CLINICAL- ELDERLY Flashcards
How do we tell the difference between Alzeihmers, vascular dementia and Lewy Body dementia??
Alzheimer’s presents as memory loss especially short term memory, constant slow deterioration
Vascular dementia also memory loss but it’s a stepwise deterioration, symptoms are constant them suddenly worsen after a TIA/ other vascular event.
Lewy body dementia symptoms are problems with alertness/ attention, slow movements, mask-like face, shuffling gait, tremor
Why Not recommended in Elderly: phenothiazines (eg. Chlorpromazine) for dizziness due to postural hypotension?
Will make dizziness worse
Treat the postural hypotension: is there a cause of this why is BP so low??
Why Not recommended in Elderly: benzodiazepines for insomnia due to depression
Risk of falls, sedation and confusion
Treat the depression not the insomnia
Why Not recommended in Elderly: Levodopa for non-Parkinsonism tremor or drug-induced Parkinsonism?
The Parkinson’s in this case is not caused by dopamine deficiency so no evidence that levodopa will be effective!!
Get rid of the drug causing Parkinson’s rather than treat the side effect: avoid poly pharmacy!!
Why Not recommended in Elderly: loop diuretics for dependent oedema?
We want to get the fluid back into the circulation with dependent (gravitational) oedema
Use compression stockings and elevation
Why not use benzodiazepines, especially with long half lives, in the elderly?
Risk of falls from impaired balance Sedation Confusion Cognitive impairment Addiction
Why avoid long acting hypoglycaemic drugs e.g. Metformin in the elderly?
Can cause prolonged Hypoglycaemia so there is risk of overnight hypos: elderly not great at recognising hypos
Why try and avoid anticholiergics for Parkinson’s in the elderly??
Impaired cognition: can unmask Alzheimer’s
Confusion
Antimuscarinc side effects: e.g. Constipation and urinary problems
No evidence base
Why not use muscle relaxants for spasticity in the elderly??
Overall muscle tone is reduced as they are non specific therefore there is increased risk of falls
What four things are part of the Dementia Strategy 2009??
Improve early diagnosis
Improve support services for patients and carers
Reduce admissions to long term car (care homes)
Improve cost effectiveness of services
Where should people be referred to if they are suspected to have dementia??
Memory assessment services
Only 1/3 of people receive diagnosis of dementia of any input from specialist services!!
In a MMSE, what does a score indicates mild dementia? What treatment can be initiated??
Mild dementia is 21-25
Can instigate treatment with donepezil, rivastigmine or gelantamine
In a MMSE, what does a score of 10-20 indicate?
Moderate dementia
Can instigate treatment with donepezil, rivastigmine or galantamine
In MMSE, what score indicates severe dementia? What treatment can be considered?
Severe dementia 0-9
Can consider Memantine in severe dementia
Donepezil may also work
If we have a patient who’s got suspected dementia, it’s worth testing and retesting to confirm it. When should we review it to confirm if it’s still there?
6 months
What is mild cognitive impairment??
A syndrome defined as a cognitive decline greater than that expected for the individuals age and education level but doesn’t notably interfere with their activities of daily life.
10% of people with mild cognitive impairment develop Alzheimer’s per year!!
Apart from the more obvious types of dementia (Alzheimer’s, vascular etc) what else can NON reversible dementia result from?
Parkinsons Alcohol (Wernickes encephalopathy) Huntingtons disease HIV CJD (creutzfeldt Jakob disease of the brain)
Can you think of any of the reversible types of dementia? I.e. It’s not actual dementia they just cause symptoms of dementia?
Depression Hypothyroidism Hypoglyceamia Low sodium- causes confusion Brain tumour Subdural haemorrhage Vitamin B12 and folate deficiency
OTHER DRUGS!!
Oxybutinin (for urinary incontinence)
Antipsychotics such as Chlorpromazine
Benzodiazepines (Diazepam etc)
What can all these cause???
Can cause cognitive impairment and present dementia type symptoms
What’s the deal with antidepressants TCAs and SSRIs and dementia??
Can present with dementia type symptoms so can worsen dementia
What are the three cholinesterase inhibitors we can use to treat Alzheimer’s??
Donepezil
Rivastigmine
Galantamine
These work because there is low levels of acetylcholine in Alzheimer’s so they stop cholinesterase enzyme breaking down what’s left of acetylcholine.
They should only be continued if they are showing a worthwhile effect
What are the cholinesterase inhibitors used in Alzheimer’s disease contraindicated in??
