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
Under the ABCDEF framework, what does E stands for?
End-of-life discussion and Equipment
Under the ABCDEF framework, what does F stands for?
Financial supports
What are the 4 components to the pharmaceutical care framework?
1) What matters most/important to patient
2) Explicit criteria/high alert medicines
3) Implicit criteria
4) Successful delivery of appropriate drugs
Why must we care about PK and PD changes in older adults? (4)
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
Why do PK and PD changes occur in older adults? (3)
1) Physiological changes associated with normal aging
2) Effects of co-morbidities
3) Effects of medications
Comment on the relationship between reduced gastric secretion and age, which might cause PK changes for absorption in older adults
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
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)
1) Vitamin B12: deficiency, anemai
2) Calcium: fractures, osteoporosis
3) Iron: anemia
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)
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
Comment on the prolonged gastrointestinal transit time in old age which might affect absorption in older adults
(ref: PK changes: absorption-oral route)
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
Recall what is first-pass metabolism
(ref: PK changes: absorption- oral route)
Metabolism in the intestines and liver before the drugs get absorbed from small intestines to systemic circulation
Comment on what type of transport is p-glycoprotein and its relation with age on absorption
(ref: PK changes: absorption- oral route)
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
List 2 examples of DDIs that can occur as a result on the drugs effects on p-gp activity
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
Comment on the effects of aging on absorption of drugs via the transdermal route (4)
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
What is a key factor that can increase transdermal drug delivery and list 3 drug examples
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
Comment on the effects of aging on distribution in older adults (4)
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
Comment on the interpretation of phenytoin level (5)
(ref: PK changes- distribution)
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
Comment on the interpretation of sodium valproate
(ref: PK changes- distribution)
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
List the barriers to drug distribution into the CNS (2)
1) Blood-brain-barrier
2) P-glycoprotein: efflux protein
Comment on the effects of aging on drug distribution into the CNS/brain (4)
(ref: PK changes: distribution)
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
List 2 examples of CYP enzymes that is affected by fluconazole
(ref: PK changes: distribution)
1) CYP2C9 inhibition
2) CYP3A4 inhibition at higher doses
Metabolism mainly occurs in which organ and what are its effects? (4)
(ref: pk changes- metabolism)
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)
List the 2 types of metabolism and state the major enzyme for each type of metabolism
(ref: pk changes- metabolism)
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)
Comment on the effects of aging on phase I metabolism (4)
(ref: pk changes- metabolism)
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
Comment on the effects of aging on phase II metabolism (3)
(ref: pk changes- metabolism)
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)
Comment on the effects of aging on excretion (4)
(ref: pk changes: excretion)
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
Comment on the altered pharmacodynamic in elderly patients (4)
(ref: PD changes)
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)
What is Geriatric Syndrome? (3)
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
List 5 examples of Geriatric Syndromes
1) Frailty
2) Falls
3) Dizziness
4) Delirium
5) Urinary incontinence
What are the 5 physical characteristics of older adults with Frailty according to the Fried Frailty Tool?
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
List the criteria of pre-fail and frail according to the Fried Frailty Tool
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
Explain the hypothesized model of frailty
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
List down the components of the FRAIL scale to identify frailty and its criteria for pre-fail and frail
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
Under the clinical frailty scale (CFS), explain what does CFS 4 denotes
Pre-fail (mild frailty), functionally independent (can do iADLs), but symptoms of chronic illnesses are affecting activity tolerance
Under the clinical frailty scale (CFS), explain what does CFS 5 denotes
Need assistance for all or some of the iADLs
Under the clinical frailty scale (CFS), explain what does CFS 6 denotes
Need assistance for all outside activities and some of the basic ADLs (e.g. dressing, bathing)
Under the clinical frailty scale (CFS), explain what does CFS 7 denotes
Clinically stable but FULLY dependent for personal care
Under the clinical frailty scale (CFS), explain what does CFS 8 denotes
Nearing end of life and FULLY dependent for personal care
Under the clinical frailty scale (CFS), explain what does CFS 9 denotes
Terminally ill (<6 months) but not severely frail
List 3 main interventions for frailty
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
List 3 main questions to consider to assess fall risk
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
List the mechanisms of harms for Fall Risk Increasing Drugs (FRIDs)
1) Sedation
2) Orthostatic hypotension
3) Anticholinergics
4) Hypoglycemia
What is the explicit criteria for FRIDs?
STOPPFall
Under STOPPFall, list 4 examples of classes of medications that can induce orthostatic hypotension
1) Alpha-blockers
2) Central antihypertensives
3) Vasodilators
4) Diuretics
Under the explicit criteria for FRIDs, list 7 common classes of medications
1) Opioids
2) Antipsychotics
3) Antidepressants
4) Benzodiazepines/ Z-drugs
5) Anticonvulsants
6) First gen antihistamines (anticholinergic)
7) Muscle relaxants (anticholinergic)
List the 4 types of dizziness
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)
Explain the TiTraTE approach to evaluating dizziness
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
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?
