Geriatrics

Question 1

List 10 components of the Medication Appropriateness Index (MAI)

Answer 1

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

Question 2

Which class of antihistamines is stated in the BEERs list and why should it be avoided in elderly?

Answer 2

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

Question 3

What are some anticholinergic side effects? (list 5)

Answer 3

1) Dry mouth
2) Constipation
3) Hallucinations
4) Confusion
5) Drowsiness/dizziness
6) Blurred vision
7) Dry eyes
8) Urinary retention
9) Tachycardia

Question 4

BEERs list:
Which drug should be avoided for initiation for primary prevention of cardiovascular disease? Why?

Answer 4

Aspirin; risk of major bleeding from aspirin increases markedly with older age

Question 5

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

Answer 5

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

Question 6

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.

Answer 6

Tricyclic anti-depressants;
1) Amitriptyline
2) Nortriptyline
3) Imipramine
4) Desipramine
5) Dothiepine
6) Clomipramine

Question 7

BEERs list:
List 5 examples of antipsychotics listed in the list and the rationale.

Answer 7

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

Question 8

BEERs list:
- List 3 other CNS depressants that is listed in the beers list and their rationale

Answer 8

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

Question 9

List 2 anti-hyperglycemic agents that is listed in the BEERs list and its rationale

Answer 9

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

Question 10

Explain why PPIs are listed in the BEERs list

Answer 10

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.

Question 11

Explain why metoclopramide is listed in BEERs list

Answer 11

Can cause extrapyramidal effects, including tardive dyskinesia; risk may be greater in frail older adults and with prolonged exposure

Question 12

BEERs list:
List 5 types of antispasmodics listed in the BEERs list and its rationale

Answer 12

1) Atropine (excludes ophthalmic)
2) Clidinium-chlordiazepoxide
3) Dicyclomine
4) Hyoscyamine
5) Scopolamine

Rationale: highly anticholinergic, uncertain effectiveness

Question 13

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

Answer 13

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

Question 14

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

Answer 14

Orphenadrine;

Rationale: poorly tolerated by older adults due to anticholinergic side effects, sedation, increased risk of fractures

Question 15

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

Answer 15

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

Question 16

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

Answer 16

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

Question 17

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

Answer 17

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

Question 18

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

Answer 18

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

Question 19

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

Answer 19

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

Question 20

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

Answer 20

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

Question 21

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

Answer 21

1) Aspirin
2) Non-cox2-selective NSAIDs

Rationale: may exacerbate ulcers or cause new/additional ulcers

Question 22

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

Answer 22

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)

Question 23

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

Answer 23

1) Strongly anticholinergic drugs, except antimuscarinics for urinary incontinence

Rationale: may decrease urinary flow and cause urinary retention

Question 24

BEERs list:
List 9 types of medications that may exacerbate or cause SIADH/ hyponatremia?

Answer 24

1) Mirtazipine
2) SNRIs
3) SSRIs
4) TCAs
5) Carbamazepine
6) Oxcarbazepine
7) Antipsychotics
8) Diuretics
9) Tramadol

Question 25

BEERs list: Older adults using SGLT2 inhibitors are at an increased risk of (1) and (2)?

Answer 25

1) Urogenital infections 2) euglycemic diabetics ketoacidosis

Question 26

BEERs list: List 4 classes of medications that Lithium can interact with to cause increased risk of lithium toxicity

Answer 26

1) ACEI 2) ARBs 3) ARNIs 4) Loop diuretics

Question 27

BEERs list: List 2 types of antiemetics that has strong anticholinergic properties

Answer 27

1) Prochlorperazine 2) Promethazine

Question 28

List 2 anti-parkinsonian agents that has strong anticholinergic properties

Answer 28

1) Benztropine 2) Trihexylphenidyl

Question 29

Based on STOPPFall, when should medications be considered to be deprescribed ALWAYS? (2 reasons)

Answer 29

1) If no indication for prescribing 2) If safer alternatives available

Question 30

List 4 classes of drugs where stepwise withdrawal is generally required.

Answer 30

1) BZDs and BZD-related drugs 2) Antipsychotics 3) Opioids 4) Antidepressants

Question 31

STOPPFall: For BZDs and BZD- related drugs, in which cases should withdrawal be considered? (List at least 3 points)

Answer 31

If: 1) Daytime sedation 2) cognitive impairment 3) psychomotor impairment 4) Sleep and anxiety disorder (?)

Question 32

STOPPFall: For antipsychotics, when should withdrawal be considered? (List at list 5 points)

Answer 32

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 (?)

