Drugs used in old age/ Polypharmacy Flashcards
What are the aims of alzheimers dementia treatment?
Promote independence, maintain function, manage symptoms, there is no cure
3 acetylcholinesterase inhibitors are recommended as first line for managing mild to moderate AD
Donepezil
Rivastigmine
Galantamine
How do acetylcholinesterase inhibitors work?
The cholinergic hypothesis suggests that a dysfunction of neurones in the brain, containing the neurotransmitter acetylcholine significantly contributes to the cognitive decline seen in those with advanced age and alzheimers disease
Acetylcholinesterase inhibitors inhibit the enzyme acetylcholinesterase from breaking down acetylcholine into choline and acetate thereby increasing both the level and duration of action of the acetylcholine
How does memantine work? When is it used?
NMDA receptor agonist (glutamate receptor antagonist)
Recommended for patients with moderate AD who are intolerant or have a contraindication to acetylcholinesterase inhibitors or severe AD
Patients can now be started on memantine on top of their Acetylcholinesterase inhibitors
How do you treat lewy body dementia/parkinsons?
AChEi can be given, rivastigmine
VD optimise vascular risk factors- BP, DM, cholesterol etc
AChEi and memantine are not recommended in patients with frontotemporal dementia or cognitive impairment by MS
What are the cautions of anti choleresterases?
Gastric/duodenal ulcers Bladder obstruction Asthma COPD Heart block Syncope Seizures
What should you be cautious of when giving memantine?
Epilepsy/ seizures
Max 10mg OD if eGFr <30
What are the side effects of anti cholinesterases?
GI disturbance- reduced appetite, arrythmias, dizziness, drowsiness, falls, headache, GI bleed
What are the side effects of memantine??
ConstipationDizziness
Drowsiness
Headache
Seizures
What is BPSD?
Behavioural and psychological symptoms of dementia
Very common- point prevelance is 60-80%
Cumulative risk >90% over the course of the illness
The number, type, severity of BPSD varies between patient
Symptoms- agitation, agression, wandering, sexual disinhibition, shouting out, sleep disturbance, depression, anxiety, hallcuinations and delusions, sundowning
What are the non pharmacological managements of BPSD?
ABC charts (date and time of behaviours, where, description of behaviour)
Nutrition
Hearing aids/glasses to compensate for sensory impairements
Reminscence therapy ie: life story books
Complimentary therapies (hand massage, aromatherapy, beauty therapies)
Risk assesment, reduction and intervention- are the patients needs being met
Psychological
Know about their life
Structure of days are important
What are the general principles of pharmacological management of dementia?
Benefits must outweigh the any anticipated risks for the individual
If meds started, review in 6 weeks
Start low and go slow
What meds are used in BPSD?
Antidepressants- SSRIs, mirtazapine
For low mood and anxiety
AcheI / memantine for agitation in AD
Benzos- lorazepam
Analgesia- regular paracetamol or buprenorphine patch if indicated
Mood stabilisers/ anticonvulsants (depakote)
Are antipsychotics used in BPSD?
Not routinely, only if severe agitation
Risperidone is usually used
Where do you find patients drugs?
MAR chart
What are important parts of prescribing
Tell nurses about once only dose Write renal function on front Allergies Write micrograms or units in full Write insulin brand
How to measure elderly patients clearance?
EGFR
(Age, gender, ethnicity, creatinine level)
Creatinine clearance
However this doesn’t take into account the patient’s size
MHRA recommend oral anticoags, nephrotoxic, extremes of muscle mass, and if they have nephrotoxic meds then use the calculated creatinine clearance (system one tool) affects Enoxaparin, apixaban
Cockcroft-Gault formula should be used to calculate creatinine clearance (CrCl).
What is the prescribing cascade?
The treatment of side effects of drugs as a new disease
What are the side effects of anticholinergics?
Constipation
Blurred vision
Affect on heart
Increase cognitive impairement
What problems do elderly patients have taking tablets?
- memory
- not knowing when to take them
- shaky
- swallowing problems
- don’t know why they are on them
- reading labels
What can be done to aid the elderly taking lots of drugs?
Blister packs
MAR chart- a chart that old people can tick off
Phone apps
Pharmacy Carousel
Give information Leaflets
Pharmacy’s can print larger labels for medications
Can try and switch them to less frequent tablets by giving them slow release ones
For big tablets- some can be crushed (some have protective gastro lining you can’t crush these ones)
How can you help old people use eye drops?
Opticare devices
What class is Haloperidol?
1st generation antipsychotic
What is the indication for Haloperidol?
Delirium not treated by pharmalogical treatment
Post operative nausea and vomiting
Restlessness and confusion in palliative care
What side effects of haloperidol is there?