Assessment: Dix-Hallpike maneuver
Positive results: benign paroxysmal positional vertigo
Negative results: orthostatic hypotension
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?
Assessment: further history taking
- Unilateral hearing loss/ sensation of ear fullness: Meniere’s disease
- Migraine headache: vestibular migraine
- Psychiatric symptoms: panic attack etc.
Under targeted examination of TiTraTE to evaluate dizziness, what is a common cause of continuous vestibular dizziness?
Trauma/ toxin (drugs) e.g. dizziness intensity is assoc/w peak of drug
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?
HINTs exam (Head impulse/ Nystagmus/ Test of Skew)
- Central: Stroke/TIA
- Peripheral: vestibular neuronitis e.g. caused by viral infection
Discuss if vestibular suppressants should be used for symptomatic relief of all dizziness
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
List 7 classes of vestibular suppressants and give examples for each class
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
Which geriatric syndrome is also a geriatric medical emergency?
Delirium
What are the subtypes of delirium?
1) Hyperactive delirium
- agitation
- inattentiveness
- psychosis (delusions/ hallucinations)
2) Hypoactive delirium
- slow response
- increased sedation
What are the risk factors for delirium? (4)
1) Age 65 years or older
2) Cognitive impairment (past/present) and/or dementia
3) Current hip fracture
4) Severe illness
List down the components of 4AT for detection of delirium (4)
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
List down the common etiologies of delirium (IWATCHDEATH)
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)
List 5 classes of drugs known to increase risk of delirium, and remark on its use
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)
What is the first line approach to managing delirium? List 5 examples
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
Comment on the use of pharmacotherapy for agitation in delirium and hypoactive delirium
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
List 3 types of antipsychotics that is used for treatment of agitation in delirium, state its dose and maximum dose
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)
Comment on the use of benzodiazepine for agitation in delirium, give 1 example with dose
- 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
What are the prerequisites for urinary continence? (2)
1) Normally functioning lower urinary tracts
2) adequate physical and cognitive functions to use toilets
Explain what happens during the bladder filling phase in those with normal lower urinary tract (3)
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
Explain what happens during the bladder voiding phase in those with normal lower urinary tract (2)
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)
List the 4 types of Urinary incontinence and define it respectively
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
List the common causes of stress urinary incontinence (3)
1) weak pelvic floor muscles (childbirth, pregnancy, menopause)
2) bladder outlet or urethral sphincter weakness
3) post-urologic surgery
List the common causes of urge urinary incontinence (3)
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)
List common causes of overflow urinary incontinence (4)
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
List common causes of functional urinary incontinence (2)
1) Severe dementia or other neurologic disorder
2) psychological factors e.g. depression and hostility
List the differential diagnosis of transient causes of urinary incontinence (DIAPPERS)
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
List 2 classes of allergy medications that could contribute to urinary incontinence and its respective effect on bladder function
1) Antihistamine: decreased contractility via anticholinergic effect
2) Decongestants (e.g. pseudoephedrine): increased urethral sphincter tone
List 2 classes of analgesic and sedatives that could contribute to urinary incontinence and its respective effect on bladder function
1) Benzodiazepines: impaired micturition via muscle relaxant effect
2) Opioids: decreased sensation of fullness and increased urethral sphincter tone
List 3 classes of anticholinergic medications that could contribute to urinary incontinence and its respective effect on bladder function
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
List 5 classes of cardiology medications that could contribute to urinary incontinence and its respective effect on bladder function
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
List 2 classes of antidepressants that could contribute to urinary incontinence and its respective effect on bladder function
1) SNRIs (e.g. duloxetine): increased urethral sphincter tone; used for stress incontinence
2) TCAs (e.g. amitriptyline, clomipramine): decreased contractility via anticholinergic effect
List 2 class of antipsychotics that could contribute to urinary incontinence and its respective effect on bladder function
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
List 3 class of other medications that could contribute to urinary incontinence and its respective effect on bladder function
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
List 2 types of food that could contribute to urinary incontinence and its respective effect on bladder function
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
List the management strategies for stress urinary incontinence (4)
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)
List the management strategies for urge urinary incontinence (7)
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.
List the management strategies for overflow urinary incontinence
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
List the different types of elder abuse (5)
1) Physical e.g. chemical/ physical restraint
2) Sexual
3) Psychological
4) Neglect
5) Financial
What are some risk factors from patient’s perspective that puts them at risk of abuse? (3)
1) Dementia, esp. BPSD (caregiver stress)
2) Physical disability
3) Poor relationship with caregiver pre-morbidly
What are some risk factors from caregiver’s perspective that puts them at risk of elder abuse? (4)
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
