Exam 2: the old farts Flashcards
1
Q
what are 4 components that make up frailty?
A
-chronic malnutrition
-sarcopenia
-decreased metabolic rate and activity
-decreased appetite
2
Q
frailty + stressor event = _____ & ______
A
falls and delirium
3
Q
what are 5 phenotypes model indicators of frailty?
A
1- weight loss
2-self-reported exhaustion
3- low energy expenditure
4- slow gait speed
5- weak grip strength
4
Q
Dementia onset, duration, cause and course
A
-slow and gradual, with an uncertain begining point
-usually permanent
-usually cause by a chronic brain disorder (alzheimers, lewy body dementia, vascular dementia)
-slowly progressing
5
Q
Dementia effect at night, attention, level of consciousness, & orientation to time and place
A
-often worse at night
-A & LOC: unimpaired until dementia has become severe
-impaired
6
Q
dementia use of language, memory & need for medical attention
A
-sometimes difficulty finding the right word
-lost memory, especially for recent events
-required medical attention but less urgent
7
Q
Delirium use of language, memory & need for medical attention
A
-slow, often incoherent + inappropriate
-varies memory loss
-IMMEDIATE medical attention
8
Q
Delirium effect at night, attention, level of consciousness, & orientation to time and place
A
-almost always worse at night
-attention is greatly impaired
-LOC & time and place: varies
9
Q
Delirium onset, duration, cause and course
A
-sudden, with a definite beginning point
-days to weeks, although it may be longer
-almost alway due to another condition (infection –> UTI, dehydration, use or withdrawal of certain drugs)
-usually reversible
10
Q
what drugs are not metabolized as well due to dec in hydroxylation?
A
-alprazolam
-midazolam
-quinidine
-propranolol
-triazolam
-r-warfarin
11
Q
what drugs are not metabolized as well due to decrease in demethylation?
A
-imipramine
-sertraline
-verapamil
-therophylline
12
Q
active metabolites with detrimental effects in excretion:
A
-norpropoxyphene
-hydroxyaminodapsone
-normeperidine
13
Q
gastrointestinal absorption changes in the elderly
A
-unchanged passive diffusion and no change in bioavailability for most drugs
-dec active transport and dec F for some drugs
-dec first pass metabolism, inc F for some drugs and dec F for some prodrugs
14
Q
distribution changes in the elderly
A
-dec volume of distribution and inc plasma concentration of water-soluble drugs
-inc volume of distribution and inc terminal disposition t 1/2 life for soluble drugs
15
Q
hepatic metabolism changes in the elderly
A
-dec clearance and inc t 1/2 life for some drugs with poor hepatic excretion (capacity-limited metabolism). Phar 1 metabolism may be affected more than phase II
-dec clearance and inc T 1/2 life for drugs with high hepatic extraction ratios (flow-limited metabolism)
16
Q
renal excretion changes in the elderly
A
-dec clearance and inc T 1/2 life for renally eliminated drugs and active metabolites
17
Q
anticholinergic side effects: vision, oral cavity & GI
A
V: impaired ALD, falls and accidents
OC: decline in nutritional status, increased risk of infection, worsened communication
GI: decline in nutritional status, worsening of disease (constipation), anxiety and pain
18
Q
anticholinergic side effects: Cardio, urinary tract & CNS
A
C: worsening of disease, anxiety
UT: incontinence, infection, loss of independence
CNS: cognitive dysfunction, impaired ADL
19
Q
Anticholinergic: muscle relaxants
A
-cyclobenzaprine
-methocarbamol
-carisoprodol
-oxybutynin
20
Q
anticholinergic TCAs
A
amitriptyline
21
Q
anticholinergic antispasmodics
A
-dicyclomine, hyoscyamine, propantheline
22
Q
anticholinergic antihistamines
A
-diphenhydramine
-chlorpheniramine
-cyproheptadine
-hydroxyzine
-promethazine
23
Q
benzodiazepine use in the elderly leads to an increased risk of:
A
-cognitive impairment, delirium, falls/fractures & motor vehicle crashes
–> MAY be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, benzo withdrawal;, ethanol withdrawal, severe generalized anxiety disorder and periprocedural anesthesia
24
Q
NSAID: GI toxicity in elders
A
-ulcer risk 4-5x nonusers
-~4 fold increase mortality related to PUD