Question 33

STOPPFall: For opioids, when should withdrawal be considered? (List 3 points)

Answer 33

If: 1) Slow reaction 2) Impaired balance 3) Sedative symptoms 4) If given for chronic pain

Question 34

STOPPFall: For antidepressants, when should withdrawal be considered? (List 5 points)

Answer 34

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

Question 35

STOPPFall: For antiepileptics,when should withdrawal be considered? (List 5 points)

Answer 35

If: 1) Ataxia 2) Somnolence 3) Impaired balance 4) Dizziness 5) Given for anxiety disorder / neuropathic pain

Question 36

STOPPFall: For diuretics, when should withdrawal be considered? (list 3 points)

Answer 36

If: 1) Orthostatic hypotension 2) hypotension 3) Electrolyte disturbance

Question 37

STOPPFall: For alpha-blockers used for hypertension, when should withdrawal be considered? (List 3)

Answer 37

If: 1) Hypotension 2) Orthostatic hypotension 3) Dizziness

Question 38

STOPPFall: For alpha-blockers used for BPH, when should withdrawal be considered? (List 3)

Answer 38

If: 1) Hypotension 2) Orthostatic hypotension 3) Dizziness

Question 39

STOPPFall: For centrally-acting hypertensives, when should withdrawal be considered? (list 3)

Answer 39

If: 1) Hypotension 2) Orthostatic hypotension 3) Sedative symptoms

Question 40

STOPPFall: For sedative antihistamines, when should withdrawal be considered? (list 4)

Answer 40

If: 1) Confusion 2) Drowsiness 3) Dizziness 4) blurred vision

Question 41

STOPPFall: For vasodilators used in cardiac disease, when should withdrawal be considered? (list 3)

Answer 41

If: 1) Hypotension 2) Orthostatic hypotension 3) Dizziness

Question 42

STOPPFall: For overactive bladder and incontinence medications, when should withdrawal be considered?

Answer 42

If: 1) dizziness 2) confusion 3) blurred vision 4) drowsiness 5) Increased QT-interval

Question 43

STOPPFall: Which diuretic is more fall-risk increasing than other diuretics?

Answer 43

Loop diuretics

Question 44

Which antidepressant is more fall-risk increasing than other antidepressants?

Answer 44

TCAs- tricyclic antidepressants

Question 45

List 3 aspects that is missing from Medication Appropriateness Index

Answer 45

1) Untreated indications 2) Adverse Drug Reactions 3) Failure to receive drug

Question 46

What constitutes a DRP? (2 points)

Answer 46

1) Drug-related 2) Affect outcome

Question 47

List the 5 classifications of DRP

Answer 47

1) Indication related 2) Dose-related 3) Interactions 4) Adverse drug reactions 5) Failure to receive drugs

Question 48

List 3 barriers for appropriate medicines to reach patients

Answer 48

1) Non-adherence 2) Poor technique 3) Inappropriate storage

Question 49

List the 5 domains of the Comprehensive Geriatric Assessment

Answer 49

1) Functional status 2) Medical 3) Mental 4) Medication/Nutrition 5) Socioeconomic resources

Question 50

Under the functional status domain of the Comprehensive Geriatric Assessment, list 5 components of basic activities of daily living (recall: DEATH)

Answer 50

1) Dressing 2) Eating 3) Ambulating (transfer) 4) Toileting 5) Hygiene

Question 51

Under the functional status domain of the Comprehensive Geriatric Assessment, list 7 components of Instrumental Activities of Daily living (recall: SHAFTTT)

Answer 51

1) Shopping 2) Housekeeping 3) Accounting 4) Food 5) Taking meds 6) using Telephone 7) taking Transport

Question 52

Must all older adults receive Comprehensive Geriatric Assessment

Answer 52

No. CGA is most beneficial for older adults who are at least CFS 4 and above, but not more than 8-9

Question 53

Under the ABCDEF framework, what does A stands for?

Answer 53

Accurate diagnosis of dementia

Question 54

Under the ABCDEF framework, what does B stands for?

Answer 54

Behavioural and psychological symptoms

Question 55

Under the ABCDEF framework, what does C stands for?

Answer 55

Caregiver stress

Question 56

Under the ABCDEF framework, what does D stands for?

Answer 56

Drug and disabilities

Question 57

Under the ABCDEF framework, what does E stands for?

Answer 57

End-of-life discussion and Equipment

Question 58

Under the ABCDEF framework, what does F stands for?

Answer 58

Financial supports

Question 59

What are the 4 components to the pharmaceutical care framework?

