Geriatrics Flashcards
Where pharmacists interact with older adults
Inpatient units (wards)
Retail setting
Ambulatory care setting
Long term care (LTC)
Goals of pharmacy in LTC
Identify unnecessary medications
Identify adverse rxns
Ensure appropriate monitoring of tx
Dose reduction of psychiatric medications
Common geriatric “syndromes”
Sensory impairment
Constipation
Depressing / insomnia
Falls –> immobility
Dementia
Goals of tx for older adults (4M framework)
Maintain independence
Address “what matters most”
Optimize risk/benefits of medications
Preserve cognition
Maintain functional mobility
ADLs
Dressing
Bathing
Feeding
Toileting
IADLs
Managing finances
Shopping for groceries
Using telephone
Housekeeping / laundry
Medications and risk of falls
Sedatives
Antipsychotics
Antidepressants
Opioids (esp long term)
Loop diuretics
Alpha-blockers
Medication problems in older adults
Polypharmacy
Non-adherence
Altered pharmacokinetics
Physiological changes with aging
Decr TBW
Decr lean body mass –> Incr body fat
Decr baroreceptor response/activity
Reduced HR variability
Decr hepatic and renal blood flow
Decr neurotransmitter volume
Pharmacokinetic changes with aging
Decr Vd and incr conc of water-soluble drugs
Incr Vd and incr half-life of lipid-soluble drugs
Decr clearance and incr half-life of hepatically and renally cleared drugs
Beers criteria
Criteria for potentially inappropriate medication use in older adults
How are recommendation about Beers criteria decided?
Based on how medications impact the safety of older adults
Who is involved in the decision-making process of Beers criteria?
American Geriatrics Society
What types of evidence is evaluated for Beers criteria?
Clinical trials and research studies published since the last revision
How does the committee describe quality of evidence and strength of recommendation of Beers criteria?
- Potentially inappropriate medications
- Potentially inappropriate medications if certain conditions
- Use with caution
- Potentially inappropriate drug-drug interactions
- Doses should be adjusted by renal function
Considerations in choosing medications
Life expectancy
Goals of care
Treatment targets
Time required to benefit
Palliative care
Disease is not responsive to curative treatment or treatment doesn’t exist
Hospice care
Life expectancy ≤ 6 months
Provided at home, in LTC, or independent facility
Role of pharmacists in end of life care
Align medications with goals
Control bothersome symptoms
Educate family and providers
Adjust doses as needed
Support financial concerns
Advanced care directives (ACD)
Instructions about future medical care
Health care representative
Someone who makes decisions if you’re unable
Psychiatric advance directive
Treatment preferences if in an unstable state
Power of attorney
Financial or health care grants power to others you choose
Physician orders for scope of treatment (POST)
Agreement between patient and physician
Must be signed and dated to be valid (but can be updated at any time)
Urinary incontinence
Involuntary leakage
Ex. OAB, stress, overflow
Goal of UI treatmen
Improve QOL
Regain sense of independence
Improve self-esteem
Bladder function pathway
Stretch receptors notify brain bladder is full
B3 receptors support detrusor relax/fill
Neurologic stimulation initiates contraction
Ach receptors in dome
Alpha-adrenergic receptors in base and proximal urethra
Sphincter relaxes
Urine released
OAB
Urgency: uncontrollability
Frequency: excessive feeling of urination
Can be caused by medications
Stress urinary incontinence
Outlet incompetence with abdominal pressure
Risk factors: multiple child births, estrogen deficiency
Overflow incontinence
Outlet obstruction or altered detrusor constriction
Commonly from BPH or prostatic blockage of urethra
Neurogenic (atonic) bladder
Disruption in innervation of the bladder
Increases risk of UTI and kidney stones
Non pcol UI treatment
Scheduled voiding
Pelvic floor muscle strengthening daily
Avoiding irritants (coffee, alc, caffeine)
Avoid water before bed
Absorbent products
Catheters
UI management: urge
Anticholinergics:
Oxybutynin, tolterodine, solifenacin, darifenacin, trospium, fesoterodine
AE: dry mouth, constipation
B3 agonists:
Mirabegron, vibegron
AE: UTI, incr BP
UI management: stress
Non-pcol: Kegel
Pcol:
Duloxetine
Topical estrogen
Alpha agonists (pseudoephedrine) –> rare
UI management: overflow
Non-pcol: Address obstruction, catheter
Pcol:
Alpha adrenergic blockers (if BPH)
Doxazosin, Tamsulosin
UI management: neurogenic
Pcol management not routinely effective
Non-pcol:
Scheduled voiding
Catheter
Botox
Augmentation cystoplasty
Catheters
Intermittent straight
Indwelling (foley) –> chronic
Condom
Suprapubic
