Geriatrics Flashcards
List 10 components of the Medication Appropriateness Index (MAI)
1) Indication
2) Efficacy
3) Correct dosage
4) Correct directions
5) Practical directions
6) Drug-drug interactions
7) Drug-disease/condition interactions
8) Unnecessary duplication with other drugs
9) Duration of therapy acceptable?
10) Cost- is the drug the least expensive alternative compared to others of equal utility
Which class of antihistamines is stated in the BEERs list and why should it be avoided in elderly?
First-gen antihistamines
Rationale: highly anticholinergic, clearance reduced with advanced age, tolerance develops when used as hypnotic. Associated with increased risk of falls, delirium, dementia
What are some anticholinergic side effects? (list 5)
1) Dry mouth
2) Constipation
3) Hallucinations
4) Confusion
5) Drowsiness/dizziness
6) Blurred vision
7) Dry eyes
8) Urinary retention
9) Tachycardia
BEERs list:
Which drug should be avoided for initiation for primary prevention of cardiovascular disease? Why?
Aspirin; risk of major bleeding from aspirin increases markedly with older age
BEERs list:
Which drug should be avoided for initiation for the treatment of non-valvular AF or VTE? Why? List 2 exceptions where this drug may still be used
Warfarin. Compared with DOACs, has a higher risk of major bleeding with similar/lower effectiveness, DOACs are preferred.
Exceptions:
- unless alternative options are CI / substantial barriers to their use
- for older adults who have been using warfarin long term, may be reasonable to continue with warfarin, particularly among those with well-controlled INRs
BEERs list:
Which class of antidepressants is known to have strong anticholinergic side effects and can cause orthostatic hypotension? List down 5 examples of antidepressants belonging to this class.
Tricyclic anti-depressants;
1) Amitriptyline
2) Nortriptyline
3) Imipramine
4) Desipramine
5) Dothiepine
6) Clomipramine
BEERs list:
List 5 examples of antipsychotics listed in the list and the rationale.
1st-gen antipsychotic:
- Haloperidol
2nd-gen antipsychotic:
- Aripiprazole
- Olanzapine
- Quetiapine
- Risperidone
Rationale: increased risk of stroke, greater rate of cognitive decline and mortality in persons with dementia
- avoid use except in FDA-approved indications e.g. schizophrenia, bipolar disorder, Parkinson disease psychosis, short-term use as antiemetic
BEERs list:
- List 3 other CNS depressants that is listed in the beers list and their rationale
1) Barbiturates- high rate of physical dependence, tolerance to sleep benefits, greater risk of overdose at low dosages
2) Benzodiazepines- increase risk of cognitive impairment, delirium, falls, fractures; risk of abuse, misuse and addiction
3) Z-drugs (e.g. zolpidem, zopiclone) - similar to benzodiazepine drugs
List 2 anti-hyperglycemic agents that is listed in the BEERs list and its rationale
1) Insulin, sliding scale (insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal/long-acting insulin): higher risk of hypoglycemia without improvement in hyperglycemia management
2) Sulfonylureas: higher risk of cardiovascular events, all-cause mortality and hypoglycemia than other agents; may increase CV death and ischemic stroke; among sulfonylureas, long-acting agents confer a higher risk of prolonged hyperglycemia than short acting agents
Explain why PPIs are listed in the BEERs list
Risk of C. difficile infection, pneumonia, GI malignancies, bone loss, fractures;
avoid scheduled use for >8 weeks unless for high-risk patients (e.g. oral corticosteroids/ chronic NSAID use), erosive esophagitis etc.