-highest risk early
-risks increase ~4% per year of age > 65
25
NSAID induced injury prevention: Misoprostil
-800 mcg/day needed
-lower doses do have less diarrhea but less effective
26
NSAID induced injury prevention: H2- RA
-use double doses to be effective
27
NSAID induced injury prevention: PPI
-standard dose effective
28
NSAID induced injury prevention: HIGH risk GI pts
-COX2 alone or NSAID + PPI: offer similar but potentially insufficient protection
-COX-2 + PPI: can be considered
29
NSAIDs and cardiovascular risk
-all NSAIDs increase the risk of acute mirtrocardial infarction
FDA warning: NSAIDS can cause heart attacks or strokes
30
NSAID renal effects in elders
-reductions in renal blood flow
-sodium and water retention
-concern for combinations with ACEI or diuretics commonly used in elders (can cause a decrease in renal blood flow and acute renal injury)
--> 2 fold increase in hospitalizations for CHF in pts on NSAIDs and diuretics
31
Beers list: common anticholinergic drugs to avoid (1st gen antihistamines)
-diphenhydramine
-doxylamine
-hydroxyzine
-promethazine
-pyrilamine
-tiprolidine
32
Beers list: antiparkinsonian agents to avoid
-benztropine
-trihexyphenidyl
33
Beers list: antispasmodics to avoid
-atropine (excludes ophthalmic)
-belladonna alkaloids
-clidnium-chlordiazepoxide
-dicyclomine homatropoine (not ophthalmic)
-hyoscyamine
-methoscopolamine
-propantheline
-scopolamine
34
Beers list: antithrombotics to avoid
-dipyridamole- oral short acting --> does not apply to the extended release combo with aspirin
35
Beers list: anti infective to avoid
nitrofurantoin
36
Beers list: cardiovascular drugs to avoid
--> peripheral alpha-1 blockers for tx of hypertension
-doxazosin
-prazosin
-terazosin
-clonidine
37
Beers list: cardiovascular drugs to avoid - other CNS alpha agonists
-guanabenz
-guanfacine
-methyldopa
-reserpine
-disopyramide
-dronedarone
-digoxin
-nefedipine
-amiodarone
38
Beers list: CNS antidepressants to avoid
-amitrptyline
-amoxapine
-clomipramine
-desipramine
-doxepin > 6 mg/day
-imipramine
-nortriptyline
-paroxetine
-protriptyline
-tripipramine
39
Beers list: barbiturates to avoid
-amobarbital
-butaburbital
-butalbital
-mephorbarbital
-secobarbital
40
Beers list: short and intermediate benzos to avoid
-alprazolam
-estazolam
-lorazepam
-oxazepam
-temazopam
-trazolam
41
Beers list: long acting benzos to avoid
-chlordiazepoxide
-clonazepate
-diazepam
-flurazepam
-quazepam
-random: meprobamate
42
Beers list: z-drugs to avoid
-eszocipiclone
-zalepion
-zolpidem
43
Beers list: endocrine related drugs to avoid
-methyltestosterone, testosterone
-desiccated thyroid
-estrogens w or w/o progestins
-growth hormone
-insulin (sliding scale- hypoglycemia)
-megestrol
44
Beers list: sulfonylureas to avoid
-chlorprapamide
-glimepiride
-glyburide
45
Beers list: GI meds to avoid
-metaclopramide
-mineral oil (given oral)
-PPIs
46
Beers list: main meds to avoid (non selective NSAIDs)
-mependine
-aspirin > 325 mg/day
-diclofenac
-diflurisal
-etodlac
-fenoprofen
-ibuprofen
-ketoprofen
-meclofenamate
-mefeamic acid
-meloxicam
-nabumentone
-naproxen
-oxaprozin
-piroxicam
-sulindac
-tolmetin
-indomethacin
-ketorolac
47
Beers list: muscle relaxants to avoid
-carisopeodol
-chlorzoxazone
-cyclobenzaprine
-metaxalone
-metocarbamol
-orphenadrine
48
Beers list: genitourinary drug to avoid
desmopressin
49
Deprescribing
-the systematic process of identifying and discontinuing drugs in instances in which existing potential harms outweigh existing or potential benefits within the context of an individual patients care goals, current level of functioning, life expectancy, values and preferences
Goal: to reduce medication burden and harm while maintaining or improving QOL
50
Process of deprescribing ( 5 steps)
1) ascertain all drugs the patient is currently taking and the reasons for each one
2) consider overall risk of drug-induced harm in individual pts to determine the required intensity of deprescribing intervention
3) assess each drug for its eligibility to be discontinued
4) prioritize drugs for discontinuation
5) implement and monitor drug discontinuation regimen
51
what is ascertain?
