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Clinical - Rosie > Care of elderly > Flashcards

Care of elderly Flashcards

1
Q

what is dementia?

A

dementia is a progressive and largely irreversible syndrome that is characterised by a widespread impairment of mental function.

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2
Q

Why do anticholinergic drugs cause so many side effects?

A

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

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3
Q

Why are anticholinergics of concern in dementia?

A

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

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4
Q

What is the anticholinergic burden scale?

A

Scoring system for anticholinergic effect of common;y used medicines 0-3
0= no activity
3= high activity

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5
Q

What are the common side effects associated with cholinesterase inhibitors?

A 
Nausea, vomiting and diarrhoea - usually transient
Weight loss
Muscle weakness
Syncope
Urinary retention
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6
Q

Cholinesterase inhibitors are CI in who?

A

Glaucoma, sick sinus syndrome, unexplained syncope, severe hepatic/renal impairment, uncontrolled COPD

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7
Q

What is memantine?

A

NMDA receptor antagonist - blocks action of glutamate

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8
Q

Why might phenytoin cause ataxia, slurred speech, confusion etc.

A

Has narrow therapeutic window - TDM monitoring needed

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9
Q

Define postural hypotension

A

Fall of 20mmHg in SBP or 10mmHg in DBP on assuming upright position.

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10
Q

How can we manage postural hypotension?

A

Medication review
Increase fluid input, TEDS
Medication - fludrocortisone

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11
Q

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?

A

Amiodarone-induced hypothyroidism.

Test TSH, T3, T4 levels

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12
Q

Why is prescribing more difficult in older people?

A

Mutliple pathology
Polypharmacy
Difficulties with adherence
Alternated drug handling - more susceptible to adverse events, interactions etc.

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13
Q

What is the difference between adherence and compliance?

A 
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
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14
Q

Outline some unintentional causes of nonadherence that might be seen in the elderly

A 
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
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15
Q

Outline possible intentional causes of nonadherence that might be seen in the elderly

A

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

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16
Q

What are some issues with multi compliance aids?

A

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.

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17
Q

Outline some of the reasons for inappropriate prescribing in elderly

A

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

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18
Q

The cholinesterase inhibitors have no demonstrated differences in efficacy, but what might influence your choice?

A

Donezepil is the only one that is once daily

Rivastigmine is available as a patch

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19
Q

What should be prescribed/offerred alongside an NSAID in elderly patients?

A

PPI

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20
Q

In elderly patients taking maintenance corticoidsteroid therapy what should we consider prescribing?

A

Bisphosphonate

21
Q

When should NSAIDs be stopped?

A

Patients with history of peptic ulcer disease
Heart failure - risk of exacerbation
With warfarin - risk of bleeding
Renal impairment

22
Q

Why should prochloperazine or metoclopramide be prescribed to patients with parkinsons?

A

Risk of exacerbating parkinsons

23
Q

At what eGFR should metformin not be prescribed?

A

eGFR <50ml

24
Q

Give five drugs that have been identified as having a significant associated with falls in elderly patients

A 
Antihypertensives
Diuretics
Beta-blockers
Antidepressants
Benzos
Antipsychotics
Sedatives
Opioids
25
Q

Describe the signs and symptoms of AD

A

Memory loss, especially of recent events

Problems with language and forming sentences

26
Q

Why might LMWH dose need to be reduced in elderly?

A

Often low body weight and renal impairment

Dose reduced to dalteparin 2500 units

27
Q

How should hypotension be managed?

A

Stop any antihypertensives

Fluids - oral where possible

28
Q

How should benzodiazepines be stopped?

A

Need to taper dose to prevent withdrawal symptoms - 5-10% reduction every 1/2 weeks.

Can taper quicker in a hosptial setting.

29
Q

Outline signs of benzodiazepine withdrawal

A

Sleep disturbance, irritability, sweating, headache, tremor, anxiety

30
Q

You want to take a patient off their amitryptiline, how should you do this?

A

Dose should be gradually reduced over 4 weeks (6 months if patients have had long term maintenance treatment)

31
Q

How can we assess pain?

A

Could use abbey pain score

32
Q

Why should NSAIDs be stopped in elderly patients where possible

A

Renal impairment, increased risk of fractures and GI bleed

33
Q

When might we want to reduce paracetamol dose?

A

If patient weighs less than 50kg

  • IV reduce to 750mg TDS
  • orally may want to consider dose reduction
34
Q

What should be prescribed with all opioids?

A

Laxative and antiemetic

35
Q

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?

A

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.

36
Q

What is the targe BP in elderly patients?

A

150/90

37
Q

When should anticholinesterase inhibitors be taken and why?

A

At night as can cause drowsiness

38
Q

People with a possible or suspected diagnosis of dementia should be referred to who?

A

Memory assessment services should be the single point of referral for all people with suspected dementia

39
Q

What drug(s) could be used for overactive bladder instead of oxybutynin to reduce anticholinergic burden?

A

mirabegron

trospium

40
Q

why is doxazosin of concern in elderly?

A

can cause hypotension

41
Q

Outline how you should manage amiodarone-digoxin interaction

A

Amiodarone doubles the levels of digoxin, need to half the dose of digoxin.

42
Q

How should you manage digoxin toxicity?

A

Stop digoxin for 2-3 days
Replace K+ levels
Repeat level and start at lower dose
If severe - used IV Digibind

43
Q

How should people with dementia and depression be managed?

A

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.

44
Q

How should a patient taking an ACEi manage their medication when suffering from vomiting and diarrhea?

A

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.

45
Q

How long shoud cholinesterase inhibitors be continued for?

A

Should only be continued when its considered to be having a worthwhile effect on cognitive, global function or behavioral symptoms.

46
Q

What are the common adverse side effects of memantine?

A

Hallucinations, confusion, dizziness, headache, and tiredness.

47
Q

what are common causes of confusion in elderly patients?

A

UTI
Hyponatremia - look for PPIs, SSRIs
Dementia
Dehydration

48
Q

High urea levels could be indicative of what?

A

Renal impairment

Dehydration

Clinical - Rosie (16 decks)

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