Answer 59

1) What matters most/important to patient 2) Explicit criteria/high alert medicines 3) Implicit criteria 4) Successful delivery of appropriate drugs

Question 60

Why must we care about PK and PD changes in older adults? (4)

Answer 60

1) Less oldest adults in trials 2) Healthier older adults recruited 3) Affect Generalizability 4) Knowledge of PK/PD changes help optimize pharmacotherapy in older adults

Question 61

Why do PK and PD changes occur in older adults? (3)

Answer 61

1) Physiological changes associated with normal aging 2) Effects of co-morbidities 3) Effects of medications

Question 62

Comment on the relationship between reduced gastric secretion and age, which might cause PK changes for absorption in older adults

Answer 62

Gastric acid secretion is not reduced by age alone if mucosal atrophy is absent Reduced gastric acid secretion is usually due to mucosal atrophy and not by age

Question 63

List 3 types of vitamins and minerals whose absorption is reduced by gastric acid suppression therapy, and what disease condition it can manifest (ref: PK changes- absorption in older adults, oral route)

Answer 63

1) Vitamin B12: deficiency, anemai 2) Calcium: fractures, osteoporosis 3) Iron: anemia

Question 64

List 5 examples of medications whose absorption can be affected by use of gastric acid suppression therapy (Ref: PK changes-absorption in older adults, oral route)

Answer 64

1) Itraconzaole (up to 85% reduction): can be overcome through using IV/oral suspension 2) Ketoconazole (up to 64-66% reduction): rarely used, mostly for hormonal indications 3) Erlotinib (Tarceva) 4) Dasatinib (Sprycel) 5) Nilotinib Note: 3,4,5 are cancer therapies, not all -tinibs are affected by gastric acid suppression therapy

Question 65

Comment on the prolonged gastrointestinal transit time in old age which might affect absorption in older adults (ref: PK changes: absorption-oral route)

Answer 65

1) Unable to separate the effects of diseases and/or drugs on this parameter: prolonging of transit time not due to aging alone, but due to certain diseases e.g. gastroparesis & medications e.g. anti-spasmodics, opioids, anti-cholinergics 2) Same oral bioavailability: extent of absorption not affected 3) Theoretical risk that 1/2 hour wait may not be enough for risedronate/alendronate: may make it less effective, or increase risk of esophageal ulceration; need to give time for meds to go into small intestine for absorption to happen

Question 66

Recall what is first-pass metabolism (ref: PK changes: absorption- oral route)

Answer 66

Metabolism in the intestines and liver before the drugs get absorbed from small intestines to systemic circulation

Question 67

Comment on what type of transport is p-glycoprotein and its relation with age on absorption (ref: PK changes: absorption- oral route)

Answer 67

P-gp: efflux transporter: binds to drugs and push it back to the lumen, reducing absorption Age: no change for most drugs on the account of age alone

Question 68

List 2 examples of DDIs that can occur as a result on the drugs effects on p-gp activity

Answer 68

1) Phenytoin is a p-gp inducer, and may affect dexamethasone's bioavailability from 84% to 33% 2) Carbamazepine is a p-gp inhibitor, and can increase the Cmax of digoxin by 84% and levels of the drug by 64% -> increased risk of S.E and toxicity

Question 69

Comment on the effects of aging on absorption of drugs via the transdermal route (4)

Answer 69

1) Epidermis and dermis thins when ones ages 2) Cutaneous blood supply drops with aging 3) The former increases transdermal absorption, the latter reduces absorption 4) effect of age on transdermal absorption of drugs hard to characterize

Question 70

What is a key factor that can increase transdermal drug delivery and list 3 drug examples

Answer 70

Heat can increase drug delivery via transdermal route; rate of drug delivery depends on ambient heat e.g. heat could increase due to fever -> serious harm, even death may result as it can increase passive diffusion and blood supply 1) Fentanyl patch 2) Exelon patch (rivastigmine) 3) Nitroglycerin patch

Question 71

Comment on the effects of aging on distribution in older adults (4)

Answer 71

1) Total body water and lean muscle mass drops 2) Fat increases 3) Effects on distribution depends on physical properties of drugs 4) Serum albumin and alpha-1 acid glycoprotein: - aging associated with 10-15% decrease in serum albumin, more if sick (due to increased inflammation) - alpha-1 acid glycoprotein increases with age but mainly because of illness - the above changes are not clinically important- in terms of pharmacological actions of the drug

Question 72

Comment on the interpretation of phenytoin level (5) (ref: PK changes- distribution)

Answer 72

1) In adults, 90-95% phenytoin bound to serum albumin 2) Only free phenytoin is pharmacologically active 3) When serum albumin drops, free concentration increases transiently 4) All factors being constant, free concentration drops to the same level before serum albumin decreases -> same free concentration but total concentration drops 5) Conclusion: phenytoin levels need to be interpreted in conjunction with serum albumin -> phenytoin albumin correction

Question 73

Comment on the interpretation of sodium valproate (ref: PK changes- distribution)

Answer 73

Hypoalbuminemia also associated with falsely suppressed total valproic acid concentration, but no established formula for correction When it comes to interpreting sodium valproate levels, it is better to interpret the free serum concentration level than using formula or total concentration -> usually hospitals dont have the capacity to do so

Question 74

List the barriers to drug distribution into the CNS (2)

Answer 74

1) Blood-brain-barrier 2) P-glycoprotein: efflux protein

Question 75

Comment on the effects of aging on drug distribution into the CNS/brain (4) (ref: PK changes: distribution)