-ask patient (and caregiver) about all prescribed, OTC, complementary and alt meds, and supps they currently take
--> assess adherence to current regimen with special attention paid to drugs not being taken and the reasons why
52
Potential drug induced harm: drug factors
-number of medication prescribed
-use of potentially inappropriate or "high risk" meds
-past or current toxicity
-NNT/NNH
53
Potential drug induced harm: patient factors
-age > 80y/o
-cognitive impairment
-multiple comorbidities
-substance abuse
-multiple prescribers
54
medications that would be good candidates for discontinuation include:
-no valid indication
-part of a prescribing cascade
-harm clearly outweights potential benefit
-time to benefit/time to harm
-drugs imposing unacceptable treatment burden
--> important to ask pts about treatment emergent side effects
--> consider patient preference
55
prioritizing when it comes to deprescribing
-decision on what to recommend stopping first should be based on integration of the criteria:
1) those with the likelihood of greatest harm and least benefit
2) those easiest to d/c (lowest likelihood of withdrawal reactions or disease rebound)
3) those that the patient is most willing to d/c first (to gain buy-in to deprescribing other drugs)
--> suggested approach is to rank drugs from high harm/low benefit t low harm/high benefit anf d/c in sequntial order
56
Implement and monitor deprescribing
-gain pt buy in before attempting d/c
-d/c one agent at a time
-taper meds more likely to cause withdrawal symptoms
-communicate plan for deprescribing to all care givers and healthcare professionals involved in pts care
-clearly document rationale and outcomes of deprescribing
57
Physiologic changes with aging that can lead to increased fall risk
-dec lean body mass
-dec myocardial sensitivity to B-adrenergic stimulation
-dec baroreceptor activity
-dec cardiac output
-alterations in several aspects of cognition
-pulmonary issues
-dec accommodation of the lens of the eye = causing farsightedness
-dec conduction velocity
-loss of skeletal bone mass (osteopenia)
58
intrinsic (non modifiable) risk factors for falls
-muscle weakness
-impaired balance, mobility and activities of daily living
-arthritis, stroke, diabetes, HTN, heart disease and dementia
59
Extrinsic (modifiable) risk factors for falls
-medication use
-poor foot care
-impaired vision
-unsafe footwear
-hearing problems
-an unsafe environment
60
drug burden index and falls
-DBI is a method for measuring an individual's total exposure to anticholinergic and sedative drugs
61
fall risk increasing drugs
-any psychotropic drug
-antidepressants
-benzos
-antipsychotics
-sedative hypnotics
-tranquilizers
62
Common causes of Incontinence
-urethral obstruction: BPH/strictures/stenosis
-impair bladder contraction: DM/MS/Spinal injuries/detrusor hyperactivity
-incompetent sphincter: stress incontinence/cystocele
-bladder inflammation: UTI/interstitial cystitis
-bladder stones: obstruction/metabolic disease/UTI
-malgnancy: bladder CA, carcinoma in situ, invasive CA
63
meds that affect continence
-alpha agonists/antagonists
-alcohol
-anticholinergics
-cholinesterase inhibitors
-CCBs
-diuretics
-narcotics
-antidepressants
-antipsychotics
-sedative/hypnotic
64
Desmopressin nasal spray in nocturnal polyuria dosing
indication: nocturnal polyuria in adults, awaken > 2 x/night to void
age 50-65: 1 spray (1.66) either nostril ~ 30 mins before bed
age >/ 65: 1 spray (0.83) either nostril ~30 mins before bed (inc to 1.66 after 1 week if Na stays wnl)
65
Desmopressan nasal spray warnings & CI
warning: fluid retention, hyponatremia, nasal conditions (beers list "avoid")
CI: hyponatremia, polydipsia, primary nocturnal enuresis, concomitant use w/ loop diuretics or systemic glucocorticoids. eGFR < 50
66
what can be some causes of detrusor hyperreflexia?
