geriatrics Flashcards
medication problems in the elderly populaiton
Polypharmacy
Nonadherance
Altered clearance
60% of elderly understand their meds well - focus on the 40% who do not
common geriatric problems
Impaired vision and hearing Incontinence Constipation Poor nutrition Falls – impact on independence Delirium, dementia Immobility Depression Insomnia Weakness / fatigue Iatrogenesis (especially due to poly-pharmacy) Poverty
medications and risk of falls
Sedative / hypnotics Neuroleptics / antipsychotics Antidepressants Benzodiazepines Opioids (esp. long-acting) Loop diuretics Alpha-blockers
goal of care for older adults
Maintain independence
Avoid need for institutionalization
Maintain QOL
ADLs
Dressing Bathing Transferring Feeding Toileting Walking
What are the common physiologic* changes associated with aging?
Decreased total body water Decreased lean body mass Increased body fat Decreased baroreceptor activity Decreased hepatic blood flow Decreased renal blood flow Decreased brain size -Increased sensitivity to CNS effects of meds
What changes occur to drug pharmacokinetics* as one ages?
No change in bioavailability of most drugs
Decreased Vd and increased concentration of water-soluble drugs
Increased Vd and increased t ½ of lipid-solubledrugs
Decreased clearance and increased t½ of most hepatically-extracted drugs
Decreased clearance and increased t½ of most renally-cleared drugs and metabolites
beers criteria overview
Criteria for potentially inappropriate** medication use in older adults
Results of a US Consensus Panel of Experts
-Originally published in 1991
-Several updates
-Most recently updated: J Am Geriatr Soc. 2015; 1-20
beers criteria
Examines the use of individual agents and
their risk for adverse events in the elderly.
-Agents with anti-cholinergic properties: Recent focus on impact on cognitive impairment
-Sedatives / drugs with CNS effects
-Agents associated with GI toxicity
-Recent: PPIs – risk of falls and fractures
urinary incontinence
Involuntary leakage of urine
Overactive bladder (OAB)
Affects up to 30% of community dwelling and hospitalized elderly.
Approximately 60% of LTCF patients suffer from incontinence.
$11 billion is spent annually in the US on managing incontinence.
females more than males
UI experience - decreased QOL
-loss of independence
-lack of self-esteem
-medical complications
UI - overflow
urethral blockage
bladder unable to empty properly
UI - stress
relaxed pelvic floor
increased abdominal pressure
UI - urge
bladder oversensitivity from infection
neurologic disorders
Changes to the bladder and urethra caused
by aging may also increase the incidence
rate of incontinence:
a decrease in bladder capacity/elasticity
incomplete bladder emptying
reduced sphincter compliance
decreased ability to postpone urination
increase in spontaneous detrusor contractions
Role of the pharmacists in treating patients with urinary incontinence
Helping to assure a positive outcome… -QOL -Prevent perineal skin breakdown Avoiding adverse effects from drug tx Avoiding impact of drug tx on other conditions
nonpharm treatment for UI
step 1
absorbent products
PT
catheters
scheduled or prompted voidings - especially helpful in patients with cognitive decline
Kegel exercises (30-60 X per day) - Physical therapy
Urge suppression strategies
Stable fluid intake - Timing of fluid intake
Dietary changes
-Avoid fluids that irritate the bladder: Caffeinated and carbonated beverages; citrus juices, Artificial sweetners; EtOH
-Avoid spicy foods
urge incontinence
features: overactive bladder, detrusor muscle over activity, large volume, urgency, frequency (over 8/day)
causes: Exact cause – usually unknown, Strokes, Alzheimer’s Disease - Meds (cholinesterase inhibitors) may contribute, Parkinson’s Disease, BPH with overactive bladder
urge incontinence pharm treatment
Anticholinergic / Antimuscarinic Agents
-Several weeks or months are required to observe the maximum benefit
-Some pts may respond to alternative agent or may experience fewer adverse effects.