Answer 75

1) More leaky BBB in old age (meta-analysis) 2) Dementia associated with more porous BBB than aging alone (meta analysis) 3) P-gp activity lower in elderly (small study) 4) Leaky BBB in old age increase the risk of adverse drug reactions - elderly more sensitive to CNS side effects of anticholinergic drugs

Question 76

List 2 examples of CYP enzymes that is affected by fluconazole (ref: PK changes: distribution)

Answer 76

1) CYP2C9 inhibition 2) CYP3A4 inhibition at higher doses

Question 77

Metabolism mainly occurs in which organ and what are its effects? (4) (ref: pk changes- metabolism)

Answer 77

Organ: liver 1) Inactivate and facilitate elimination 2) Activate (for prodrugs -> active metabolite) 3) Toxic metabolite e.g. paracetamol (NAPQI due to CYP2E1, which is induced by alcohol)

Question 78

List the 2 types of metabolism and state the major enzyme for each type of metabolism (ref: pk changes- metabolism)

Answer 78

1) Phase I: Cytochrome P450 enzymes - 15 CYP enzymes, 3A4 most abundant 2) Phase II: conjugation such as glucuronidation, acetylation, sulfation - major enzyme: uridine 5'diphospho glucoronyltransferase (UGT)

Question 79

Comment on the effects of aging on phase I metabolism (4) (ref: pk changes- metabolism)

Answer 79

Phase 1 metabolism lower with age: 1) Mainly due to reduced liver mass, hepatic blood flow and thickening of sinusoidal endothelium 2) CYP enzyme may not be affected by aging alone 3) Frailty may reduce activity of CYP enzymes through increased inflammation 4) Drug-induced inhibition and induction important - inhibitor: azoles, clarithromycin, cimetidine - inducers: phenytoin, carbamazepine, rifampicin

Question 80

Comment on the effects of aging on phase II metabolism (3) (ref: pk changes- metabolism)

Answer 80

Phase II metabolism largely unchanged with age 1) enzyme itself may not be affected by age alone 2) but quantity dropped with smaller liver 3) frailty caused more drop as it affects enzyme activity (reduces enzyme activity)

Question 81

Comment on the effects of aging on excretion (4) (ref: pk changes: excretion)

Answer 81

1) Kidney is the most important organ in drug/metabolites elimination 2) Decline in kidney function occurs with age 3) Many diseases/drugs prevalent in old age contributes to the decline 4) Even robust elderly with good kidney functions less likely to recover after an insult (e.g. AKI), due to less physical reserve in kidneys in elderly: - high prevalence of chronic dehydration among community dwelling patients who sough help at an Emergency Department: - prostaglandin/ angiotensin II important to maintain GFR - caution with NSAIDs/Coxib/ACEi/ Diuretics

Question 82

Comment on the altered pharmacodynamic in elderly patients (4) (ref: PD changes)

Answer 82

1) Change in receptor sensitivity, post-receptor signaling system, and/or homeostatic mechanism - e.g. reduced sensitivity of baroreflex -> less likely to respond to postural drop in BP 2) Elderly are more sensitive to CNS suppressant such as benzodiazepine 3) Dementia reduces cholinergic reserves and increases CNS side effects of anticholinergics 4) Neuroleptics (antipsychotic) Sensitivity Reaction in patients with DLB/PDD: - sedation, confusion, increase in Parkinsonism, cognitive decline, higher death rate - NO metoclopramide, promethazine, prochlorperazine, antipsychotics (except low-dose quetiapine)

Question 83

What is Geriatric Syndrome? (3)

Answer 83

In general, it includes conditions that are: 1) Prevalent in elderly population e.g. frailty 2) Impairments in multiple organ system 3) Negative impact on QOL, functional status and mortality

Question 84

List 5 examples of Geriatric Syndromes

Answer 84

1) Frailty 2) Falls 3) Dizziness 4) Delirium 5) Urinary incontinence

Question 85

What are the 5 physical characteristics of older adults with Frailty according to the Fried Frailty Tool?

Answer 85

1) Weak: poor hand grip strength, difficulty walking up 1 flight of stairs 2) Slow walking: >6-7s to walk 10 feet 3) Low physical activity 4) Weight loss: 5% or more weight loss in the last year 5) Exhaustion: positive answer to whether they feel fatigued when performing daily activities

Question 86

List the criteria of pre-fail and frail according to the Fried Frailty Tool

Answer 86

1-2 characteristics present: pre-fail 3 or more characteristics present: frail Note: more suitable for research than clinical use, need patient participation and specialized equipment

Question 87

Explain the hypothesized model of frailty

Answer 87

1) Immunosenescence, dysfunctional immune system -> old cells stays in the body -> immune system reacts to it -> increased inflammation 2) Impaired physiologic systems: - Increased inflammation leads to: increased CRP and IL-6 - Neuroendocrine dysregulation leads to: reduced IGF-1. DHEA-S and increased cortisol levels (however, replacing these hormones does not help with frailty) => anorexia, sarcopenia, osteopenia, reduced immune function, cognition and glucose metabolism, increased clotting 3) Clinical Frailty: - slowness - weakness - Weight loss - low activity - fatigue