Parkinsonism (bradykinesia, resting pinrolling tremor 4-6Hz, rigidity)
Hypersalivation
Angiooedema
Hypertension
Eye disorders
Headaches
Neuromuscular dysfunction
Nausea
Psychotic disorders
What are the interactions of haloperidol?
Alcohol
Hypertensive meds- acebutolol/amlodipine/candesartan
Amitriptyline
Does haloperidol have an impact on falls?
Yes research indicates that antipsychotics are associated with increased fall risk
What class is macrogol and what is it used for?
Osmotic laxative
It is used for chronic constipation
What are the SEs of Macrogol?
Flatulence GI Discomfort Nausea Vomiting
What is alendronate, how does it work?
It is a bisphosphonate
It works by being adsorbed onto hydroxyapatite crystals in bone which slows their rate of growth and dissolution
What are the side effects of alendroate?
Alopecia Anaemia Arthralgia Constipation Diarrhoea Dizziness Electrolyte imbalance Peripheral oedema RENAL IMPAIREMENT (shouldn’t use if the eGFR is <35mmol/l) GI disorders Joint swelling Vertigo
What is the indication of alendroate?
Treatment of postmenopausal osteoporosis
Prevention and treatment of corticosteroid induced osteoporosis in both men and women
Treatment of osteoporosis in men
How should you advise someone to take bisphosphonates ie: alendronate…
Take whole with plenty of water
Can take either sitting or standing but must be sat upright or standing half an hour after
Take on an empty stomach, at least 30 mins before breakfast or another oral medicine
What warning should you give a patient taking alendroate?
Atypical femoral fractures- patients should be advised to report any thigh, hip or groin pain during the treatment
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
Also warn about symptoms of oesophageal irritation such as- dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain
What medications does Alendroate interact with?
Antacids- these decrease the absorption of alendroate, alendroate should be taken 30 mins before antacids
Aspirin- increases gastrointestinal irritation
Calcium carbonnate/acetate- again should be taken 30 mins before
NSAIDS- increase GI irritation
What is Adcal D3?
Chewable tablets
This is a combination of Vit D3 and Calcium carbonate
What are the indications for Adcal D3?
Osteoporosis
Where body’s calcium and vit D levels need to be increased
What are the side effects of Adcal D3?
Constipation Nausea Abdominal pain Diarrhoea Hypercalcaemia
What drugs should not be taken at the same time as Adcal D3?
Antacids- this might damage the enteric coatings which are designed to prevent dissolution in the stomach
What is the class of strontium ranelate?
Strontium salt of ranelic acid
What is the indication of strontium ranelate?
Used in the management of severe osteoporosis in high risk postmenopausal women and adult men
What are the side effects of strontium ranelate?
Hyperactivity Consciousness impaired Angioedema Arthralgia Bronchial hyperactivity Constipation Diarrhoea Dizziness
What interacts with strontium ranelate?
Calcium! Avoid taking the same time as calcium rich foods or calcium supplements as this decreases the absorption
What is colchicine and what is it used for?
An alkaloid which is used in the symptomatic relief of pain in attacks of gout
Short term prophylaxis during initial therapy with allopurinol
What are the side effects of colchicine?
Common- abdo pain, diarrhoea, nausea, vomiting
Frequency not known- agranulocytosis, alopecia, bone marrow disorders, GI haemorrhage, Kidney injury, Liver injury
What class is Allopurinol and what are the indications for it’s use?
Xanthine Oxidase inhibitor
1) management of patients with signs and symptoms of primary or secondary gout
2) the management of patients with leukaemia, lymphoma and malignancies who are receiving cancer therapy which causes elevations of serum and urinary uric acid levels
What are the side effects of allopurinol?
Rash- common
Hypersensitivity, N and V- uncommon
Rare/very rare- agranulocytosis, alopecia, aplastic anaemia
What cautions should you take with allopurinol?
Ensure adequate fluid intake (2-3L/day)
For hyperuricaemia associated with cancer therapy then allopurinol treatment should be started before cancer therapy
Thyroid disorders
What class is prednisolone and what is it used for?
Corticosteroid Acute exacerbations of COPD Severe croup for kids Mild to mod asthma UC/Crohn’s
What are the side effects of prednisolone?
Side effects- Anxiety Behaviour abnormal Cataract subscapular Cognitive impairment Cushing’s syndrome Electrolyte imbalance Fatigue Fluid retention GI discomfort Headache Heeling impaired Hirsutism HYPERTENSION Increased risk of infection Menstrual cycle irregularities Mood altered Nausea Osteoporosis Peptic ulcer Psychotic disorder Skin reactions Sleep disorders Weight increased
In terms of prednisolone, what do you need to make the patient aware of in terms of adrenal suppression?