-cystitis
-stones
-tumor
-neurologic (most often)
67
Smooth muscle relaxants: Anti-musc drugs
-oxybutynin: 5 mg BID-TID
-tolterodine: 1-2 BID ER, dec BBB crossing
-trospium: 20 md bid, empty stomach, dec BBB crossing
-fesoterodine: 4-8 mg ER qd, dec BBB crossing
68
Smooth muscle relaxants: M3 specific drugs
-darifenacin: 7.5 mg qd, dec CNS
-solifenacin: 5 mg qd, dec CNS
69
smooth muscle relaxants adverse effects
-dose dependent
-dry mouth, dry eyes/blurred vision, urinary retention
-palpitations
-constipation
-dizziness/drowsiness
-confusion/delirium/dementia (our biggest concern)
70
which anticholinergic drugs are most useful for OAB symptoms in adults?
ER tolterodine, solifenacin and fesoterodine are the most effective and least likely to cause adverse effects
71
other agents used in adult OAB:
-Imipramine or other TCA: usually in childhood, do not use in elderly
-Botox: detusor overactivity associated with a neurologic condition, in adults with an inadequate response or intolerance to an anticholinergic medication
--> IM injection to detrusor during cystoscopy
72
B3 adrenergic receptor agonist: Mybetreiq
MOA: detrusor muscle relaxation
SEs: N/diarrhea, headache, HTN, constipation, dizziness, sinus tachycardia
-precaution: uncontrolled HTN (> 180.> 110)
73
B3 adrenergic receptor agonist: Vibegron (gemtesa)
MOA: detrusor muscle relaxation
SEs: N/diarrhea, headache, constipation, naso-pharyngitis, bronchitis, URI, UTI
74
1st line tx for OAB
-behavioral therapies: bladder training, bladder control strategies, pelvic floor muscle training, fluid management +/- pharm
75
2nd line tx for OAB
-oral anti-muscarinics or oral B3 agonists
-ER > IR
-transdermal oxybutynin (patch or gel) can be offered
-combo anti-muscarinic and b3 agonist refractory to mono therapy
-manage constipation and dry mouth before abandoning effective anti-muscarinic therapy
-caution with med use in the frail OAB pts
76
stress incontinence - alpha receptor agonists
goal is to increase intra-urethral pressure
-pseudoephedrine: 15-30 mg PO up to TID (AEs: insomnia, HTN, HA, tremor, palpitations)
-midodrine: peripheral alpha1-receptor agonism, 2.5-5mg po 2-3 x day
77
Stress incontinence - other therapies
-estrogen replacement: improves mucosal outflow resistance--> vaginal applications acceptable (AEs: pap/mammogram, bleeding, DVT)
-duloxetine (not FDA approved): suppresses bladder activity and enhances external urethral sphincter activity
78
Overflow incontinence: bethanechol (urecholine)
--> leak urine throughout day, "weight" of urine --> BPH, neuropathies, anticholinergics
Beth: stimulates muscuranic receptors = inc bladder tone
-10 mg TID
AEs: GI cramping/diarrhea/salivation, orthostasis with reflex tachy, urgency, bronchial constriction
79
symptoms of BPH
-incomplete emptying
-frequency
-intermittency
-urgency
-weak stream
-straining to pee
-nocturia
-QOL dec due to urinary symptoms
80
non-pharm management of BPH
-incontinent pads
-TURP
-urethral dilation
-foley catheters
81
BPH meds: alpa -1 blocking
terazosin > doxazosin > prazosin
AEs: postural hypotension, dizziness/vertigo, blurred vision, drowsiness, asthenia, "first dose" effect- added effect with other HTN meds
82
alpha- 1 A specific blockers for BPH
silodosin > alfuzosin ~ tamsulosin
--> tamsulosin 0.4-0.8 mg = mainstay of therapy
AEs:
RARE: hypotension, vertigo, drowsiness, flippy iris syndrome, ejaculatory dysfunction