Question 88

List down the components of the FRAIL scale to identify frailty and its criteria for pre-fail and frail

Answer 88

1) Fatigue: have you felt fatigue most of the time over the past month? yes=1, no=0 2) Resistance: do you have difficulty climbing 1 flight of stairs? yes=1, no=0 3) Ambulation: do you have difficulty walking one block (80m)? yes=1, no=0 4) Illness: HTN, DM, Cancer (other than minor skin CA), chronic lung disease, asthma, heart attack, CHF, angina, stroke, arthritis, and kidney disease; >5 = 1, otherwise =0 5) Loss of weight: have you lost more than 5% of your weight in the past year? yes=1, no=0 Pre-fail= 1-2; frail=3 or higher

Question 89

Under the clinical frailty scale (CFS), explain what does CFS 4 denotes

Answer 89

Pre-fail (mild frailty), functionally independent (can do iADLs), but symptoms of chronic illnesses are affecting activity tolerance

Question 90

Under the clinical frailty scale (CFS), explain what does CFS 5 denotes

Answer 90

Need assistance for all or some of the iADLs

Question 91

Under the clinical frailty scale (CFS), explain what does CFS 6 denotes

Answer 91

Need assistance for all outside activities and some of the basic ADLs (e.g. dressing, bathing)

Question 92

Under the clinical frailty scale (CFS), explain what does CFS 7 denotes

Answer 92

Clinically stable but FULLY dependent for personal care

Question 93

Under the clinical frailty scale (CFS), explain what does CFS 8 denotes

Answer 93

Nearing end of life and FULLY dependent for personal care

Question 94

Under the clinical frailty scale (CFS), explain what does CFS 9 denotes

Answer 94

Terminally ill (<6 months) but not severely frail

Question 95

List 3 main interventions for frailty

Answer 95

1) Physical exercise/ occupational therapy 2) Nutritional intake, with oral nutritional supplement (milk feeds) if necessary - medication side effects (appetite, anticholinergics, sense of taste, sedation) - depression - access to food - feeding assisted - chewing/ swallowing - unnecessary dietary restriction 3) Medication Review - DRPs affecting ability to take part in physiotherapy/ occupational therapy and adequate nutritional intake - vitamin D supplementation

Question 96

List 3 main questions to consider to assess fall risk

Answer 96

1) Fall in the past 12 months? 2) Gait & balance impaired? e.g. feel like falling or not? 3) any concerns on falling? -> if yes to any of the 3 qns, risk of future falls

Question 97

List the mechanisms of harms for Fall Risk Increasing Drugs (FRIDs)

Answer 97

1) Sedation 2) Orthostatic hypotension 3) Anticholinergics 4) Hypoglycemia

Question 98

What is the explicit criteria for FRIDs?

Answer 98

STOPPFall

Question 99

Under STOPPFall, list 4 examples of classes of medications that can induce orthostatic hypotension

Answer 99

1) Alpha-blockers 2) Central antihypertensives 3) Vasodilators 4) Diuretics

Question 100

Under the explicit criteria for FRIDs, list 7 common classes of medications

Answer 100

1) Opioids 2) Antipsychotics 3) Antidepressants 4) Benzodiazepines/ Z-drugs 5) Anticonvulsants 6) First gen antihistamines (anticholinergic) 7) Muscle relaxants (anticholinergic)

Question 101

List the 4 types of dizziness

Answer 101

1) Vertigo: objects are spinning 2) Pre-syncopal dizziness: assoc/w change in posture e.g. postural hypotension 3) Dysequilibrium: lightheadedness/ unsteadiness when patients is walking about 4) Unspecified dizziness: older adults can have more than 1 type of dizziness; not enough to determine cause(s)

Question 102

Explain the TiTraTE approach to evaluating dizziness

Answer 102

1) Ti: Timing, i.e. continuous or episodic (onset, frequency, duration) 2) Tr: Triggers, i.e. head movement, posture change etc. 3) TE: targeted examination

Question 103

Under targeted examination of TiTraTE to evaluate dizziness, what is the assessment used to differentiate between episodic triggered dizziness, and what are the 2 dizziness that can be distinguished from this assessment?

Answer 103

Assessment: Dix-Hallpike maneuver Positive results: benign paroxysmal positional vertigo Negative results: orthostatic hypotension

Question 104

Under targeted examination of TiTraTE to evaluate dizziness, what is the assessment used to differentiate between episodic spontaneous dizziness, and what are the 3 dizziness that can be distinguished from this assessment?

Answer 104

Assessment: further history taking - Unilateral hearing loss/ sensation of ear fullness: Meniere's disease - Migraine headache: vestibular migraine - Psychiatric symptoms: panic attack etc.

