Geriatric Medication Critique Study Guide Flashcards
What anticoagulant is preferred for elderly patients?
DOACs
Apixaban
What dose limit is placed on Digoxin?
greater than 0.125 mg/day
Should be avoided as first-line therapy for
-atrial fibrillation
-heart failure
What diabetes medications are concerning?
Insulin (sliding scale with short-acting insulin w/o basal insulin)
Sulfonylurea
Are PPIs ever okay?
avoid for more than 8 weeks
-unless high-risk patient:
chronic NSAID use
erosive esophagitis, Barrett’s esophagitis,
pathologic hypersecretory condition, or
demonstrated need for maintenance treatment (failed H2RA)
What disease states list antipsychotics as concerning?
-Delirium (may make it worse)
avoid unless non-pharmacologic has failed or they threaten to hurt themselves or others
-Dementia: risk of strokes and mortality
-risk of falls
-Parkinson’s: except clozapine, pimavanserin, quetiapine
Which antipsychotics are less likely to worsen Parkinson’s Disease
-clozapine
-pimavanserin
-quetiapine
What is the concern with NSAIDs in elderly patients?
-may exacerbate existing ulcers or cause
new/additional ulcers
-risk of GI bleeding
-can make heart failure worse
What should be avoided in older patients with a history of falls?
Benzos
Z-drugs (Eszopiclone, Zaleplon, zolpidem)
Antihistamines
Anticholinergics
Antidepressants
Antiepileptics
Antipsychotics
Opioids
Dextromethorphan-quinidine
Skeletal muscle relaxants
Which drugs should be avoided in older patients with BPH?
avoid Strongly anticholinergic drugs, they can cause urinary retention
may use antimuscarinics for urinary incontinence
What medications are used with caution due to bleeding risk?
-avoid aspirin (except for secondary prevention)
-avoid starting warfarin (may continue if they were using it long-term and INR is stable)
-avoid rivaroxaban (for long-term use)
-dabigatran (use with CAUTION)
-Prasugrel, ticagrelor (use with CAUTION
-avoid Fondaparinux
-Enoxaparin (need dose reduction)
-avoid NSAIDs (for long-term, may consider if no other alternative and with gastroprotection)
When is careful monitoring of sodium recommended?
-Mirtazapine, SSRIs, SNRIs, TCAs
-Antiepileptics: Carbamezapine, Oxcarbamazepine
-Antipsychotics
-Diuretics
-Tramadol
May exacerbate or cause SIADH or hyponatremia
What are 3 major categories of risk factors for falls? List 2 examples for each of these categories.
Environment: stairs, low lighting
Medication: anticholinergics, CNS agents
Diseases: arthritis, Depression, Orthostatic hypotension
What are common FRIDs?
benzos
sedatives
opioids
antipsychotics
antidepressants
diuretics
antihypertensives (orthostasis)
List 5 anticholinergic side effects.
dry mouth
blurred vision
urinary retention
constipation
reduced sweating
confusion
delirium
sedation, dizziness
List 5 medications with significant anticholinergic burden (see Beers Criteria Table 7).
-Antidepressants: Amitriptyline, Paroxetine !!!
-Antiemetics: Prochlorperazine, Promethazine
-Antihistamines (1st gen): Meclizine, Hydroxyzine, Promethazine
-Antimuscarinics: Oxybutynin, Solifenacin
-Antiparkinsonian: Benztropine
-Antipsychotics: Olanzapine !!!
-Antispasmodics: Dicyclomine, Scopolamine
-Skeletal muscle relaxants, Cyclobenzaprine
List 3 risk factors for ADEs in older patients.
-bleeding risk: anticoagulants, NSAIDs
-fall risk: CNS agents
-hypoglycemia: insulin, sulfonylurea
-hypotension, orthostasis, syncope: doxazosin (α1 blocker), clonidine (central α1 agonist), CNS agents
What types of medications are commonly implicated in ADEs in older patients?
anticoagulants
CNS agents
antihypertensives
antidiabetics
Based on available evidence, what drug interactions are of the highest concern in older patients (see Beers Criteria Table 5)?
-avoid using 2 RAAS inhibitors (ACEi/ARB) or RASS with K-sparing diuretics (spironolactone) in older patients with CKD stage 3a
-Opioids with Benzos or Gabapentin (sedation, resp. depression)
-multiple anticholinergics
-Lithium with ACEi/ARB (Lithium accumulation, toxicity)
-Lithium with loops (lithium toxicity)
-Warfarin with SSRIs (bleeding risk)
also Fab5
Digoxin
macrolides (azithromycin)
sulfonylureas
Norma is an 84-year-old female, 5’3”, 140 pounds, SCr 1.2. Calculate her CrCl using one or more appropriate method(s). What is her estimated CrCl?
if geriatric and average weight, use Cockcroft-Gault with
-no body weight
-actual SCr (without 72)
if overweight: use adjusted BW and multiply with 0.3
if underweight: use ideal BW
is SCr is less than: use total BW and round SCr to 1
Which drugs used in older patients need dose adjustments? (Table 6)
-Antibiotics: Cipro, Nitrofurantoin
-Anticoagulant: Enoxaparin, Fondaparinux, Rivaroxaban
-diuretics: spironolactone, Triamterene
-CNS agents: Baclofen, duloxetine, gabapentin
-analgesics: COX-2 NSAIDs
-GI: Famotidine, cimetidine
List 3 examples of underuse due to under-prescribing.
-undiagnosed or untreated condition
Afib -> need anticoagulant
CAD -> need antiplatelet, statins unless end-of-life or over 75y
Diabetes with albuminuria: ACEi
-preventive: immunizations, vitamins, screenings
When should an older adult receive Tdap vaccination?
1 dose every 10 years
At what age should patients be immunized for shingles?
What vaccine should be used and what is the regimen?
50 and older
2 doses (2-6 months apart) of Shingrix (rzv, recombinant zoster vaccine)
Which pneumococcal vaccine(s) is/are indicated in a 66-year-old patient with no PMH and no vaccination history? How would this change if the 66-year-old patient had COPD and got a Pneumovax at age 62?
-if no previous vaccine:
single dose: PCV21, PCV20
or PCV15 -> then PPSV23 1 year later
if they had pneumovax (PPSV23) before:
A single dose of PCV21, PCV20, or PCV15 after 1 year
What calcium and vitamin D recommendations do you make for a 72-year-old husband and wife?
Calcium:
Men: 51-70 yoa = 1,000mg; > 70 yoa = 1,200mg
Women: 51 and older = 1,200mg
Men: 1200 mg
Women: 1200 mg
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Vitamin D:
Men & Women: 51-70 yoa = 600 IU daily; > 70 yoa = 800 IU daily (800-1000 if osteoporosis at any age)
Husband: 800 IU
Wife: 800 IU
When should aspirin use for primary prevention be stopped in older adults?
don’t start for primary prevention if older than 60, or increased bleeding risk
-may use it for secondary prevention
When should primary prevention with statin therapy be initiated in older adults? When should it be stopped?
initiate if they are younger than 75, when they get older, may continue based on risk assessment
-may not start for secondary prevention if older than 85