83
5-alpha- reductase inhibitors for BPH
-finasteride: inhibits type 2 5-alpah1-reductase: decrease DTH, 3-6 months of therapy, <50% have symptomatic improvement
-dutasteride: more potent
-Jayln (dutasteride/tamsulosin) --> may be the best choice in those with slightly larger prostate enlargement
84
5-alpha-reductase inhibitors AEs
-impotence
-libido
-ejaculation volume
-gynecomastia/matalagia
-pregnancy X: abnormalities of external genitalia of male fetus
85
Drugs to avoid in BPH
-TCAs
-diphenhydramine
-disopyramide
-pseudoephedrine
-ephedrine
-anticholinergic (including OTC)
86
Tadalafil for BPH
-mechanism has not been estabilished
-PDE5 inhibitor -mediated smooth muscle relaxation of the prostate, bladder, urethra, and their vascular supply
-may lead to symptomatic hypotension in some pts
87
when to use a 5 alpha reductase in BPH
-if prostate is > 30 cc, consdier adding it on
(but want to start with alpha blocker --> PDE5 --> 5ARI)
88
risk factors for erectile dysfunction
-metabolic syndrome
-lower urinary tract symptoms
-cardiovascular disease
-tobacco smoking
-central neurologic conditions
-spinal cord injury
-depression or social/marital stress
-endocrinologic conditions
-diabetes
89
drugs that are associated with erectile dysfunction
-diuretics (THIAZIDES)
-antihypertensives (BBs)
-cardiac or cholesterol drugs (digoxin, gemfibrozil)
-antidepressants
-tranquilizers
-H2 antagonists (ranitidine, cimettidine)
-hormones
-cytotoxic agents (methotrexate)
-immunomodulators
-anticholinergic agents
-recreational drugs
*only thiazide diuretics and beta blockers except nebivolol may adversely influence erectile function
90
PDE5 use in pts with low cardiac risk
-has asymptomatic cardiovascular disease with < 3 risk factors
-has well controlled HTN
-has mild congestive HF
-has mild valvular heart disease
-had a MI > 8 weeks ago
--> can be started on PDE5
91
PDE5 use in pts with intermediate cardiac risk
-has >/ 3 risk factors for cardiovascular disease
-has mild or moderate, stable angina
-had a recent MI or stroke within the past 2-8 weeks
-has moderate congestive HF
-hx of stroke, transient ischemic attack or peripheral artery disease
--> undergo complete cardiovascular work up
92
PDE5 use in pts with high cardiac risk
-has unstable or refractory angina, despite treatment
-has uncontrolled HTN
-has severe congestive heart failure
-had a recent MI or stroke within past 2 weeks
-has moderate or severe valvular heart disease
-has high-risk cardiac arrhythmias
-has obstructive hypertrophic cardiomyopathy
--> NO PDE5 use!!
93
Sildenafil for ED
-50mg/day
-onset of 30-60 mins
-2-4 hour duration
-fat meals dec T max and C max
-blurred/blue tint vision
-wait 24 hr till nitrate use
94
Vardenafil use for ED
-10 mg
-60 min onset
-4-6 hr durationn
-fat meals dec C max
-wait 24 hr until nitrate use
95
Tadalafil for ED use
-10 mg
-30-45 min onset
-24-36 hr duration of effect
-wait 48 hrs until nitrate use
96
Avanafil use for ED
-100 mg
-15 min onset
-4-6 hour duration
-12-24 hours until nitrate use
97
mild symptoms of dementia
depression
anxiety
irritability
apathy
98
severe symptoms of dementia
agitation
aggression
vocalizations
hallucinations
delusions
disinhibition
99
medical causes of agitation in dementia
medications
infection
CVA
trauma
pain
100
what is psychobehavioral metaphor?