Question 105

Under targeted examination of TiTraTE to evaluate dizziness, what is a common cause of continuous vestibular dizziness?

Answer 105

Trauma/ toxin (drugs) e.g. dizziness intensity is assoc/w peak of drug

Question 106

Under targeted examination of TiTraTE to evaluate dizziness, what is the assessment used to differentiate between spontaneous dizziness, and what are the 2 dizziness that can be distinguished from this assessment?

Answer 106

HINTs exam (Head impulse/ Nystagmus/ Test of Skew) - Central: Stroke/TIA - Peripheral: vestibular neuronitis e.g. caused by viral infection

Question 107

Discuss if vestibular suppressants should be used for symptomatic relief of all dizziness

Answer 107

Symptomatic relief of dizziness by using vestibular suppressants should only be given if vestibular symptoms are prolong (>30 minutes); almost all vestibular suppressants are Beers List drugs, timely review is required

Question 108

List 7 classes of vestibular suppressants and give examples for each class

Answer 108

1) First- gen antihistamine: dimenhydrinate, diphenhydramine, meclizine 2) Anticholinergic: scopolamine (hysocine hydrobromide) 3) Phenothiazines: prochlorperazine / promethazine (note: additional antidopaminergic effects, avoid in pts with parkinson disease) 4) Benzodiazepines: clonazepam, diazepam, lorazepam; more sedating, fall risk, can cause cognitive impairment, depression when used long term 5) Antidpoaminergic: metoclopramide; contraindicated in PD, DLB, PD dementia; for n/v; alternative: ondansetron 6) Calcium channel antagonists: cinnarizine; increasing circulation in cochlear; sedating, weight gain due to antihistaminergic effect; caution in patients with Parkinsonism 7) Histamine analogues: betahistine; type 3 histamine receptor antagonist, partial agonist at H1 receptor, negligible agonism at H2 receptor; caution in Asthma (can cause bronchospasm); CI if active/ history of PUD

Question 109

Which geriatric syndrome is also a geriatric medical emergency?

Answer 109

Delirium

Question 110

What are the subtypes of delirium?

Answer 110

1) Hyperactive delirium - agitation - inattentiveness - psychosis (delusions/ hallucinations) 2) Hypoactive delirium - slow response - increased sedation

Question 111

What are the risk factors for delirium? (4)

Answer 111

1) Age 65 years or older 2) Cognitive impairment (past/present) and/or dementia 3) Current hip fracture 4) Severe illness

Question 112

List down the components of 4AT for detection of delirium (4)

Answer 112

1) Level of Alertness 2) Abbreviated mental test 4 (AMT4): DOB, Age, Place, Current year 3) Attention: asking patients to subtract for non-eng speakers, recite months backwards for english speakers 4) Acuity

Question 113

List down the common etiologies of delirium (IWATCHDEATH)

Answer 113

I: Infectious W: Withdrawal (alcohol, benzodiazepines, barbiturates) A: Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure) T: Trauma (head injury, postoperative) C: CNS pathology (stroke, hemorrhage, tumour, seizure disorders, Parkinson's) H: Hypoxia (anemia, cardiac failure, pulmonary embolus) D: Deficiencies (vitamin B12, folic acid, thiamine) E: Endocrinopathies (thyroid, parathyroid, adrenal, glucose) A: Acute vascular (shock, vasculitis, hypertensive encephalopathy) T: Toxins, substance use, medication (alcohol, anesthetics, anticholinergics, narcotics) H: Heavy metals (arsenic, mercury, lead)

Question 114

List 5 classes of drugs known to increase risk of delirium, and remark on its use

Answer 114

1) Anticholinergics (e.g. anarex, chlorpheniramine, diphenhydramine) - remarks on use: if newly started, to stop; avoid use, unless when diphenhydramine is used for severe allergic reactions 2) Benzodiazepines (e.g. lorazepam, alprazolam): - remarks on use: DO NOT cease chronic BZDs abruptly, especially if used for seizure, sleep disorders, and anxiety; not first line for insomnia 3) Z-drugs (e.g. zolpidem, zopiclone) - remarks on use: not first line for insomnia 4) Opioids (especially pethidine) - remarks on use: consider regular paracetamol; consider regular bowel regimen; avoid pethidine (v. neurotoxic metabolite tt will accumulate in elderly with poor kidney function); start low and go slow; consider dose reduction or opioid rotation 5) H2 receptor antagonist (e.g. famotidine, ranitidine): - remarks on use: if delirious, use PPI if no contraindications; if PPI not possible, use famotidine at renally adjusted dose (has least degree of anticholinergic effect)

Question 115

What is the first line approach to managing delirium? List 5 examples

Answer 115

Prevention: - sensory functions optimization - hydration/nutrition - bowel movement/ urination - early mobility - pain control - medication review - social interaction with loved ones - reorientation with clock/ calendar/ proper lighting - conducive environment - promote goof sleep - address infection/ hypoxia

