Geriatrics Flashcards
Aging effects on GI system & effect on pharmacokinetics
Increased or no change to stomach pH (less acid)
Decrease GI blood flow
Slowed gastric emptying
Slowed GI transit
-Decreases absorption of drugs/nutrients that need acidic environment
-Prolonged absorption rate
Aging effects on skin & effect on pharmacokinetics
Thinning of dermis
Loss of SC fat
Decrease or no change to drug reservoir formation with patches
Aging effects on body composition & effect on PK
Decrease total body water, lean body mass, and serum albumin
Increase body fat and alpha1-acid glycoprotein
-Increased Vd of lipid soluble
-Decreased Vd of water soluble
-Increased free fraction of highly protein bound drugs
Aging effects on liver & effect on PK
Decreased liver mass, blood flow to liver, and CYP enzyme activity
Decreased first pass extraction & metabolism
Increased half-life (depending on Vd)
Decreased clearance of drug with high first pass metabolism
Decreased phase I (oxidative) metabolism
No change in phase II metabolism
Aging effects on kidney & effect on PK
Decreased GFR, renal blood flow, tubular secretion, and renal mass
Decreased renal elimination
Increased half life of renally eliminated drugs, metabolites
Absorption key points for geriatrics
-Hypochlohydria/achlohydria: decrease absorption of iron, b12, antifungals, calcium
-Slowed gastric emptying: increase risk of ulcer from NSAIDs, bisphosphonates, potassium
P-glycoprotein effect on distribution in geriatrics
P-gp is an efflux transporter present on many organs
Decreases activity with aging
This leads to higher drug concentrations in affected areas, like opioids in the brain
Benzos less affected by age-related metabolism changes
Lorazepam
Oxazepam
Temazepam
Why? Solely depend on phase II metabolism, which is unaffected in aging.
Drugs requiring actual body weight for CrCl
Dabigatran
Dofetilide
Rivaroxaban
Otherwise, use IBW
Pharmacodynamic effects on CNS with aging
Effects from anticholinergic, BZD/opioid, antipsychotics, TCA/alpha
Increased permeability of BBB
Anticholinergics: confusion, agitation, hallucination
BZD & opioid: somnolence, confusion, agitation
Antipsychotics & metoclopramide: EPS, TD
TCA, alpha-blocker, alpha-agonist: orthostatic hypotension, drowsiness, confusion
Pharmacodynamic effects on cardiovasculature
Increased catecholamine concentration = down-regulation of B1 receptors
= blunted effect of BB
= Increased sensitivity to QT prolongers (antipsychotics, FQs, azithromycin)
Meds that may cause withdrawal/rebound in geriatrics
Antihypertensives
Antidepressants
Anxiolytics
Pain meds
BEERS criteria
Explicit tool for inappropriate med use. Does not require clinical judgment for interpretation
Evidence-based list of drugs to avoid, drugs to avoid in certain diseases or conditions, and drugs to use with caution
Ex: anticholinergics, BZDs, sedative-hypnotics, select opioids, hypoglycemics, NSAIDs, PPIs, select anticoagulants, aspirin (primary prevention)
STOPP/START
Explicit tool for inappropriate med use. Does not require clinical judgment for interpretation
Screening tool to look at older person’s prescriptions
Medication Appropriateness Index
Implicit tool for inappropriate med use. Patient centered, requires clinical judgment
10 questions to ask about each med, with indication, effectiveness, and correct dosage being most important
Choosing Wisely criteria
10 things to question in older adults. These are the 7 that are drug related
- Antipsychotics in pts w/ dementia should be avoided
- Target A1c is >=7.5%
- Avoid BZDs or sedative-hyponotics
- Do not initiate antimicrobials for asymptomatic bacteriuria
- Assess benefit-risk of cholinesterase inhibitors
- Appetite stimulants are not helpful for anorexia or cachexia
- DUR is necessary for every new prescription
Fall etiologies and risk factors
Etiologies
-psychoactive meds
-polypharmacy
-orthostatic hypotension
-hypoglycemia
-hyponatremia