-identify most salient symptomatic cluster
-define pattern of symptoms analogous to more typically drug-responsive syndrome
-use as rational guide to therapy
-remember that behavioral syndromes interact
-select medication in class relevant to metaphor with evidence of efficacy and safety
101
neuropsychiatric symptoms of dementia
-psychotic symptoms (delusions, hallucinations)
-depressive symptoms
-apathy
-manic-like behavioral syndromes
-agitation or aggression
-"sundowning"
-insomnia
102
Parkinson's Disease
-secondary dopaminergic agent, visual hallucinations before ant medications are started
-significant emotional distress or dangerous or upsetting behavior, cautious use
--> quetiapine or olanzapine be br beneficial
(pimavaserin = $$)
103
Lewy Body Dementia
-cognitive decline accompanied by motor features of Parkinsonism, prominent visual hallucinations are a key part of the diagnosis --> these hallucinations are often vivid and troubling
--> quetiapine tends to be the best agent here, avoid conventional APs
104
depressive symptoms in AD
-seen in 40% of AD pts
-signs include sadness, loss of interest in usual ativities, anxiety and irritability
-suspect if pt stops eating or withdraws
105
treatment of depressive symptoms
first line: SSRI (citalopram, escitalopram, fluoxetine, sertraline)
-->mirtazapine: useful for depression with insomnia and weight loss
--> trazodone: when sedation is desirable
106
Apathy symptoms and treatment
-lower dopamine transporter binding; lower cholinergic receptor binding
-causes more impairment in activities of daily living than expected for cognitive status
-high overlap with depressive symptoms but lacks depressive mood, guilt and hopelessness
Treatment: methylphenidate, dextroamphetamine, modafinil
107
manic-like behavioral syndromes & tx
-characterized by pressured speech, disinhibition, elevated or irritable mood, intrusiveness, hyperactivity, impulsivity, reduced sleep
-frequent co-occurence with confusional states
treatment: #1 = divalproex sodium, carbamazepine, lamotrigine, lithium
108
agitation in context of psychosis treatment
-aripiprazole
-olanzapine
-quetiapine
-risperidone
109
agitation in context of depression treatment
-SSRI --> citalopram
110
anxiety, mild to moderate irritability treatment
-buspirone
-trazodone
111
agitation or aggression unresponsive to 1st line tx
*divalproex sodium
-carbamazepine
-olanzapine (IM)
112
sexual aggression, impulse-control symptoms in men treatment
1) 2nd generation antipsychotic or divalproex
2) if no response, conjugated equine estrogens OR medroxyprogesterone injectables
113
Sundowning
-late afternoon to evening/night
Symptoms: forgetful, confused, delirious, agitated, anxious, restless
-insomnia with: pacing, wandering, yelling, combative
114
Sundowning treatments
non-pharm: night-lights, check-ins
acute: trazodone, quetiapine (ONLY if pt has insomnia and sundowning and hallucinations)
long term: trazodone, melatonin
115
insomnia treatment in the elderly
-principles of sleep hygiene: caffeine, fluid intake, light, activity, time in bed, screens, BPH
-acute: trazodone, melatonin, short acting BZDs, mirtazapine
-long term: trazodone, melatonin
116
pros and cons of acetaminophen use for pain in the elderly
Pro: useful for mild to moderate pain, elder "safe", adjunctive
Con's: very few- hepatic failure, EtOH use, DI with warfarin, watch total APAP use: 4mg/day
117
pros and cons of using NSAIDs & COX-II for pain in the elderly
Pros: useful for milk to moderate pain, musculoskeletal (inflammation, cancer), --> diclofenec (topically)
Cons: toxicity, ABSOLUTE CI: PD, CKD, HF, relative CI: HTNm H. pylori, hx of PUD, GI risk, cardiac (CHF, MI risk), coagulation, drug interactions
118
adjunctive agents in neuropathic pain
-duloxetine: approved for chronic muscuoskeletal pain
-lidocaine
-avoid TCAs
119
Neuropathic pain 1st and 2nd line treatments
-1st line: pregabalin, gabapentin, SNRIs, TCA (caution! use noritryptylline if really need to use them)
-2nd line: topical agents (lidocaine)
120
Neuropathic pain treatment: other agents
-steroids: reserved only for patients with pain-associated inflammatory disorders or metastatic bone pain
-regional pain syndromes: capsaicin or menthol + lidocaine
121
opioid analgesics in elders: pulmonary SEs
SE: respiratory depression (esp w/ concomitant Dx of asthma, COPD, sleep apnea)
toxicity: severe resp depression, apnea
122
opioid analgesics in elders: CNS SEs
SEs: lethargy/sedation, pre-existing cognitive impairment, dysphoria, delirium, hallucinations
toxicity: decreased LOC, unarousable
123
opioid analgesics in elders: ocular SEs
SEs: miosis
toxicity: "pinpoint pupils" fixed
124
opioid analgesics in elders: other SEs
-constipation, N/V
-orthostasis
-urinary incontinence
-fears of addiction or dependence
125
preferred analgesics for elders
-morphine* - 10 mg IV, 10, 60 mg PO
-hydrocodone
-oxycodone
-hydromorphone* - 1.3-1.5 mg IV, 7.5 mg PO
-fentanyl
1 mg IV hydromorphone = 20 mg PO morphine
126
management of opioid-induced N/V
-haloperidol*, droperidol
-chlorpromazine, prochlorperazine, thiethylperazine
-cyclizine, diphenhydramine, hydroxyzine, meclizine, promethazine
-hyoscine, scopolamine
-dolasetron, granisertron, ondansetron
-metoclopramide
-lorazepam
127
management of opioid - induced constipation
-docusate + _____
-bisacodyl, casanthranol, senna
-glycerin suppositories, lactulose, mannitol, polyethylene glycol, sorbitol
-magnesium citrate, magnesium hydroxide, magnesium sulfate, sodium phosphates
-naloxegol, methynaltrexone, nalmefene, naloxone
-mineral oil as lube
128
what is palliative care?
