Geriatric Medication Critique (online) EXAM 2 Flashcards
Name the implicit and explicit criteria that assess PIMs (potentially inappropriate medications).
Implicit: gives questions to critique the meds, but doesn’t tell exactly if its right or wrong to use the drug
-Medication Appropriateness Index (MAI)
-V.I.O.N.E
Explicit:
-Beer’s criteria
What is the Medication Appropriate Index?
ask a series of questions about each drug to check if its use is appropriate
What are the criteria in the VIONE assessment tool?
-drugs are being categorized into: VIONE
Vital
Important
Optional
Not indicated
Every medication has a diagnosis/indication
-developed by the Veterans Association
The Medication Appropriate Index and V.I.O.N.E. are considered implicit or explicit?
implicit
bc it doesn’t tell if the drug use is right or wrong but gives a direction
The Beers Cirtertia is consiered implicit or expliocit?
explicit
clear recommendations on which drugs are appropriate in patients older than 65
Table 2 PIMS in all older adults
Which anti-infective is amongst the PIMs in the Beer criteria?
Nitrofurantoin
avoid if CrCl < 30 ml/min
Which CCB is amongst the PIMs in the Beer criteria?
Nifedipine
Which drugs should be avoided for Afib in the elderly?
Amiodarone
Dronedarone
Digoxin
Antidepressants with strong anticholinergic effects that should be avoided
TCAs:
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin >6 mg/day
Imipramine
Nortriptyline
Paroxetine (SSRI) !!!
Why should Barbiturates be avoided?
-High rate of physical dependence
-tolerance of sleep benefits
-greater risk of overdose at low dosages
Butalbital
Phenobarbital
Primidone
Why to avoid Sulfonylureas?
-higher risk for CV events, mortality, hypoglycemia
-higher risk for CV death, stroke
Why should Metoclopramide be avoided in the elderly?
EPS: tardive dyskinesia
Why should muscle relaxants be avoided?
anticholinergic effects
sedation
increased risk of fractures
Why should the treatment of nocturia with Desmopressin be avoided?
high risk for hyponatremia
Which NSAID has the greatest risk for adverse effects?
Indomethacin
also CNS effects
Table 3 PIMS in elderly with specific diseases
What is the concern of Dextromethorphan-quinidine in older patients with HF?
QT prolongation
What is the concern of NSAIDs and NHD-CCB in older patients with HF?
fluid retention
Which drugs are associated with bradycardia in patients who suffer from syncope?
AChEIs (acetylcholinesterase inhibitors)
Donepezil
Rivastigmine
What is the concern of antipsychotics and TCAs in patients who suffer from syncope?
orthostasis
Antipsychotics should be avoided in elderly patients with Parkinson’s. Which antipsychotics are an exception?
clozapine
pimavanserin
quetiapine
Table 4 Drugs to use with caution in elderly
Which drugs are known to cause hyponatremia or SIADH?
Mirtazapine
SSRI
SNRI
TCA
Oxcarbazhepine
Carbamazepine
Diuretics
Tramadol
Antipsychotics
Which drugs can cause hyperkalemia when used with ACE/ARB or ARNI when CrCl is low?
Bactrim
Table 5: DDI that should be avoided in elderly
Table 6 Meds with renal dosing or avoidance in elderly
At what CrCl is dose adjustment required with Dofetilide?
<60
At what CrCl is dose adjustment required with Edoxaban?
reduce if CrCl is 15-50 ml/min
avoid if CrCl is less <15 and more than 95 ml/min
At what CrCl is dose adjustment required with Baclofen?
<60
Dose adjust if <50 with wich drugs?
Cimetidine
Famotidine
Nizatidine
also Edoxaban
Which Antibiotic needs dose adjustment?
Ciprofloxacin
Nitrofurantoin
Bactrim
all <30
Which anticoagulants need dose adjustments?
Enoxaparin <30
Fondaparinux <30
Rivaroxaban <50
Edoxaban 15-50 ml/min
Which antidepressant need dose adjustment?
Duloxetine <30
Table 7 Drugs with strong anticholinergic effect
What are the 3 major categories that contribute to falls in elderly patients?
-Environment: stairs, slip rugs, loose cords, lack of assistive device, low lighting
-Medication
-Diseases
What are the environmental risk factors that can lead to falls?
-stairs
-slip rugs
-loose cords
-lack of assistive device
-low lighting
Which disease states can lead to falls?
Arthritis
Depression
Orthostatic hypotension
impaired cognition
impaired vision
gait or balance impairment
muscle weakness
Which drug classes are more likely to lead to falls?
-Psychoactive
-Antidepressants
-Antiepileptics
-Opioids
-Anticholinergic
-Sedative: Benzos, Z-drugs (zolpidem, zaleplon)
-more than 4 meds
Which of the categories of fall are intrinsic, and which ones are extrinsic?
Extrinsic: Environment, Medications
Intrinsic: Diseases
Older patients have increased sensitivity to which drug class?
Benzos
+ decreased metabolism -> leads to physical dependence, cognitive impairment, delirium, falls
What is the maximum number of fall risk-inducing and CNS-active drugs that elderly patients should take?
older patients should not have
-2 or more FRIDS
-3 or more CNS agents
-not more than 4 meds in general
Which SSRI is more anticholinergic than other antidepressants?
Paroxetine
Which second-gen antipsychotic has the highest anticholinergic effect?