Question 116

Comment on the use of pharmacotherapy for agitation in delirium and hypoactive delirium

Answer 116

Hyperactive delirium: Should be used as a last resort if behaviors are a danger; if agitation is not a problem in terms of safety of patients and caregiver, do not need to treat it Hypoactive delirium: don't treat, instead, withdraw as many CNS suppressants as possible, treat underlying cause if possible

Question 117

List 3 types of antipsychotics that is used for treatment of agitation in delirium, state its dose and maximum dose

Answer 117

1) Haloperidol (SC/IM/PO): 0.3mg-1mg BD; up to 5mg/day (non-ICU) - CI: Prolonged QTC, parkinsonism (incl, DLB, PDD) 2) Quetiapine (PO): 6.25-12.5mg BD, up to 100mg/day (PD friendly) 3) Olanzapine (PO, orodispersible): 1.25mg-2.5mg, up to 10mg/day (safest QTC wise)

Question 118

Comment on the use of benzodiazepine for agitation in delirium, give 1 example with dose

Answer 118

- 1st-line for alcohol/benzo withdrawal - Alternative if antipsychotic not safe. benzo may prolong delirium - Lorazepam (PO/IV/SC): 0.5-1mg - BZDs may cause paradoxical agitation -> pt may become more agitated/ alert

Question 119

What are the prerequisites for urinary continence? (2)

Answer 119

1) Normally functioning lower urinary tracts 2) adequate physical and cognitive functions to use toilets

Question 120

Explain what happens during the bladder filling phase in those with normal lower urinary tract (3)

Answer 120

1) Sympathetic nervous system activated/ parasympathetic nervous system blocked 2) beta-3 adrenergic receptors activated -> bladder relaxation 3) alpha-1 adrenergic receptor activated -> tightening of bladder outlet/ urethra

Question 121

Explain what happens during the bladder voiding phase in those with normal lower urinary tract (2)

Answer 121

1) Sympathetic nervous system blocked/ parasympathetic nervous system activated 2) M3 receptor in the bladder activated -> bladder contraction (acetylcholine released from the system will act on M3 receptors)

Question 122

List the 4 types of Urinary incontinence and define it respectively

Answer 122

1) Stress: involuntary loss of urine (small amounts) with increased intraabdominal pressure e.g. coughing, laughing, exercise 2) Urge: leakage of urine (can be large volumes) because of inability to delay voiding after sensation of bladder fullness is perceived 3) Overflow: leakage of urine (small amounts) caused by either mechanical forces on an overdistended bladder (resulting in stress leakage) or other effects of urinary retention on bladder and sphincter function (contributing to urge leakage) 4) Functional: urinary accidents assoc/w the inability to toilet because of impairment of cognitive and or physical functioning, psychological unwillingness, or environmental barriers

Question 123

List the common causes of stress urinary incontinence (3)

Answer 123

1) weak pelvic floor muscles (childbirth, pregnancy, menopause) 2) bladder outlet or urethral sphincter weakness 3) post-urologic surgery

Question 124

List the common causes of urge urinary incontinence (3)

Answer 124

1) detrusor overactivity, either isolated or assoc/w 1 or more of the following: 2) local genitourinary conditions (e.g. tumours, stones, diverticula, outflow obstruction) 3) CNS disorder (e.g. stroke, parkinsonism, dementia, spinal cord injury)

Question 125

List common causes of overflow urinary incontinence (4)

Answer 125

1) Anatomic obstruction by prostate, stricture, cystocele 2) Acontractile bladder assoc/w diabetes or spinal cord injury 3) Neurogenic assoc/w multiple sclerosis or other spinal cord lesions 4) Medication effect

Question 126

List common causes of functional urinary incontinence (2)

Answer 126

1) Severe dementia or other neurologic disorder 2) psychological factors e.g. depression and hostility

Question 127

List the differential diagnosis of transient causes of urinary incontinence (DIAPPERS)

Answer 127

D: Delirium I: Infection e.g. acute UTI A: Atrophic vaginitis P: Pharmaceuticals P: Psychological disorder, esp. depression E: Excessive urine output e.g. hyperglycemia R: Reduced mobility (i.e. functional incontinence) or reversible (e.g. drug-induced) urinary retention S: Stool impaction

Question 128

List 2 classes of allergy medications that could contribute to urinary incontinence and its respective effect on bladder function

Answer 128

1) Antihistamine: decreased contractility via anticholinergic effect 2) Decongestants (e.g. pseudoephedrine): increased urethral sphincter tone

Question 129

List 2 classes of analgesic and sedatives that could contribute to urinary incontinence and its respective effect on bladder function

Answer 129

1) Benzodiazepines: impaired micturition via muscle relaxant effect 2) Opioids: decreased sensation of fullness and increased urethral sphincter tone