During prolonged therapy with corticosteroids, particularly with systemic use, adrenal atrophy can develop and persist for years after stopping
Abrupt withdrawal after a long period can lead to acute adrenal insufficiency, hypotension or death
To compensate for a diminished adrencortical response caused by prolonged corticosteroid treatment then any significant illness, trauma or surgical procedure requires a temporary increase in corticosteroid dose, or if already stopped, a temporary reintroduction of corticosteroid treatment
What advice should you give in regards to infections and steroids?
Prolonged courses of corticosteroids increase susceptibility to infections and severity of infections
Clinical presentation of infections may also be atypical
Unless they have had chickenpox, patients are at risk of severe chickenpox (DIX/pneumonia/hepatitis, rash in not a prominent feature)
Confirmed chickenpox warrants specialist care and urgent treatment
Corticosteroids shouldn’t be stopped, doses may need to be increased
Measles- should take extra care to avoid exposure and IM normal immunoglobulin prophylaxis may be needed
What should you advise in terms of psychiatric reactions when giving prednisolone?
Systemic corticosteroids- particularly in high doses are linked to psychiatric reactions including euphoria, insomnia, irritability, mood lability, suicidal thought, psychotic reactions and behavioural disturbances.
What is pizotifen and what are some side effects?
It is a drug which is used in the prevention of vascular headache, prevention of classical migraine, prevention of common migraine, prevention of cluster headache
Side effects= appetite increased, dizziness, drowsiness, dry mouth, fatigue, nausea, weight increased
What is zopiclone used for?
What are the side effects?
Why is zopiclone relevant in the elderly?
This is used for insomnia (short term use)
Side effects- dry mouth, taste bitter
For hypnotic z- drugs, prescription is potentially inappropriate (STOPP criteria) in elderly as may cause protracted daytime sedation and/or ataxia.
What is Entacapone, how does it work, when is it given?
Entacapone prevents the peripheral breakdown of levodopa, by inhibiting catechol- O- methyltransferase, allowing more levodopa to reach the brain.
It is used as an addjunct to co-beneldopa or co-careldopa in Parkinsons disease with ‘end of dose’ motor fluctuations
What are the side effects of entacapone?
Abdo pain
CONFUSION
Constipation
Diarrhoea
Dizziness
FALL
IHD
Etc
What is ropinirole, what are the side effects?
Why is it relevant in terms of prescribing in old people?
This can be used alone or as an adjunct to co-beneldopa or co-careldopa
Can also be used in moderate to severe restless legs syndrome
The MOA is unkown, thought to be related to activated D2 receptors
Side effects….
Common- confusion, dizziness, drowsiness, fatigue, GI discomfort, hallucination, movement disorders, nausea, nervousness, peripheral oedema, sleep disorders, syncioe, vertigo, vomiting
In the elderly it can cause hypotension and severe cardiovascular disease- need to monitor the blood pressure
What are the indications for Amitriptyline, should it be used in the elderly?
Used for multiple things;
- Major depressive disorder
- Neuropathic pain
- Migraine prophylaxis
- Chronic tension-type headache prophylaxis
- Emotional lability in MS
Although it is a great drug for young people, it shouldn’t be used for the elderly as it can cause them to fall, they are also particularly susceptible to many of the side effects of TCAS…
- Anticholinergic syndrome
- Drowsiness
- QT INTERVAL PROLONGATION
(shouldn’t be used in severe hepatic impairment)
What are the symptoms/signs of anticholinergic syndrome?
Fever Mydriasis Tachycardia Hypertension Delirium Warm, dry skin Coma Ileus Urinary and gastric retention
What are the symptoms/signs of serotonin syndrome?
Fever Mydriasis Tachycardia Hyperkinesia Tremor Irritability Diaphoresis Diarrhoea Hyperreflexia
What is co-beneldopa/co-careldopa?
They are the brand names for LEVODOPA used in parkinsons disease
They work by being converted to dopamine in the brain, by taking it as a drug treatment it boosts the supply, meaning the nerve cells can make more dopamine.
What are the benefits of taking Levodopa?
Helps with bradykinesia and rigidity!
However they don’t prevent the disease progressing- dopamine producing cells are still being lost.
What are the side effects of levodopa?
Involuntary movements- with long term use, the patient may experience involuntary movements (dyskinesia), these are muscle movements which the patient can’t control- twitches, jerks, writhing movements.