Explain why metoclopramide is listed in BEERs list
Can cause extrapyramidal effects, including tardive dyskinesia; risk may be greater in frail older adults and with prolonged exposure
BEERs list:
List 5 types of antispasmodics listed in the BEERs list and its rationale
1) Atropine (excludes ophthalmic)
2) Clidinium-chlordiazepoxide
3) Dicyclomine
4) Hyoscyamine
5) Scopolamine
Rationale: highly anticholinergic, uncertain effectiveness
BEERs list:
List 5 examples of non-selective NSAIDs listed in the BEERs list and the rationale why it may not be suitable for elderly
1) Aspirin (>325mg/day)
2) Diclofenac
3) Ibuprofen
4) Ketorolac
5) Naproxen
Rationale: increased risk of GI bleeding or peptic ulcer diseases, incl. >75 y/o; taking oral/parenteral steroids; anticoagulants/anti-platelets
BEERs list:
List 1 example of skeletal muscle relaxants listed in the BEERs list and explain why there is a need to avoid its use
Orphenadrine;
Rationale: poorly tolerated by older adults due to anticholinergic side effects, sedation, increased risk of fractures
BEERs list:
List 3 classes of medications listed in the BEERs list that has potential for drug-disease interaction in heart failure patients and its rationale
1) Non DHP CCBs (Diltiazem & Verapamil): promote fluid retention, exacerbate heart failure
2) NSAIDs & COX-2 inhibitors: promote fluid retention, exacerbate heart failure
3) Thiazolidinediones (Pioglitazone): promote fluid retention, exacerbate heart failure
4) Dronedarone: potential to increase mortality in older adults with heart failure
BEERs list:
List 4 classes of medications listed in the BEERs list that has potential for drug-disease interaction in syncope patients and its rationale
1) Antipsychotics (Chlorpromazine & olanzapine): increase risk of orthostatic hypotension
2) TCAs: Increase the risk of orthostatic hypotension
3) Acetylcholinesterase inhibitors (donepezil, galantamine, rivastigmine): can cause bradycardia, should avoid use in syncope patients due to bradycardia
4) Non-selective peripheral alpha-1 blockers (doxazosin, prazosin, terazosin): can cause orthostatic hypotension
BEERs list:
List 7 classes of medications listed in the BEERs list that has potential for drug-disease interaction in delirium patients and its rationale
1) Anticholinergics
2) Antipsychotics
3) Benzodiazepines
4) Corticosteroids (oral & parenteral)
5) H2-receptor antagonists (cimetidine, famotidine, nizatidine)
6) Z- hypnotics (zolpidem, eszopiclone)
7) Opioids
Rationale: avoid in older adults with or at high risk of delirium due to potential of inducing/worsening delirium; except for prescribed exceptions
BEERs list:
List 4 classes of medications listed in the BEERs list that has potential for drug-disease interaction in dementia/cognitive-impairment patients and its rationale
1) Anticholinergics
2) Antipsychotics, chronic use/ persistent prn use: increased risk of stroke and greater rate of cognitive decline and mortality
3) Benzodiazepines
4) Z-hypnotics (zolpidem, eszopiclone)
Rationale: due to adverse CNS effects
BEERs list:
List 9 classes of medications listed in the BEERs list that has potential for drug-disease interaction in patients with history of falls and fractures and its rationale
1) Anticholinergics
2) SNRIs
3) SSRIs
4) TCAs
5) Antiepileptics: avoid except for seizures and mood disorders
6) Antipsychotics
7) Benzodiazepines
8) Z-hypnotics
9) Opioids: avoid except for pain management in severe acute pain
Rationale: may cause ataxia, impaired psychomotor function, syncope, or additional falls
BEERs list:
List 4 types of medications listed in the BEERs list that has potential for drug-disease interaction in Parkinson disease patients and its rationale
1) Metoclopramide
2) Prochlorperazine
3) Promethazine
4) antipsychotics (except Clozapine, quetiapine and pimavenserin)
Rationale: dopamine receptor antagonists have potential to worsen parkinson symptoms
Exception: Clozapine, quetiapine and pimavenserin less likely to precipitate worsening of PD
BEERs list:
List 2 types of medications listed in the BEERs list that has potential for drug-disease interaction in patients with history of gastric/duodenal ulcer and its rationale
1) Aspirin
2) Non-cox2-selective NSAIDs
Rationale: may exacerbate ulcers or cause new/additional ulcers
BEERs list:
List 2 types of medications listed in the BEERs list that has potential for drug-disease interaction in women with urinary incontinence (all types) and its rationale
1) Non-selective peripheral alpha-1 blockers (doxazosin, prazosin, terazosin)
2) Estrogen (oral and transdermal): excludes intravaginal estrogen
rationale: aggravation of incontinence (alpha-1 blockers), lack of efficacy (oral estrogen)
BEERs list:
List 1 type of medications listed in the BEERs list that has potential for drug-disease interaction in patients with lower urinary tract symptoms/ BPH and its rationale
1) Strongly anticholinergic drugs, except antimuscarinics for urinary incontinence
Rationale: may decrease urinary flow and cause urinary retention
BEERs list:
List 9 types of medications that may exacerbate or cause SIADH/ hyponatremia?
1) Mirtazipine
2) SNRIs
3) SSRIs
4) TCAs
5) Carbamazepine
6) Oxcarbazepine
7) Antipsychotics
8) Diuretics
9) Tramadol
BEERs list:
Older adults using SGLT2 inhibitors are at an increased risk of (1) and (2)?
1) Urogenital infections
2) euglycemic diabetics ketoacidosis
BEERs list:
List 4 classes of medications that Lithium can interact with to cause increased risk of lithium toxicity
1) ACEI
2) ARBs
3) ARNIs
4) Loop diuretics
BEERs list:
List 2 types of antiemetics that has strong anticholinergic properties
1) Prochlorperazine
2) Promethazine
List 2 anti-parkinsonian agents that has strong anticholinergic properties
1) Benztropine
2) Trihexylphenidyl
Based on STOPPFall, when should medications be considered to be deprescribed ALWAYS? (2 reasons)
1) If no indication for prescribing
2) If safer alternatives available
List 4 classes of drugs where stepwise withdrawal is generally required.