Glaucoma
Sick sinus syndrome (abnormal heart rhythm)
Severe hepatic or renal impairment!!!!
Uncontrolled COPD
Unexplained syncope (loss of conciousness)
Which types of dementia do cholinesterase inhibitors show benefit in??
Alzheimer’s disease (prolongs the time before people need to go into care homes, slows progression)
Vascular dementia: no significant benefits of these drugs!!
Mild cognitive impairment: possibly prevention in progression to Alzheimer’s
Lewis body and parkinsons dementia: can help cognition and psychosis
What is memantines mechanism of action??
It’s an NDMA receptor antagonist:
Excess Glutamate is present in Mid to late stage Alzheimer’s which interferes with neurotransmission and contributes to neurone loss.
Memantine blocks the action of glutamate.
When should memantine be used??
Severe Alzheimer’s disease
It can be considered in moderate disease if the person is intolerant to or there’s a contraindication with the cholinesterase inhibitors (e.g. Severe hepatic or renal impairment or glaucoma)
What’s the leading cause of death in people over 75 in the UK?
Injuries as a result of Falls
What kind of things are being looked at as the FUTURE for Alzheimer’s disease treatment??
Vaccines
Monoclonal antibodies against beta amyloid (contributes to formation of plaques)
Vitamin E
Identifying biomarkers in the CSF and in the genome to see who will respond to amyloid lowering drugs at an early stage
What is GAIT and what does it pose a risk to??
Large gaps between peoples feet when they walk (aka ATAXIC)
Present when there is problems in the cerebellar
Poses a risk of FALLS
Whys it important to do vitamin D level testing in the elderly??
If people are severely deficient in vitamin D they are more at risk of falls
People with lots of vitamin D seem to have better balance
Vitamin D also very important in osteoporosis
We can give people calceos or adcal D3 forte containing calcium and vitamin D.
If very low we can give people high doses of vitamin D such as cholecalciferol 50,000 units
What’s the risks with the elderly on Phenytoin?
It’s got a very narrow therapeutic window (we should use drugs with a wide therapeutic window in the elderly)
Little changes in dose can result in bit changes to its effects
Can cause confusion, balance problems, falls, tremors, blood pressure drop, gait, hallucinations
Lots of problems for elderly patients!!! Dirty drug
What do we define as Postural Hypotension (Hint: think of systolic and diastolic BP falls)
A fall of 20 mmHg in Systolic BP or 10 mmHg in Diastolic BP on assuming upright position
What drugs can cause postural hypotension??
Anti hypertensives!! Especially diuretics and Doxazosin
TCA’s
Parkinsons medication
Antipsychotics
What is “coathanger” ache??
Neck pain
Can be a symptom of postural hypotension
How do we treat postural hypotension?? I.e. How do we get Blood pressure back up??
Firstly review their medications: is there anything we can take them off that may be causing the low BP?? E.g. Take them off their antihypertensive if they have had a fall resulting from postural hypotension.
Increase fluid input!! Getting fluid back into their circulation increases blood pressure.
TEDs stockings: pushes fluid back into circulation
Medication:
Fludrocortisone: causes fluid retention so pushes the blood pressure up! Can’t give it to patients with Heart failure- would make it worse!!
Midodrine
But be careful!! Anything that drives blood pressure up: you have to be wary of the risks of stroke
Why is Digoxin a risk in the elderly??
It’s a red flag drug like phenytoin
It slows down you heart rate, used in AF treatment
In elderly patients their renal function declines: won’t process digoxin as well, digoxin levels rise and people start passing out, causes risk of falls.
Levels also affected by Frailness and Hypokaleamia (low potassium) so should use K+ sparing diuretics
It has a narrow therapeutic window. Should do blood test to check levels aren’t in toxic range in elderly!
What are the concerns with warfarin in the elderly ??
It can cause falls!!
Can cause dementia: avoid in dementia patients
Can cause unexplained aneamia
You need to work out the benefit vs risk of warfarin: some elderly dependent on it for anticoagulation but if they’re falling regularly you should take them off it
Why not recommended the benzodiazepines like diazepam temazepam etc in the elderly?
They are the most dissociative drugs and can sedate
Therefore they can cause people to fall
Very hard to get people off them: ween them off slowly..!!
What drug can double the levels of digoxin?
Amiodarone
What drug causes a Slate grey pigmentation of the skin?
Amiodarone
Also can cause hypo and hyperthyroidism!!!!
and peripheral neuropathy
What should we do if digoxin toxicity occurs?