-the active total care of pts whose disease is not responsive to curative treatment
-focus = control of pain, other symptoms, and psychological, social and spiritual problems
outside of hospice= does not require a terminal diagnosis, do not have to forgo curative therapy
129
what is hospice and how does a pt qualify?
-program that delivers palliative care --> end of life care
-Medicare benefit: terminal illness with a prognosis of 6 months or less as certified by the attending physician and the hospice medical director
130
Palliative care toolkit
-roxanol 100mg/5 ml (morphine liquid)
-lorazepam liquid 2 mg/ml or alprazolam liquid 1mg/ml
-haloperidol liquid 2mg/ml
-atropine 1% opth. gtts
-dexamethasone liquid 1 mg/ml
-ondasetron ODT (metoclipramide liquid but $)
131
what makes up Roxanol (morphine liquid)?
-methadone liquid 10 mg/ml
-hydromorphone liquid 1mg.ml
-oxycodone liquid 20 mg/ml
132
treatment of N/V caused by gut wall
-gastric irritants, abdominal radiotherapy, intestinal distention, cytotoxic chemo
1) H2 RA or PPI
2) add on metoclopramide
3) last line: zofran
133
treatment of N/V caused by area postrema
caused by: morphine, digoxin, hypercalcemia/uremia, clinidine, cytotoxic chemo
1) haloperidol or metoclopramide
2) step 1 + dexamethasone or pamidronate for hypercalcemia
30 ondansetron + dexamethasone
134
treatment of N/V caused by cerebral cortex
caused by: fear/anxiety, raised intracranial pressure, hyponatremia
1) dexamethsone
2) amitriptyline, haloperidol, lorazepam
3) limited free water + 3% saline + haloperidol
135
treatment of N/V caused by vestibular nuclei
caused by: movement or vertigo
1) diphenhydramine or dimenhydrinate
2) meclizine or cyclizine
3) glycopyrrolate or scopolamine
136
how to treat dyspnea in the dying
1- ipratropium/albuterol +/ dexamethasone (if you hear wheezing)
2- morphine (any opioid) +/ dexamethasone
3- morphine AND chlorpromazine/diazepam/midazolam (helps to reduce anxiety)
137
role of opioids in dyspnea tx in the dying
-help relieve sensation of SOB
-in the opioid naive pt, low doses of oral (2.5-5mg) or parenteral morphine (1-2 mg) provide relief for most patients
-more frequent dosing is more effective than higher doses if dyspnea not adequately treated
138
cough treatment in the dying
1- treat underlying cause
2- promote production : nebulized saline and/or guaifenesin
3- suppress cough: morphine, hydrocodone, dextromethorphan
4- (cancer) dexamethasone or glycopyrrolate/atropine, NAC (nebulized or oral)
5- LAST LINE: nebulized lidocaine, gabapentin etc
139
anxiety treatment in the dying
-worry, tense, unable to relax
1- non-pharm
2- short term: lorazepam, alprazolam, amitriptyline (w/ depression)
2- long term: buspirone, SSRI (escitalopram or sertraline), mirtazapine (w/ depression, insomnia and anorexia)
140
delirium treatment in the dying
-disorientation, hallucinations, aggressive
1- haloperidol
2- haloperidol + lorazepam (sedation required)
3- haloperidol + midazolam or chlorpromazine (really sedating)
--> agitation in terminal stages
141
constipation prevention in the dying
1- opioid induced: senna or bisacidyl +/ docusate +/ metoclopramide
-aging or disease induced: fiber, fluids, docusate
2- sorbitol, lactulose, PEG 3350
3- refractory: MOM, citrate of mag, bisacodyl sup peripherally- acting mu-opioid receptor antagonists
142
treatment of acute constipation in the dying