1) BZDs and BZD-related drugs
2) Antipsychotics
3) Opioids
4) Antidepressants
STOPPFall:
For BZDs and BZD- related drugs, in which cases should withdrawal be considered? (List at least 3 points)
If:
1) Daytime sedation
2) cognitive impairment
3) psychomotor impairment
4) Sleep and anxiety disorder (?)
STOPPFall:
For antipsychotics, when should withdrawal be considered? (List at list 5 points)
If:
1) Extrapyramidal side effect
2) Cardiac Side effects
3) Sedation/ signs of sedation
4) Dizziness
5) Blurred vision
6) Given for BPSD or sleep disorder (?)
STOPPFall:
For opioids, when should withdrawal be considered? (List 3 points)
If:
1) Slow reaction
2) Impaired balance
3) Sedative symptoms
4) If given for chronic pain
STOPPFall:
For antidepressants, when should withdrawal be considered? (List 5 points)
If:
1) Hyponatremia
2) Orthostatic hypotension
3) Dizziness
4) Sedative symptoms
5) Tachycardia/arrhythmia
6) If given for depression but depended on symptom-free time and history of symptoms
7) Given for sleep disorder
STOPPFall:
For antiepileptics,when should withdrawal be considered? (List 5 points)
If:
1) Ataxia
2) Somnolence
3) Impaired balance
4) Dizziness
5) Given for anxiety disorder / neuropathic pain
STOPPFall:
For diuretics, when should withdrawal be considered? (list 3 points)
If:
1) Orthostatic hypotension
2) hypotension
3) Electrolyte disturbance
STOPPFall:
For alpha-blockers used for hypertension, when should withdrawal be considered? (List 3)
If:
1) Hypotension
2) Orthostatic hypotension
3) Dizziness
STOPPFall:
For alpha-blockers used for BPH, when should withdrawal be considered? (List 3)
If:
1) Hypotension
2) Orthostatic hypotension
3) Dizziness
STOPPFall:
For centrally-acting hypertensives, when should withdrawal be considered? (list 3)
If:
1) Hypotension
2) Orthostatic hypotension
3) Sedative symptoms
STOPPFall:
For sedative antihistamines, when should withdrawal be considered? (list 4)
If:
1) Confusion
2) Drowsiness
3) Dizziness
4) blurred vision
STOPPFall:
For vasodilators used in cardiac disease, when should withdrawal be considered? (list 3)
If:
1) Hypotension
2) Orthostatic hypotension
3) Dizziness
STOPPFall:
For overactive bladder and incontinence medications, when should withdrawal be considered?
If:
1) dizziness
2) confusion
3) blurred vision
4) drowsiness
5) Increased QT-interval
STOPPFall:
Which diuretic is more fall-risk increasing than other diuretics?
Loop diuretics
Which antidepressant is more fall-risk increasing than other antidepressants?
TCAs- tricyclic antidepressants
List 3 aspects that is missing from Medication Appropriateness Index
1) Untreated indications
2) Adverse Drug Reactions
3) Failure to receive drug
What constitutes a DRP? (2 points)
1) Drug-related
2) Affect outcome
List the 5 classifications of DRP
1) Indication related
2) Dose-related
3) Interactions
4) Adverse drug reactions
5) Failure to receive drugs
List 3 barriers for appropriate medicines to reach patients
1) Non-adherence
2) Poor technique
3) Inappropriate storage
List the 5 domains of the Comprehensive Geriatric Assessment
1) Functional status
2) Medical
3) Mental
4) Medication/Nutrition
5) Socioeconomic resources
Under the functional status domain of the Comprehensive Geriatric Assessment, list 5 components of basic activities of daily living (recall: DEATH)
1) Dressing
2) Eating
3) Ambulating (transfer)
4) Toileting
5) Hygiene
Under the functional status domain of the Comprehensive Geriatric Assessment, list 7 components of Instrumental Activities of Daily living (recall: SHAFTTT)
1) Shopping
2) Housekeeping
3) Accounting
4) Food
5) Taking meds
6) using Telephone
7) taking Transport
Must all older adults receive Comprehensive Geriatric Assessment
No. CGA is most beneficial for older adults who are at least CFS 4 and above, but not more than 8-9
Under the ABCDEF framework, what does A stands for?
Accurate diagnosis of dementia
Under the ABCDEF framework, what does B stands for?
Behavioural and psychological symptoms
Under the ABCDEF framework, what does C stands for?
Caregiver stress
Under the ABCDEF framework, what does D stands for?
Drug and disabilities
