Geriatrics Flashcards
Define: Potentially Inappropiate Medications (PIMs)
risks associated with use of the medication outweighs the benefit
What is the purpose of the Beers Criteria?
identify potentially inappropiate medications that should be avoided in many older adults
What are the med classes that should raise alarm when used in the older patient population?
- anticholinergics
- antipsychotics
- sulfonylurea
- PPIs
- benzodiazepines
- NSAIDs
- opioids
- orthostatic agents
AND MORE
Why should first generation antihistamines be generally avoided in the elderly?
cognitive impairment, risk of confusion, dry mouth, constipation
What is the recommendation of antihistamines use in the elderly?
avoid use of first generation
What may be used in place of antihistamines in the elderly?
- nasal steroids, second generation antihistamines, or saline nasal spray for allergies
- sleep hygiene (non-pharmacologic) for insomnia use
Why should TCAs and paroxetine be avoided in the elderly?
sedation, orthostatic hypotension and anticholinergic side effects
What is the recommendation of antidepressants in elderly?
avoid use of TCAs and paroxetine
What is the alternative therapy in elderly for antidepressants?
- depression: SSRIs (sertraline or escitalopram), bupropion
- Neuropathic pain: gabapentin, pregabalin, or topical agents
When may benzodiazepines be used in the elderly?
- seizures
- withdrawal (EtOH and BZD)
- severe/refractory anxiety
Why should benzodiazapines be generally avoided in the elderly?
risk of cognitive impairment, falls, delirium, fractures and motor vehicle crashes
sedative hypnotics should also be avoided for same reason
Why should PPIs be avoided in the elderly?
risk of C. diff infections and fractures
What is the recommendation for digoxin use the elderly?
- avoid first line use in HF (use agents that decrease morbidity and mortality) and A Fib (ate control with BB or CCB)
- avoid doses > 0.125mg/day
Why should alpha blockers (non-selective) be avoided as hypertensives in the elderly?
risk of orthostatic hypotension
Why should central alpha agonists (clonidine) be avoided in the elderly?
CNS effects, bradycardia, and orthostatic hypotension
What glucose lowering medication should be avoided in the elderly?
- glyburide, glimepride, and short-acting sulfonylureas (glipizide)
- sliding scale insulin
What is the recommendation of SGLT2 use in the elderly?
use with caution due to increased risk of urogenital infections
What is the recommendation of NSAID use in elderly?
avoid chronic use unless patient has failed safer therapy and is on PPI due to increased risk of bleeding or peptic ulcer disease in high risk patients (>75 yo, corticosteroid use, anticoagulant use, antiplatelet use)
Urinary Incontinence
What are the types of urinary incontinence?
- overactive bladder (OAB) or urge (UUI)= bladder overactivity; urgency, frequency, large amount of urinary leakage, may be unable to reach toilet, frequent nocturia, nocturnal incontinence; micturition occurs > 8 times a day
- stress (SUI)= urethral underactivity; leaking during physical activity, typically a small amount of leakage; risk factors: pregnancy, childbirth, menopause, cognitive impairment, obesity, aging
- overflow= urethral underactivity and/or bladder underactivity; bladder leakage due to disease or medication, increased post void residual urine volume, straining to void, interrupted stream; associated with BPH
- functional= difficult reaching toilet in time due to physical limitations
- mixed= often stress and urge, but can be a combination of any
Urinary Incontinence
What are the common causes of urinary incontinence?
DRIP-DRIP
- Drugs
- Retention
- Impaction
- Polyuria
- Delirium
- Restricted mobility
- Infection
- Prostatits
Urinary Incontinence
What tools may be used to diagnose Urinary Incontinence?
international consultation on incontinence modular questionnaire- urinary incontinence or voiding diary to identify triggers and potential causes
Urinary Incontinence
What is the first line treatment for overactive bladder (OAB)?
non-pharmacological therapy (for 4-6 weeks), such as: voiding diary, bladder control exercises, kegel exercises, avoiding diet triggers- according to guidelines. other measures, such as: lifestyle modifications (weight reduction, fluid modification), scheduling regimens, pelvic floor rehabilitation, incontinence devices, supportive interventions
Urinary Incontinence
What is the first line pharmacological treatment for overactive bladder (OAB)?
- beta3 adrenergic receptor agonists
2. antimuscarinic agents
Urinary Incontinence
What is the pathophysiology of overactive bladder (OAB)?
involuntary contractions of the detrusor muscle
Urinary Incontinence
What are the 2 receptors found on the detrusor muscle that are targeted in overactive bladder (OAB)?
- beta adrenergic receptors
- muscarinic receptors (M2 and M3)
Urinary Incontinence
What is the mechanism of action of antimuscarinics?
supressed the involuntary bladder contractions by blocking muscarinic receptors in the bladder
Urinary Incontinence
What drugs are antimuscarinics?