-MI
-UTI
Risk factors
-Vit D deficiency
-poor balance
-muscle weakness
-poor vision
-environment
Delirium etiologies and risk factors
Etiologies:
-psychoactive meds
-polypharmacy
-hypoglycemia
-hyponatremia
-MI
-infection
Risk factors
-dementia
-stroke
-B12 deficiency
-poor hearing
-lack of sleep
-constipation
-pain
-thyroid disorder
Hospitalization hazards for geriatrics
Immobilization = increased falls, fractures
Sensory deprivation (isolation, unable to wear glasses, hearing aids) = delirium
NPO or prescribed diets = dehydration, decreased plasma volume, malnutrition, aspiration pna
Dementia types that do not respond to CI
Vascular dementia (also does not respond to memantine)
Frontotemporal dementia
Avoid typical antipsychotics in these dementia types
Lewy body dementia
Dementia of advanced parkinsons disease
Reversible causes of memory impairment
Vitamin B12 deficiency (<300)
Hypothyroid
Depression
Normal pressure hydrocephalus (need surgical placement of shunt)
Meds (own card)
Meds that may cause memory impairment
Anticholinergics
Antiseizure
BZDs
Muscle relaxants
Opioids
TCAs
Dementia assessment tools
Cognitive:
Mini-Mental State Exam
SLUMS
Montreal Cognitive Assessment
Mini-Cog
Functional:
Reisberg Functional Assessment Staging
Mild-Moderate AD treatment
CI (donepezil, rivastigmine, galantamine)
No agent preferred
Moderate-Severe AD treatment
NMDA receptor antagonist (memantine)
CI (donepezil, rivastigmine, galantamine)
Combination or monotherapy
cholinesterase inhibitor side effects
GI: N/V, diarrhea (**highest w/ rivastigmine)
CNS: HA, insomnia, dizziness
Cardiac: bradycardia, orthostatic hypotension ,syncope (BEERS for pts w/ syncope)
Long-term risks: falls, hip fracture ,pacemaker
Renal dosing required for galantamine
Cholinesterase inhibitor approved for dementia with parkinsons disease
rivastigmine
Memantine ADR
CNS: headache, dizziness, confusion, agitation, hallucinations
GI: diarrhea, vomiting
Usually well tolerated
Aducanumab
Disease modifying immunotherapy.
Anti-amyloid MAB
1mg/kg q4 week then 10mg/kg q4 week. Use ABW.
Serious ADR: ARIA-H (micro-hemorrhage), ARIA-E (brain edema, HA), seizure
Have MRI within 1 year of initiation and repeat with signs/symptoms of ARIA
ARIA = Amyloid-Related Imaging Abnormalities
Lecanemab
Disease-modifying immunotherapy. Anti-amyloid MAB
10mg/kg q2w using ABW
MRI before initiation and 5th, 7th, 14th infusion. Additional if experience s/s of ARIA
Serious ADR: ARIA-H, ARIA-E, anaphylaxis, decreased lymphocytes
MMSE 20-24
Mild dementia
Cognitive loss: short-term memory loss, word-finding problems
Functional loss: loss of IADLs, gets lost easy
MMSE 10-19
Moderate dementia
Cognitive loss: disorientation to time/place, inability to engage in activities & conversation
Functional loss: Assistance with ADLs (bathing, toileting, dressing)
MMSE <10
Severe dementia
Cognitive loss: loss of speech, ambulation, control of bladder & bowel
Functional loss: Around the clock care
PRNs vs Scheduled meds in dementia
Scheduled preferred because they may not be able to communicate issues (pain, constipation, sleep)
FDA approved treatment for agitation caused by dementia (of AD)
Brexpiprazole
Still has BBW of increased risk of death
First line treatment for behavioral/psychological symptoms of dementia
Nonpharmacologic
Figure out what need is unmet
Preferred agent for paranoia w/ parkinsonian symptoms
Quetiapine (less dopaminergic)
Pimavanserin
DRIP
Causes of transient incontinence
D= drugs, delirium
R= retention, restricted mobility
I= impactation, infection, inflammation
P= polyuria, prostatitis
Aging effects on bladder
Decreased bladder elasticity & capacity
More frequent voiding
Decline in bladder outlet & urethral resistance (women)
Decrease in flow rate with enlarged prostate (men)
Urge incontinence
Loss of moderate amount of urine
Increased need to void
Common w/ AD, PD, MS, stroke
Induced by cholinergic agents (bethanechol, cholinesterase inhibitors)
