Geriatrics Flashcards
Meds that may result in more adverse events than benefits
- Incr risk of falls:
- Sedative/hypnotics
- Neuroleptics/antipsychotics
- Antidepressants
- Opioids
- Loop diuretics
- Alpha-blockers
Safer alternative meds for older adults
- Anticholinergics: several exist, are indication-specific
- Sedatives: use non-pharm tx for anxiety
- Sulfonylureas: use shorter-acting agents and relax treatment targets
Role of palliative care and advance care directives supporting end of life care
- Palliative care: for illnesses that don’t respond to treatment or treatment doesn’t exist
- Goal: optimize QOL (stop meds not improving QOL), focus on symptoms, can use meds on Beers Criteria if it helps pt be comfortable
BEERS CRITERIA
* How are decisions about recommendations decided?
* Who is involved in the decision-making process?
* What types of evidence/literature are evaluated?
* How does the committee describe quality of evidence and strength of recommendation?
* Know meds that are diabetes-related
- Decisions about recommendations decided: the GRADE criteria for clinical trials and observational studies and by the AMSTAR criteria for systematic reviews and meta-analyses –> use 5-point scale to vote
- Who is involved: 12 experts in geriatric care and pharmacotherapy from medicine, nursing, and pharmacy
- Type of literature evaluated: Literature searches in PubMed from 2017-2022; included targeted controlled clinical trials, observational studies, and systematic reviews and metaanalyses
- Quality of evidence: high quality (further research unlikely to change confidence), moderate (further research probably have effect on confidence), low (further research very likely to have effect on confidence)
- Strength of recommendation: strong (harms, adverse events, and risks clearly outweigh the benefits), weak (harms, adverse events, and risks may not outweigh the benefits)
- Diabetes meds: fast/rapid insulin w/o concurrent use of basal/long-acting insulin, sulfonylureas (choose short-acting, glipizide, if necessary, -ide), SGLT2 (risk of UTI, -gliflozin)
Physiologic changes associated w/ aging
- Decr total body water
- Decr lean body mass
- Incr body fat
- Decr baroreceptor response/activity
- Decr hepatic and renal blood flow
- Decr neurotransmitter volume (sensitivity to CNS AE)
- Decr heart rate variability
Pharmacokinetic changes
bioavailability
- No change in bioavailability
- Slower Tmax
Pharmacokinetic changes
water-soluble drugs
Decr volume of distribution & Incr concentration (ex: atenolol)
Pharmacokinetic changes
lipid-soluble drugs
Incr volume of distribution and half-life (ex: rifampin)
Pharmacokinetic changes
hepatically-cleared drugs
Decr clearance and incr half-life (ex: propranolol)
Pharmacokinetic changes
renally-cleared drugs
Decr clearance and incr half-life (ex: atenolol)
Advanced Care Directives (ACD)
- Verbal and written instructions about future medical care & treatment
- Includes: health care representative (names someone or prevents someone from making decisions for you), psychiatric advance directive (sets preferences; ex: mental illness during periods of incapacity), power of attorney
Normal bladder function
- Stretch receptors notify brain that bladder is full and needs emptied (B3 receptors support detrusor relaxation)
- Neurologic stimulation initiates contraction
- Sphincter relaxes, urine released
Urinary incontinence: age-related changes to bladder
- decr bladder capacity/elasticity
- decr sphincter compliance
- incr spontaneous detrusor contractions
Urinary Incontinence: Urge
Overactive bladder
* Hyperactivity of detrusor muscle –> large or small volume accidents
* Symptoms: urgency, frequency
* Causes: neurologic or meds (AChE inhibitors)
Urinary Incontinence: Stress
Sudden, involuntary loss of urine
* Small volume of accidents
* Exacerbated or caused by alpha-antagonists
* Associated w/ coughing, laughing, drinking pop or alc
* Risk factors: mulitple childbirths, estrogen deficiency
Medication causes for incontinence
Frequency:
* Diuretics
* Alpha antagonists
Urgency:
* AChE inhibitors
Overflow:
* Alpha antagonists
* Antihistamines
Neurogenic (Atonic) Bladder
disturbed function of the nervous system
* small volume accidents
* incr risk of UTI and kidney stones
* loss of feeling that bladder is full
* Causes: stroke, neuropathy (ex: uncontrolled diabetes), spinal cord injury
UI Treatments: Non-Pharm
- Scheduled/timed voiding
- Kegels (pelvic floor muscle strengthening)
- Avoid irritants like coffee, alc, caffeine, avoid water before bed
- Use absorbent products (pads, adult diapers)
- Catheters
UI Treatments: Urge
- Non-pharm
- Pharm: anticholinergic/antimuscarinic, B3-agonists, combo (meds lead to about 50% reduction in episodes)
- Injections or surgery
* Goal: reduce detrusor contraction frequency
* ~4 wks for meds to work
* don’t stop meds abruptly –> may lead to accidents worse than before
UI Treatments: Stress
- Non-pharm (kegel)
- Duloxetine (incr sphincter tone to prevent leaks)
- Topical estrogen
- Alpha-agonists
- Vaginal pessaries or surgery
UI Treatments: Overflow
- Address obstruction
- If BPH, alpha-adrenergic blockers
- Catheter
UI Treatments: Neurogenic
- No pharm management is effective
- Focus on non-pharm (scheduled voiding)
- Intermittent catheterization
- Botox injections
- Surgery
Urinary Incontinence: Overflow
due to blockage of urethra
* most commonly from BPH, kidney stones, or prostatic blockage of urethra
* Sx: abdominal pain, frequency, feeling the need to pee shortly after peeing
Anticholinergic/Antimuscarinic
- Drugs: oxybutynin, tolterodine, solifenacin, darifenacin, trospium, fesoterodine
- Adverse Events: dry mouth, constipation, fatigue, confusion, tachychardia
B3-Agonist
- Drugs: mirabegron, vibegron
- Adverse Events: minor incr in BP, UTI