Olanzapine
What are two examples of adverse drug withdrawal events (ADWEs)?
caused by the removal of a drug
-withdrawal from benzos (not tapered)
-rebound tachycardia from a Beta-blocker (not tapered)
Drug classes that are known to cause side effects in eldery pateitns.
-Psychoactive: Anticholinergic, Antipsychotics, Benzos
-Cardio: Anticoagulants and antiplateltes, HTN meds and diuretic
-Hypoglycemic: Insulin and Sulfonylureas
-Pain meds: NSAIDs and Opioids
Which drugs are known to cause Hyperkalemia in elderly patients?
ACEi/ARB, ARNI, spironolactone, Aliskiren (renin inhibitor), potassium supplement
high risk to cause hospitalization for hyperkalemia
Which drug interactions are known to cause overdose leading to sedation, CNS depression, and respiratory depression in elderly patients?
Opioids + Benzos
Opioids + Gabapentin
Known DDI with CNS agents
Benzos and Z-drugs
Which drugs have a higher risk of causing lithium toxicity when used in combination with Lithium?
Lithium + ACEi/ARB, ARNI, loops (cause sodium and water loss -> more Lithium reabsorption -> toxicity)
need sufficient salt and fluid intake when taken with Lithium
Loop diuretic combined with which drug is known to cause urinary incontinence? (especially in women)
Loops + peripheral alpha blocker (doxazosin, prazosin)
Combining Phenytoin with which drug has a higher risk for Phenytoin toxicity?
Phenytoin + Bactrim
close monitoring for signs of toxicity is needed
Which drugs can cause Theophylline toxicity when used together?
Theophylline (xanthine, for asthma, emphysema, bronchitis) + Cimetidine (H2blocker)
Theophylline + Ciprofloxacin
Which drugs increase the risk of bleeding when used with Warfarin?
Warfarin +
Digoxin
Antimicrobials
Hypoglycemic agents
Fab5: Flagyl, Flucanozole, FQ, amiodarone, bactrim
There is a higher risk for Digoxin toxicity with which drug?
Digoxin + Macrolides (clarithromycin, erythromycin)
Macrolides and which antihypertensive drug increases the risk for hypotension and shock?
Macrolide + CCB
Which drugs increase the risk for hypoglycemia when used with antidiabetics?
especially sulfonylureas with antibiotics (fluconazole, bactrim, macrolides)
-multiple antidiabetics: sulfonylureas + insulin
Which drug interactions increase the risk for GI bleeding or peptic ulcers?
NSAIDs with corticosteroids, anticoagulants, antiplatelets
-also avoid NSAIDs with hyperkalemic agents
if can’t be avoided use GI protection (H2 blocker, PPI)
How should the Cockcroft-Gault equation be used for elderly average-weight patients to calculate CrCl?
exclude the weight and don’t divide by 72 from the equation
How to calculate CrCl in geriatrics and overweight or underweight patients
overweight: Adjusted body weight, multiplied with a 0.3 or 0.4
underweight: use IBW
Renal dose adjustment drugs
-Colchicine, Duloxetine, and Enoxaparin
check video 37:00
Reasons for underused drugs in geriatrics
Untreated conditions
-might be a condition that was missed
-the team may have decided not to treat
-unused preventive care (immunizations, vitamins, statins, BP control)
-nonadherent (intended (cost, due to ADE; non-intended: too complex, forgotten refills, patient not knowing)
What are non-pharmacological ways to prevent diseases?
-ear and eye exams
-prevent DDIs and ADEs, falls
-improve diet and exercise, social interactions
-vitamins
-immunizations
Which vaccines should be considered at the age of 65 or older or based on comorbidities
COVID-19: fully boosted
influenza: Annually
RSV (respiratory virus): in 60 and older: COPD, asthma, HF, CVD (clinical judgment)
Tdap
Zoster
Pneumococcal
What is the recommended dose of calcium for elderly patients?
Men:
51-70: 1000 mg
older than 70: 1200 mg
Women:
51 and older: 1200 mg
-start with diet then supplement the rest
Which calcium formulation is more appropriate in patients with achlorhydria, constipation/gas, PPI/H2 blocker use, and risk for renal stones?
calcium citrate formulation
What is the recommended dose of vitamin D for elderly patients?
Men and women
51-70 yoa: 600IU daily
70 and older: 800 IU daily
start with diet, more sun exposure
How much Vitamin D is recommended in patients with osteoporosis?
800-1000 IU daily
-may get Vitamin D levels and supplement the deficiency
50,000 IU weekly of ergocalciferol (D2) or !!
5000-6000 IU daily of cholecalciferol (D3) - more efficient !!
after the deficiency is replenished -> 2000 U per day !!
When should Vitamin B12 supplementation be considered?
-Neurological concerns
-Metformin long-term use
get a Vitamin B12 level and treat based on the level
When might Aspirin be indicated and when contraindicated?
-don’t use it for primary prevention
-may use it for secondary prevention
-avoid in patients with bleeding risk
What is the recommended use of statins for primary and secondary prevention in elderly patients?
-primary prevention: initiate based on risk assessment and continue once older than 75 also based on risk assessment and clinician discussion
-secondary prevention:
-moderate to high-intensity statin if coronary, cerebral, or vascular disease unless older than 85 or end-of-life care
-continue until the risk is greater than the benefit