Question 130

List 3 classes of anticholinergic medications that could contribute to urinary incontinence and its respective effect on bladder function

Answer 130

1) Antimuscarinics (e.g. solifenacin, oxybutynin) 2) Spasmolytic (e.g. scopolamine, hyoscyamine) 3) Anticholinergics (antiparkinson medications) e.g. benztropine, trihexylphenidyl Effects: ALL 3 classes decrease contractility via anticholinergic effect

Question 131

List 5 classes of cardiology medications that could contribute to urinary incontinence and its respective effect on bladder function

Answer 131

1) ACE-inhibitors: decrease contractility, chronic coughing 2) Alpha-agonists (e.g. midodrine, phenylephrine, vasopressors): increased urethral sphincter tone 3) Alpha1-blockers (e.g. alfuzosin, tamsulosin): decrease urethral sphincter tone; can worsen stress incontinence 4) Antiarrhythmic (e.g. flecainide, disopyramide): decreased contractility via local anesthetic effect on bladder mucosa or anticholinergic effect 5) Diuretics: increased urine production, contractility, or rate of emptying

Question 132

List 2 classes of antidepressants that could contribute to urinary incontinence and its respective effect on bladder function

Answer 132

1) SNRIs (e.g. duloxetine): increased urethral sphincter tone; used for stress incontinence 2) TCAs (e.g. amitriptyline, clomipramine): decreased contractility via anticholinergic effect

Question 133

List 2 class of antipsychotics that could contribute to urinary incontinence and its respective effect on bladder function

Answer 133

1) First-generation (e.g. chlorpromazine) 2) second-gen antipsychotics (e.g. risperidone, olanzapine) Effects (for both): mixed effects described; decreased contractility via anticholinergic effect, increased micturition and stress incontinence via stimulation of alpha1 receptors and/or central dopaminergic receptors Note: other antipsychotics have lower effect

Question 134

List 3 class of other medications that could contribute to urinary incontinence and its respective effect on bladder function

Answer 134

1) Skeletal muscle relaxants (e.g. orphenadrine): decreased contractility via anticholinergic effect 2) Estrogens (oral): increased urinary incontinence [NOTE: topical estrogen can help in UI] 3) Beta3-agonist (e.g. mirabegron): decreased contractility via beta3-adrenergic effect; cause relaxation of bladder

Question 135

List 2 types of food that could contribute to urinary incontinence and its respective effect on bladder function

Answer 135

1) Alcohol: decreased contractility 2) Caffeine: increased contractility or rate of emptying; also an irritant, diuretic; stimulates bladder detrusor muscle, bladder contracts more easily -> not gd for pts with overactive bladder

Question 136

List the management strategies for stress urinary incontinence (4)

Answer 136

1) Kegel's exercise 2) Topical estrogen (may take up to 3 months for action onset, need counselling) 3) Duloxetine: especially if depression present, but not for patients with crcl < 30ml/min 4) Surgery/devices (not advisable for frail elderly)

Question 137

List the management strategies for urge urinary incontinence (7)

Answer 137

1) Kegel's exercise 2) Treat BPH (men) 3) Topical estrogen (delayed onset) 4) Beta-3 adrenergic receptor agonist: mirabegron, vibegron 5) Antimuscarinic agents: anticholinergic side effects (ensure pt post void residual urine is not too high as these meds ca cause acute urinary retention); M3-selective agents e.g. solifenacin (has M2-blocking activity, might affect cognitive fxn), darifenacin (NA in SG) preferred 6) Botulinum toxin injection 7) Sacral nerve stimulation etc.

Question 138

List the management strategies for overflow urinary incontinence

Answer 138

Bladder outlet obstruction: 1) men: normally BPH (treat accordingly), rare causes include stricture, malignancy, stone etc. -> specialist 2) women: normally structural e.g. uterine prolapse -> specialist 3) Bowel habit optimization Bladder underactivity: 1) Men: bethanechol (cholinergic agent) may help in patients with spinal cord injury, clean intermittent catheterization (usually only for women due to pain) 2) Women: clean intermittent catheterization +/- bethanecol

Question 139

List the different types of elder abuse (5)

Answer 139

1) Physical e.g. chemical/ physical restraint 2) Sexual 3) Psychological 4) Neglect 5) Financial

Question 140

What are some risk factors from patient's perspective that puts them at risk of abuse? (3)

Answer 140

1) Dementia, esp. BPSD (caregiver stress) 2) Physical disability 3) Poor relationship with caregiver pre-morbidly

Question 141

What are some risk factors from caregiver's perspective that puts them at risk of elder abuse? (4)

Answer 141

1) Caregiver dependent on victims for material gains e.g. food/shelter/money 2) Caregiver with mental health issues e.g. depression, substance use dsorders 3) Overwhelmed caregivers e.g. overworked professional caregiver 4) Caregiver who is victim of domestic violence