Decrease contractions of detrusor muscle
Increases bladder capacity
stress incontinence
Features: -outlet incompetence - Proximal urethral sphincter -women -rare in men - After prostatectomy or XRT -small volume causes: -Urologic procedures -History of multiple childbirths: Neuromuscular damage -Estrogen deficiency (unlikely) -Alpha-antagonists can make this worse common sxs: Small volumes of urine loss with coughing, sneezing, running, or laughing
stress incontinence treatment
Kegel exercises Estrogen replacements ??? - topical Alpha-agonists - Pseudoephedrine Both Duloxetine ??? - 40 mg BID
overflow incontinence
common in males, outlet obstruciton
causes: BPH without overactive bladder
overflow incontinence treatment
Treat the obstruction
Alpha-adrenergic blockers (BPH)
Kegel exercises
neurogenic (atonic) bladder
Features: complete loss of bladder control
Causes: Severe diabetes, Neuropathy, Stroke, Spinal cord injury
neurogenic bladder treatment
Intermittent catheterization
“Drug therapy ineffective”
functional incontinence
Features: inability to get to the bathroom in a timely fashion
Causes: Physical impairment (mobility)m Change in mental status (Dementia), UTIs, Medications
Treatment: Eliminate causes, Scheduled voidings, No pharmacologic mgmt usually needed
muscarinic receptor antagoninsts to treat incontinence
Oxybutynin Tolterodine Trospium Solfenacin (VESIcare) Darfenisin Fesoterodine
oxybutynin
BID to QID XL - QD do not crush generic - $50/mo XL - $130/mo fewer SE with XL oxytrol patch - OTC**, apply every 3-4 days, rotate sites gelnique - 10% gel, QD, abdomen, upper arms/shoulders or thighs, $125/mo, lower rate of SE
tolterodine
1-2 mg BID LA - 2-4 mg QD more specific?? $140-160/mo generic available fewer SE?? LA
trospium
BID - 1 hour AC, food decreases absorption by 70-80%
XR - QD, do not crush, $160/mo
solifenacin
vesicare
5 mg QD
more M3 selective
$160/mo
darifenacin
7.5-15 mg QD
do not crush
$150/mo
DDIs
fesoterodine
4-8 mg QD
do not crush
$140/mo
SE are dose related
AEs from ACh agents
dry mouth mydrasis constipation delerium/confusion urinary retention tachycardia somnolence blurred vision
when to avoid ACh agent
in men with BPH who have large prostate glands (over 200 ml residual urine)
in patients w alzheimer’s disease - may increase risk of cognitive impairment by 46% over 6 years
mirabegron
myrbetriq
treats incontinence
25 mg QD - titrate to 50 mg QD at 8 weeks if necessary
do not crush
beta-adrenergic agonist
allow 4-8 weeks to evaluate efficacy
SE are dose related - hypertension, nasopharyngitis, UTI
follow up and assessment for treatment of incontinence
Review effectiveness over 1-2 months
- Maximum benefit may take several months at maximum dose to assess
Monitor for side effects
Quality of life
restless legs syndrome
Also known as Ekbom syndrome
Estimated to affected 5-15% of the general population
Typical onset is middle age adults but can also appear in childhood or in elderly
s/sxs of RLS
Paresthesias in the limbs
-Described as ‘burning’, ‘itching’, ‘bugs under the skin’
Occurs at night or prior to sleep
Urges to move the affected limbs
80-90% of RLS patients have periodic leg movements during sleep
complications of RLS
Daytime drowsiness
Difficulty concentrating
Anxiety
Insomnia
etiology of RLS
Unknown etiology
Several hypothesis have been proposed
-Dopaminergic dysfunction in the CNS - conflicting studies
Iron metabolism dysfunction – some studies have shown decreased iron in substantia nigra - Iron is a cofactor for tyrosine hydroxylase, the rate limiting step in dopamine synthesis
primary RLS
idiopathic
Genetic factor – majority have family history
secondary RLS
Chronic kidney disease Iron deficiency Pregnancy Medications -Antidepressants - TCAs and SSRIs -Antihistamines -Dopamine blockers
treatment of RLS
Grading is a subjective assessment of patient symptoms Mild - Non-pharmacologic (all patients) Moderate to severe -Dopaminergic agents -Alpha-2-delta calcium channel ligands -Opioids -Benzodiazepines/Z-hypnotics Iron deficient - FeSO4
nonpharm treatment of RLS
avoid alcohol, nicotine and caffeine
moderate exercise on a daily basis
relaxation techniques - hot baths, heating pads, massage
sleep hygiene - regular sleep schedule, quiet, dark, and uncluttered bedroom, don’t eat before bedtime
dopaminergic agents for RLS
First line therapy, especially in younger and healthier patients
Augmentation can occur with these drugs – a worsening of daytime symptoms and/or early morning rebound of symptoms
carbidopa/levodopa
Unlabeled use
Mechanism of action
-Levodopa – dopamine precursor
-Carbidopa – inhibits peripheral decarboxylation of levodopa increasing CNS concentration and decreasing side effects
Dosing – varies by patient
-IR: 25/100 0.5-1 at bedtime or upon wakening
-ER: 25/100 1 before bedtime
***Augmentation is common with long-term use
Side effects:
-Dyskinesias, nausea, vomiting, confusion, headache, hallucinations
Avoid taking with high protein meals/foods
dopamine agonists for RLS
Dopamine agonists FDA-approved for RLS Pramipexole Ropinorole Rotigotine Less likely to have augmentation than carbidopa/levodopa Side effects: Orthostatic hypotension, GI - Nausea, constipation, CNS – dyskinesia, confusion, weakness, somnolence, insomnia, hallucinations, abnormal dreams, dizziness, EPS, Skin irritation (Neupro patch) Impulsive behaviors have been observed such as pathological gambling