(acetylcholine mediates bladder contractions)
Stress incontinence
Loss of small amount of urine with increased abdominal pressure (sneezing, coughing)
More common in postmenopausal women
Induced by alpha-blockers (prazosin) due to decreased urethral sphincter tone
(alpha stimulation tightens the sphincter)
Overflow incontinence
Loss of urine b/c of excessive bladder volume caused by obstruction
Likely incomplete emptying
Induced by anticholinergics, CCBs, opioids. Decrease detrusor muscle contractions
(acetylcholine mediates bladder contraction, if blocked won’t be able to contract = incomplete emptying)
Functional incontinence
Inability to reach toilet due to mobility constraints
Induced by sedating drugs (cause confusion) or diuretics (increased need to void)
Antimuscarinic agents
Oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, darifenacin
Use for urge incontinence
BEERS
Prefer LA
B3 agonist
MIrabegron, vibegron
For urge incontinence
Less anticholinergic effects than antimuscarinics, but can be used in combo wth antimuscarinics
Avoid in HTN
Botox A for incontinence
inject into Intradetrusor
Use for urge incontinence
Prevents simulation of detrusor muscle. Stimulation relaxes the detrusor muscle
Have to self-cath
Stress incontinence pharm treatments
Alpha agonists (pseudoephedrine, phenylephrine) (efficacy limited)
Topical estrogen
Duloxetine (not FDA labeled for stress incontinence)
Overflow incontinence pharm treatments
Alpha blockers (afluzosin, tamsulosin, silodosin preferred)
5alpha reductased inhibitors (finasteride, dutasteride)
-Slows progression and reduces size of prostate
Bethanecol
Tadalafil 5mg daily
Meds that can exacerbate BPH
Alpha agonists
Anticholinergics
Diuretics
Testosterone (mild prostate growth)
BPH candidates for treatment based on AUASI
score 8-19 (moderate disease)
Alpha blockers for BPH
Terazosin
Doxazosin
Alfuzosin
Tamsulosin
Silodosin
Tera/doxa (nonspecific alpha blockers) lower BP more than the others
Lower AUASI score by 4-6 points
CYP3A4 metabolism
If planned cataract surgery, start after
Take at bedtime
Combination therapy for BPH
May be used if larger prostate size, LUTS, elevated PSA, or erectile dysfunction
Finasteride + doxazosin
Dutasteride + tamsulosin (FDA approved)
5 alpha reductase inhibitors for BPH
Finasteride
Dutasteride
Prevent conversion of testosterone to dihydrotestosterone = actually shrink prostate
At least 6 months of therapy needed for benefit
Need baseline PSA concentration
Lower PSA, but long-term therapy puts at risk of high-grade tumors in prostate
Avoid if pregnant
Tadalafil for BPH
only FDA approved pde5 inhibitor
Avoid with alpha blockers due to decreased BP risks
Osteoarthritis first line
NSAIDS - prefer topical
If chronic, change to COX2 inhibitor
or Add PPI
Preferred with cardiac disease = naproxen
*if on aspirin for cardiac disease, take aspirin 30 min before any NSAID
Topical agents for OA
Diclofenac gel
Capsaicin
Other agents for OA
Methylprednisolone or triamcinolone IA inj
APAP (if NSAID contraindicated)
Duloxetine
Glucosamine
Tramadol
Osteoarthritis vs Rheumatoid arthritis
OA affects larger joints like hip, knee
RA affects smaller joints of hands, wrists, feet
First line therapy for RA with high disease activity
Nonbiologic DMARDs
DOC: methotrexate (weekly)
Alterative DOC: leflunomide (daily)
Second line: hydroxychloroquine (BID) or sulfasalazine (BID)
First line therapy for RA with low disease activity
Nonbiologic DMARDs
DOC: Hydroxychloroquine (low adverse effect profile)
Alt: Sulfasalazine > methotrexate or leflunomide
Pregnancy DOC = sulfasalazine
Nonbiologic DMARD side effects
MTX, leflunomide: myelosuppression, liver dysfunction, pulmonary fibrosis, teratogenic
Hydroxychloroquine: Ocular toxicity
Sulfasalazine: GI adverse effects limit use
When to start a nonbiologic DMARD
within 3 months of diagnosis of RA
Biologic DMARDs
Use for severe RA in combination with methotrexate
