especially of recent events
Problems with language and forming sentences
Why might LMWH dose need to be reduced in elderly?
Often low body weight and renal impairment
Dose reduced to dalteparin 2500 units
How should hypotension be managed?
Stop any antihypertensives
Fluids - oral where possible
How should benzodiazepines be stopped?
Need to taper dose to prevent withdrawal symptoms - 5-10% reduction every 1/2 weeks.
Can taper quicker in a hosptial setting.
Outline signs of benzodiazepine withdrawal
Sleep disturbance, irritability, sweating, headache, tremor, anxiety
You want to take a patient off their amitryptiline, how should you do this?
Dose should be gradually reduced over 4 weeks (6 months if patients have had long term maintenance treatment)
How can we assess pain?
Could use abbey pain score
Why should NSAIDs be stopped in elderly patients where possible
Renal impairment, increased risk of fractures and GI bleed
When might we want to reduce paracetamol dose?
If patient weighs less than 50kg
- IV reduce to 750mg TDS
- orally may want to consider dose reduction
What should be prescribed with all opioids?
Laxative and antiemetic
An elderly patient is taking Oxybutynin for BPH and has just been diagnosed with AD. Why isn’t this medication appropriate and what is a better alternative?
No appropriate because it is anticholinergic
Use finasteride instead
Tamulosin is an alpha blocker than can increase risk of falls so is not a good alternative.
What is the targe BP in elderly patients?
150/90
When should anticholinesterase inhibitors be taken and why?
At night as can cause drowsiness
People with a possible or suspected diagnosis of dementia should be referred to who?
Memory assessment services should be the single point of referral for all people with suspected dementia
What drug(s) could be used for overactive bladder instead of oxybutynin to reduce anticholinergic burden?
mirabegron
trospium
why is doxazosin of concern in elderly?
can cause hypotension
Outline how you should manage amiodarone-digoxin interaction
Amiodarone doubles the levels of digoxin, need to half the dose of digoxin.
How should you manage digoxin toxicity?
Stop digoxin for 2-3 days
Replace K+ levels
Repeat level and start at lower dose
If severe - used IV Digibind
How should people with dementia and depression be managed?
People with dementia who also have major depressive disorder should be offered antidepressant medication. Antidepressant drugs with anticholinergic effects should be avoided because they may adversely affect cognition.
How should a patient taking an ACEi manage their medication when suffering from vomiting and diarrhea?
Patients should stop because they are dehydrated. Restart when they are well.
If patient has heart failure, their condition can decompensate rapidly and they should urgently seek specialist advice.
How long shoud cholinesterase inhibitors be continued for?
Should only be continued when its considered to be having a worthwhile effect on cognitive, global function or behavioral symptoms.
What are the common adverse side effects of memantine?
Hallucinations, confusion, dizziness, headache, and tiredness.
what are common causes of confusion in elderly patients?
UTI
Hyponatremia - look for PPIs, SSRIs
Dementia
Dehydration
High urea levels could be indicative of what?
Renal impairment
Dehydration