If it’s mild them we:
Stop it for 2-3 days
Replace potassium levels
Re-check levels and Start again at Lower dose
If it’s severe: we use Digibind IV
Elderly patients have multiple pathologies which makes prescribing in this age group more difficult. What does this mean?
Many disease presents are present in the elderly. Can have complex interactions between disease and medication.
There is also a lack of clinical trial data in the elderly; not may trials are carried out on this population and even if they are they will usually only have a single disease state.
Polypharmacy is a problem in the elderly. What does this mean?
They take 4 or more medicines. This results in: Increased drug interactions Increased Side effects Non-adherence
4+ medicines triggers the need to do an MUR in community
What is the difference between adherence and compliance?
Compliance: the extent to which the patient’s behaviour matches the prescriber’s recommendations.
Adherence: the extent to which the patient’s behaviour matches AGREED recommendations from the prescriber
What kind of things can lead to non-adherence in the elderly?
Lack of dexterity: physical difficulty with opening packaging, eye sight poor
Poor swallow
Confusion and memory problems
Polypharmacy / complicated regimens
Why may an old person deliberately not take their medication?
Deliberate adjustments e.g. Water tablets; won’t take if they are going out
Lack of confidence in their medicines or prescriber
Side effects or concerns: e.g. gran reading things in the paper
Poly pharmacy: decided they’re taking too many so cut things out
Poor communication: not including patient in decision making process
Whats the problem with Multi compartment compliance aids/ Dossette boxes in the elderly?
They may not be able to manage them- may not be able to remember what day or time it is, need to be able to push open blisters
Need to understand how to use
Can take away their independence (e.g. Gran likes managing her own)
Many filled now to help carers out
With regards to the actual medicines, what is the problem with Multiple compartment compliance aids?
Concerns with medicine stability if they’re taken out of their original packaging (also become unlicensed)
Manufacturers produce stability data to indicate whether medicines will be okay out of their packaging and can go in compliance aids
Remember: The RPS guidance says that medicines compliance aids should be avoided where possible
Absorption RATE is reduced in the elderly but drugs are still absorbed to the same extent so its not a clinical problem. What causes decreased absorption?
Reduced: salivary flow, gastric emptying time, surface area for absorption, blood flow
Increased gastric pH
Exceptions:
Reduced extent of absorption of vitamins, calcium
Increased absorption of Levodopa
Why is the rate of distribution in the elderly slower?
Reduced blood flow
Reduced perfusion to organs
The elderly have reduced body water. What does this mean for drugs?
This means that there are increased Plasma concentrations of water soluble drugs so the doses of some drugs have to be reduced in the elderly!
Examples of drugs effected: digoxin gentamicin theophylline lithium
What does increased Body fat mean for drugs in the elderly?
There are pro-longed effects of fat-soluble drugs; e.g. Diazepam and Phenytoin. So may not need to administer these as often in the elderly
Little old ladies have reduced body fat
What does reduced ALBUMIN mean in the elderly population?
Increased free concentrations of protein-bound drugs (therefore higher active concentration in the blood) Drugs effected: Furosemide NSAIDs Warfarin phenytoin diazepam sulphonylureas digoxin
What drug is effected by REDUCED Muscle mass in elderly patients?
Digoxin
As it binds to muscle
Reduced muscle mass means less digoxin passes out of blood stream: leads to prolonged levels so may need to decrease the dose.
In terms of metabolism in the elderly, they usually have reduced hepatic perfusion, REDUCED FIRST PASS EFFECT, and REDUCED HEPATIC ENZYMES (mainly the cytochrome P450’s. Why is this generally considered clinically insignificant?
The liver has a large reserve for metabolism.
Unless patients are very frail and elderly: may need to decrease doses.
What is the most important pharmacokinetic change in the elderly?
ELIMINATION
Reduction in elimination via the kidneys
There is a consistent decline in kidney function with age and this causes any renally excreted drugs to accumulate in the body and therefore cause more side effects.
What drugs does a reduction in elimination in the elderly cause problems for?
Drugs with a very narrow therapeutic index such as digoxin and lithium.
What acute problems in the elderly could worsen their renal function and therefore reduce the elimination of even further?
Dehydration Cardiac failure Diabetes Infection It doesn’t take much when an elderly patient is unwell to tip their renal function over the edge so ALWAYS need to bear renal function in mind in the elderly
Why, in terms of pharmacodynamics, does the elderly body not respond the way we expect and usually become more sensitive to drugs and their side effects?