TNF blockers, non-TNF blockers, biologic kinase inhibitors
Most common: etanercept, infliximab, abatacept, rituximab
TNF blockers for RA
Etanercept (SC weekly)
Infliximab (IV @ 0, 2, 6 wk then q8w)
Adalimumab (SC q2w)
Certolizumab (SC every other week)
Golimumab (SC monthly)
Monitor infection
Check baseline PPD (purified protein derivative)
Avoid in heart failure
non-TNF biologics
Abatacept (monthly)
Anakinra (SC daily)
Rituximab (IV given 2 weeks apart)
Sarilumab (SC every other week)
Tocilizumab (q4w IV)
Monitor infection
Janus Kinase inhibitors
Baricitinib (PO daily)
Tofacitinib (PO BID)
Upadacitinib (PO daily)
Class BBW: increased risk of serious cardiac-related events (MI, stroke, cancer, blood clot, death)
Avoid in those who smoke or have smoked, with CV risk factors, and known malignancy
Glucocorticoids in RA
No longer recommended
If have to use, short term (<3 months) preferred
NSAIDs in RA
Does not inhibit disease progression
Immunosuppression with RA treatment
Prior to therapy:
-Screen for tuberculosis and viral hepatitis
-Give all immunizations, especially live. Wait 2 weeks before starting therapy
During therapy:
-avoid live vaccines
If hx of hep B or C and treated, consider as pt has never had hepatitis
If untreated hep B or C, prefer DMARD to TNF blocker
Diagnosis of gout
Ideal = aspiration of joint to visualize birefringement of urate crystals
Unlikely to occur, so use clinical judgment
Get serum uric acid level 2 weeks after flare, if >6.8 then gout likely (uric acid low during flare)
Meds that can predispose gout
Thiazide and loops
Niacin
Calcineurin inhibitors (cyclosporine, tacrolimus)
low dose aspirin
Xanthine oxidase inhibitors (during induction)
Colchicine
Start within 36 hours of gouty attack
1.2mg x1 ,then 0.6mg 1 hour later; then 0.6mg BID until flare resolves
Use with Pgp inhibitors or strong CYP3A4 inhibitors is CONTRAINDICATED in RENAL or HEPATIC impairment! Fatal toxicity has occurred*
Reduce dose if normal renal/hepatic function but strong 3A4, Pgp inhibitors
No dose adjustments necessary until on dialysis (0.6mg x1)
NSAIDs FDA approved for gout
Naproxen 750mg then 250mg q8h
Indomethacin 50mg TID
Sulindac 200mg BID
If NSAIDs contraindicated or not tolerated, can consider celecoxib (day 1: 800mg, then 400mg, day 2 on: 400mg BID)
Glucocorticoids for gout
Prednisone 0.5mg/kg/day x5-10 days (taper option available)
Medrol dose pack
Intra-articular injection if two large joints
Can use PO steroids, NSAIDs, or colchicine in combination with intra-articular injection
Xanthine oxidase inhibitors
First line for urate-lowering therapy, even if CKD stage 3 or higher
Allopurinol
Initial dose: 100mg/day
Initial dose if CKD4: 50mg/day
Titrate to target serum uric acid level (<6)
*Max doses can be as high as 800mg (normal renal fxn) or >300mg (even in CKD)
If unable to tolerate or refractory, change to febuxostat 40mg daily
*Febuxostat has BBW for increased risk of CV deathu
ALWAYS INITIATE CONCOMITANT PROPHYLACTIC THERAPY
Allopurinol hypersensitivity syndrome
SJS, TEN
Eosinophilia, rash, vasculitis, major end-organ disease
Highest risk during first few months
Risk factors: thiazide diuretics or renal impairment
HLA-B*5801 testing recommended for African Americans or Southeast Asian populations
Alternative ULT for gout
Probenecid 500mg 1-2x daily with dose titration
Pegloticase (NOT first line in any case. D/C other agents and start if SU not reached and continual gout flares)
Why anti-inflammatory ppx when starting ULT?
Increased risk of gout attacks during ULT initiation
-Rapid decrease in urate concentration = remodeling of articular urate crystal deposits
Add on colchicine, NSAIDs, or prednisone and continue as prophylaxis for 3-6 months, continuing beyond if evidence of gout disease activity (tophi, flare, chronic gouty arthritis)
Colchicine: 0.6mg 1-2x daily
Naproxen: 250mg BID
Indomethacin: 25mg BID
Prednisone: <10mg/day