R/O obstruction or impactation
1- stimulant laxative: bisacodyl or senna
2- double dose
3- osmotic laxative - sorbitol
4- MOM
5- bisacodyl suppository then enema in 2 hrs
6- peripherally-acting mu-opioid receptor antagonists: naloxegol, methylnaltreaxone
7- nuclear enema
143
bowel obstruction treatment in the dying
--> early satiety, constipation, bloating, ileus w/ N/V (intractable)
1- metoclopramide +/ dexamethasone (PARTIAL obstruction only)
2- glycopyrrolate (reduce the amount of fluid in the gut) +/ morphine +/ haloperidol
3- octreotide (reduces gut secretions) +/ above
4- PEG tube or stent
144
asthenia treatment in the dying
--> fatigue, generalized weakness, mental fatigue
1- energy conserving measures
2- methylphenidate or dexamethasone
145
depression treatment in the dying
1) > 4 weeks left: escitalopram, sertraline +/ methylphenidate
2) > 4 weeks left with other S/S: amitryptyline or nortriptyline +/- methylphenidate
3) < 4 weeks left: methylphenidate or ketamine
146
Anorexia-cachexia treatment in the dying
causes: anxiety, depression, N/V, stomatitis, constipation, dysphagia, PAIN
1- treat underlying causes
2- metoclopramide
3- < 3 months: dexamethason, > 3 months: mirtazepine, megestrol
4- dronabinol
147
insomnia causes in the dying
-wakeful stimuli, daytime sleep, normal aging
-anxiety, depression, fear of dying
-pain, dyspnea, N/V, incontinence, diarrhea, pruritis, restless legs, BPH
-diuretics, steroids, caffeine, sympathomimetics, night sedative withdrawal, bzd, alcohol
148
Insomnia treatment in the dying
1- treat underlying cause
2- difficulty sleeping: trazodone or melatonon, temazepam or zolpidem (bed bound)
2- difficulty staying sleep: haloperidol
2- also has depression: mirtazepine or amitriptyline
3- increase doses, combo of step 2- sub in midazolam or high dose lorazepam (not to exceed 7 days)
149
xerostomia treatment in the dying
1- ice chips, gum, lemon drops
2- saliva substitute
3- pilocarpine 5 mg po qid
150
treatment of terminal secretions
-gurgling "death rattle"
-atropine 1% ophth gtts SL 2-3 q2-3 hrs PRN (not earlier than end stage due to dry mouth)
-can also use scopolamine patch or gylcopyrrolate
151
drugs used in palliative sedation
-opioids, benzos, neuroleptics, barbiturates, anesthetics
152
what med provides the greatest efficacy with minimal adverse effects int he tx of OAB?
solifenacin
153
which treatment os BPH would be best to eliminate exposure to any anticholinergic effects?
mirabergon
154
in a pt with Bladder outlet obstruction caused by BPH (with no OAB symptoms) who has been found to have a large prostate use:
dutasteride and tamsulosin
155
which Ed med has the most rapid onset of action?
avanafil
156
what are the portmantaeu drugs?
-lorazepam
-dexamethasone
-morphine
-haldol
157
dexamethasone can be used in all of the following conditions:
-anorexia
-N/V due to increased ICP
-dynpsnea
-asthenia
(NOT insomnia)
158
what meds are used in the last few hours of life in the dying?
-morphine 70mg/ml
-lorazepam
-haloperidol
-artopine
159
what is not decreased in the elderly population?
phase 2 elimination
160
what is the main DD with meloxicam?
causes edema
161
what is the definition of frail
inability to maintain homeostasis
162
which medication has the highest rick of falls?
diazepam
163
meds to use in older pt with dementia and difficulty initiating sleep
-mirtazepine
-trazadone
-melatonon
-temazepam