There are changes in target receptor sensitivity
Changes in target organ responsiveness
Loss of homeostatic mechanisms
NB: changes in receptor sensitivity may result in increased effects or decreased effects:
e.g. we see Increased effects of CNS-drugs and decreased efficacy of Beta blockers in the elderly
With regards to prescribing doses in the elderly, whats the general rule:
“start low and go slow”
Start off with lower doses than you would give to a young patient and titrate slowly to reduce side effects. Remember they will probably not need as big dose for the same efficacy.
In terms of the STOPP criteria, what is the deal with digoxin?
Long term digoxin at a dose of over 125 mcg should be stopped in elderly with impaired renal function (so most of the elderly)!
Digoxin is a RED FLAG drug: we usually just stop it in the elderly where we can, as there is INCREASED RISK of toxicity
A patient, 83, has been prescribed ibuprofen. They have heart failure. Whats up?
NSAIDs in Heart Failure is a STOPP indication- take them off the NSAID- prescribe paracetamol!!
This is because NSAIDS can induce fluid retention which is bad in heart failure
My elderly patient has parkinson’s and they are feeling really sick. What must I absolutely not prescribe?
METOCLOPRAMIDE
Some examples of medicines in the START criteria:
Warfarin in chronic AF (anticoagulants needed in AF to stop pooling and clots)
ACE-I in chronic heart failure
Bisphosphonates (e.g. alendronic acid) in patients on maintenance corticosteroids- to prevent osteoporosis as steroids can induce this. We don’t really like putting patients on bisphophonates due to risk of oesophageal damage.
What are the risks of bendroflumethiazide?
Hyponeutreamia (Low sodium)
Postural Hypotension
Renal impairment
Dehydration
Antihypertensives (e.g. Nifedipine, Doxazosin)
Postural Hypotension
Renal impairment
Dehydration
NB: ACE inhibitors particular caution with renal impairment, Beta blockers- elderly may be less sensitive to them
CNS acting agents especially tricyclic antidepressants (TCA’s) such as amitriptyline, the SSRI fluoxetine and long acting benzodiazepines such as diazepam are cautioned in elderly. Why?
Elderly have increased sensitivity to CNS agents. This results in there being more risk of side effects: Postural sway confusion FALLS sedation
Problems in the elderly such as Hypotension, Constipation, CNS effects (e.g. hallucinations) can result from what kind of drugs?
OPIOIDS
Need to make sure a prophylactic laxative is given to prevent this
Long acting Hypo-glyceamics for diabetes are contra indicated in the elderly. Why? can you think of an example?
Metformin and Glibenclamide
Because elderly are more sensitive to drugs, there is a risk of HYPO-GLYCEAMIA (risk of Hypos- harder to diagnose in the elderly- Hot, sweaty, light headed, dizzy)
NB: Its not just diabetic elderly that are at risk of hypos!
Why may warfarin be a problem in the elderly?
Increased sensitivity
Risk of falls
NOTE: RISK OF FALLS SHOULD NOT BE A REASON FOR NOT PRESCRIBING ANTICOAGULANTS!! Risk of anticoagulants far outweigh this. Also DON’T TELL HELENA WARFARIN CAUSES FALLS! Just increases risk
What are the signs of Hyponeutreamia? (e.g caused by bendroflumethiazide, SSRI’s, Omeprazole)
Muscle cramps
Slurred speech
CONFUSION is a big one- But can have a UTI causing this!
normal range for blood sodium levels is 135 to 145. When it gets to 120: start panicking
We are most worried about sodium in the elderly
What are the symptoms of Hypokaleamia? (low potassium)
Muscle weakness, intestinal atony (bowel looses strength), increased sensitivity to digoxin, polyuria, polydypsia
NB: ACEi’s cause HIGH potassium (hyperkaleamia)
Normal range for potassium: 3.3- 5. Panic at about 3 or 6!
Why is Digoxin a STOPP drug in the elderly?
It is effected by reduced water volume (reduced weight), reduced muscle mass, reduced albumin
It has a narrow therapeutic window and can easily cause toxicity
Its a red flag drug: It should definitely not be used as a long term treatment at over 125g/ day with impaired renal function
What do we need to consider with statins in elderly patients?
Statins are taken to reduce cardiovascular risk in the next 10 YEARS.
We need to consider with elderly: do they have a 10 year life expectancy? Is it worth the potential muscle side effect? Consider in exam.