Impulsive and compulsive behaviours- gambling, shopaholic, binge eating, etc
Withdrawal syndrome- neruoleptic malignant syndrome, rhabdomyolysis
Anxiety, appetite decreased, arrythmia, depression, diarrhoea, hallucination, movement disorders, nausea, parkinsonism, postural hypotension, taste altered, vomiting
Can cause postural hypotension and therefore fall risk
What are the indications for trimethoprim, is it appropriate in elderly?
Respiratory tract infections
Prophylaxis of recurrent UTI
Treatment of mild to moderate pneumocystis jirovecii
Acne resistant to other antibacterials
SE’s include: diarrhoea, electrolyte imbalance, fungal overgrowth, headache, nausea, skin reactions, vomiting
Should be used with caution in elderly
What is tamsulosin used for, how does it work, what are the side effects, is it risky to use in the elderly?
It is an alpha1- selective adrenoceptor blocker
It is used for benign prostatic hyperplasia
Causes dizziness, sexual dysfunction
As it causes dizziness
Causes postural hypotension
STOPP criteria=
- This is potentially inappropriate in the elderly
- it is inappropriate with symptomatic orthostatic hypotension or micturition syncope (risk of precipitating recurrent syncope)
- In those with persistent postural hypotension ie: recurrent drop in systolic blood pressure > or equal to 20mmhG (There is a risk of syncope and falls)
What is oxybutynin hydrochloride used for?
What are the side effects?
It is a antimuscarinic
Urinary frequency
Urinary urgency
Urinary incontinence
Neurogenic bladder instability
Side effects=
Constipation, dizziness, drowsiness, dry mouth, dyspepsia, flushing, headache, nausea, palpitations, skin reactions, tachycardia, urinary disorders, vision disorders, vomiting
Can cause confusion in elderly
When is oxybutynin hydrochloride potentially inappropriate in elderly?
STOPP criteria:
To treat extrapyramidal side effects- there is a risk of antimuscarinic toxicity
With delirium or dementia (risk of exacerbation of cognitive impairement)
Narrow angle glaucoma
Chronic prostatism (urinary retention)
If two or more antimuscarinic are prescribed concomitantly (risk of antimuscarinic toxicity)
What is cinnarizine, what is it used for?
Cinnarizine is a calcium channel blocker and a antihistamine
It is used for relief of symptoms of vestibular disorders- vertigo, tinnitus,nausea and vomiting in menieres disease.
It can also be used in motion sickness in kids
What are the side effects of cinnarizine and should it be used in the elderly?
Drowsiness
GI discomfort
Nausea
Weight increased
What is baclofen, when is it used, what are the side effects, should it be used in the elderly?
It is a skeletal muscle relaxant
It it used for pain of muscle spasm in palliative care, hiccups due to gastric distension in palliative care, chronic severe spasticity from disorders like MS or traumatic partial section of the spinal cord
Can cause confusion, constipation, depression, diarrhoea, hYPOTENSION, dizziness, drowsiness, hallucination, vision disoders etc…
Should be used with caution in the elderly
What is Digoxin, when it is used, what are the side effects, should it be used in the elderly?
It is a cardiac glycoside, that increases the force of myocardial contraction and reduces conductivity within the AV node
Used in AF/flutter
Heart failure for patients in sinus rythm
Used as a loading dose for AF or flutter
Side effects= Arrythmias, cardiac conduction disorder, cerebral impairement, diarrhoea, dizziness, eosinophilia, nausea, skin reactions, vision disorders, vomiting
Prescription is potentially inappropriate in elderly…
Stopp CRITERIA
Where it is being used for heart failure with normal systolic function there is no evidence of benefit
Where it is used at high dose in renal impairement eGFR <30mL/minute, this can lead to digoxin toxicity
What is Doxasozin, when is it used, what are the side effects, should it be used in the elderly?
Doxasozin is an alpha blocker
It is used in hypertension/ BPH/
Can cause arrythmias, chest pain, cough, cystitis, drowsiness, dizziness, dry mouth
Needs to be used with caution in elderly due to the risk of postural hypotension and falls
What is simvastatin, how does it work, what is it used for, side effects and should it be used in elderly?
Statin is a HMG-CoA reductase inhibitor, which is an enzyme involved in cholesterol synthesis, especially in the liver
Lipid lowering medication
Indications- Primary hypercholesterolaemia or combined hyperlipidaemia in patients who have not responded adequately to diet and other appropriate measures
Prevention of cardiovascular events in patients with atherosclerotic cardiovascular disease or diabetes mellitus
Need to be careful in renal impairement/hypothyroidism- increases risk of muscular toxicity
Side effects- asthenia, constipation, diarrhoea, dizziness, GI discomfort, headache, myalgia, nausea, sleep disorders, THROMBOCYTOPENIA