- oxybutynin
- tolterodine
- fesoterodine
- trospium
- darifenacin (selective M3)
- solifenacin (selective M3)
Urinary Incontinence
What dosage form of oxybutynin may be preferred?
transdermal patch
due to less SE than IR tablet, but similar efficacy
Urinary Incontinence
What are the patient counseling points for oxybutynin patch?
rotate sites and avoid same site within 7 days, avoid sunlight on patch
Urinary Incontinence
What drugs for overactive bladder (OAB) require renal adjustments?
- tolterodine
- fesoterodine
- trospium
Urinary Incontinence
What drugs for overactive bladder (OAB) require hepatic adjustments?
- tolterodine
- darifenacin
Urinary Incontinence
What medication used for overactive bladder (OAB) may cause QT prolongation?
tolterodine
Urinary Incontinence
What is the important patient counseling point for trospium?
take on empty stomach
Urinary Incontinence
What CYP isoenzyme is used by antimuscarinics?
CYP3A4 and 2D6
except trospium
Urinary Incontinence
What are the contraindications to antimuscarinic agents?
- narrow angle glaucoma
- urinary retention
- severely decrease GI motility
Urinary Incontinence
What drugs are beta3 adrenergic receptor agonists?
- mirabegron
- vibegron
Urinary Incontinence
What are the adverse effects of beta3 agonists?
- headache
- nasal congestion
- mirabegron= cardiovascular effects (hypertension, tachycardia, palpitations)
Urinary Incontinence
What are the contraindications of mirabegron?
pregnancy or breastfeeding
Urinary Incontinence
What are the drug interactions of mirabegron?
CYP2D6 inhibitor
BPH
What are the risk factors of BPH?
- advancing age
- levels of endogenous testosterone and dihydrotestosterone levels
- black race
- obesity
- diabetes
- high levels of EtOH consuption
- physical inactivity
- medication
BPH
How is BPH diagnosed?
- digital rectal exam
- prostate specific antigen (PSA)
- international prostate symptom score (I-PSS)
BPH
When should pharmacologic treatment be initiated in BPH?
I-PSS score 8+ or bothersome symptoms
BPH
What are the pharmacologic treatment options for BPH?
- alpha adrenergic receptor antagonists
- 5alpha reductase inhibitors
- phosphodiesterase type 5 (PDE5) inhibitors
BPH
What drugs are alpha adrenergic receptor antagonists?
- doxazosin
- terazosin
- alfuzosin, tamsulosin, silodosin (alpha 1 selective, uroselective)
BPH
What alpha adrenergic antagonists requires renal adjustment?
silodosin
BPH
What alpha adrenergic antagonists require titrations?
non-selective agents (doxazosin, terazosin)
BPH
What are the adverse effects of alpha adrenergic agents?
- dizziness, syncope
- hypotension
- floppy iris
- headache
- 1A, uroselective agents= erectile dysfunction, anejaculation, nasal congestion, flu-like symptoms
BPH
T/F: Alpha adrenergic antagonists decrease the size of the prostate.
false, size of prostate is not affected, but I-PSS scores can be decreased 4-7 points= effective agents
BPH
When should patients expect to notice improvement while on alpha adrenergic agents for BPH?
within 1 week, if no effects seen after max dose switching agents within class is not recommended
may switch between nonselective and uroselective if benefits seen
BPH
What drug used to treat BPH should be avoided in patients with true sulfa allergy?
tamsulosin
BPH
How is tamsulosin best taken?
30 minutes after a meal
BPH
What is the MOA of 5 alpha reductase inhibitors?
inhibits 5 alpha reductase which is respondsible for converting testosterone -> dihydrotestosterone= promotes prostate growth
BPH
When would 5 alpha reductase inhibitors be used?
prostate > 30 g or PSA 1.5ng/mL+ or palpable prostate enlargement of DRE
BPH
What drugs are 5 alpha reductase inhibitors?
- finasteride
- dutasteride
BPH
What are the adverse effects of 5 alpha reductase inhibitors?
- decrease libido
- erectile dysfunction (worst in the first 6 months)
- ejeculation disorders
- gynecomastia
BPH
What is the FDA Warning associated with 5 alpha reductase inhibitors?
increased risk of prostate cancer
BPH
T/F: 5 alpha reductase inhibitors decrease the size of the prostate?
true, 50% decrease in PSA levels within 6-12 months
BPH
What are the precautions associated with 5 alpha reductase inhibitors?
pregnant women should not handle broken or crushed tablets and male partners can transmit drug through sperm
BPH
What phosphodiesterase type 5 (PDE5) inhibitor may be used to treat BPH?
tadalafil (Cialis)
BPH
What is the recommended dosing of tadalfil for BPH?
5mg PO daily
renal adjustments need
BPH
What is phosphodiesterase type 5 (PDE5) inhibitors place in therapy?
patients with ED or SE concerns with other agents
not as effective as other agents
BPH
What may be used to treat patients with BPH and concomitant OAB?
alpha adrenergic antagonist + antimuscarinic OR beta3 agonist