pramipexole for RLS
Dosing:
0.125mg daily 2-3 hours before bedtime; may be doubled every 4-7 days up to a max of 0.5mg
May require titration on discontinuation
ropinorole for RLS
Dosing -Take 1-3 hours daily before bedtime titrated based on response -Days 1-2: 0.25mg -Days 3-7: 0.5mg -Week 2: 1mg -Week 3: 1.5mg -Week 4: 2mg -Week 5: 2.5mg -Week 6: 3mg -Week 7: 4mg max 14 day titration schedule recommended with CrCL of 20-60mL/min
rotigotine for RLS
24h patches
Dosing:
1mg patch q24h; may increase by 1mg/24h weekly up to 3mg/24h max
Decrease by 1mg/24h every other day for
discontinuation
same site should not be used more than once every 14 days
alpha-2-delta calcium channel ligands for RLS
First line therapy, preferred in RLS with pain
One FDA-approved agent
-Gabapentin enacarbil (Horizant®)
Two used off-label
-Gabapentin (Neurontin®)
-Pregabalin (Lyrica®)
Mechanism of action: Structurally similar to GABA; binds to alpha-2- delta calcium channels with an unknown MOA
gabapentin for RLS
Dosing
-300mg daily 2 hours before bedtime
-May increase every 2 weeks up to a max of
1800mg - Divide doses to afternoon and 2 hours before bedtime
Renal adjustment - No guidelines in RLS
gabapentin enacarbil for RLS
Prodrug of gabapentin with greater bioavailibility Dosing -600mg daily with food at ~5PM Renal adjustment -30-59mL/min – 300mg - 600mg daily -15-29mL/min – 300mg daily -under 15mL/min – 300mg every other day -Hemodialysis – use not recommended
pregabalin for RLS
Dosing
-100mg daily in 2-3 divided doses, up to
450mg
Renal adjustment - No guidelines in RLS
alpha-2-delta calcium channel ligand side effects
Nausea
Somnolence, fatigue
Headache, dizziness
Irritability, depression
opioids for RLS
May be safest for pregnant patients Caution -Development or worsening of sleep apnea -Abuse potential Individual agents and doses vary -Dosage requirements typically don’t change over time Side effects - Nausea
benzos/z-hypnotics for RLS
Useful for insomnia, refractory RLS, or intermittent RLS
Unclear whether they actually help with symptoms or only to sleep
Clonazepam historically used but no evidence of superiority over other agents - 0.25mg qhs, max of 2mg
Side effects
-Drowsiness
-Dependence, tolerance
-Sleep behaviors – walking, driving, eating, etc.
iron supplements in RLS
Only used when patients are iron deficient
Dosing - Ferrous sulfate 325mg with vitamin C 100mg daily
Goals
-serum ferritin over 50mcg/L
-Iron saturation ver 20%
Symptom relief will take time
RLS summary
All patients should receive non-pcol therapies
**Dopaminergic agents are first line therapy in younger and healthier patients
**Alpha-2-delta calcium channel ligands are first line therapy in older patients and RLS with pain.
Opioids may be preferred in pregnant patients
Sedative-hypnotics are useful for intermittent or refractory RLS
Iron supplements are only useful in iron deficiency
addressing key geriatric issues
**Promoting successful aging
Reducing drug-related problems
Effective communications
End-of-life care
attributes associated with successful aging
Positive spirituality, absence of depression and cognitive impairment.
Absence of nutritional deficits, diabetes, arthritis, and functional disability.
A higher level of education, which is associated with higher level of functioning.
Stable housing, physical activity, preventative health measures
risk factors for functional decline
Age Immobility / Exercise tolerance Muscle strength Decreased balance Undernutrition / weight loss / decreased LBM Hospitalizations – length of stay Morbidity and disability from chronic diseases Impaired cognition Depression
Risk factors for drug-related problems in the elderly
Number of medications** Number of chronic active medical problems Types of medications -anticholinergics -opioids / NSAIDs -digoxin -CNS meds Decreased renal function Medication nonadherance Failure to receive and understand information about medication adverse effects Low body mass index
Principles of Effective Geriatric pharmacotherapy
Adequately treat both acute and chronic conditions…BUT… Do No Harm***
Promote conservative prescribing… Minimize total number of medications and non-essential medications
-Promote adherence to essential medications
-Avoid duplication
-Eliminate meds that clearly lack evidence for their usage
Minimize use of drugs that have high potential for adverse outcomes
-Avoid classes of drugs with known high risk of
ADRs in the elderly
-Avoid drug-drug, drug-disease interactions
Minimize use of drugs that have negative impact on cognitive and/or functional status
-Timed get up and go test
-Weigh benefit of individual medication against primary body functions (appetite, weight, pain,
bladder, bowel, cognition, etc.)
-Focus on functional status vs. evidence-based medicine
Optimizing dosing based on renal and hepatic function
Adjusting dosages to achieve reasonable targets for chronic diseases
Gradual dosage reduction for CNS medications
Reassess clinical, functional, and cognitive status in 1 week and prn
Know when to back off…
-Adhering to current clinical treatment guidelines in elderly with several co-morbidities may have undesirable effects.
-Functional vs. frail elderly
end of life care issues - advanced care directives (ACD)
Patient Self-Determination Act
-Educate public about laws governing refusal, withholding, and withdrawal of tx at EOL
-Encourage wider use of ACDs to prevent uncertainty among HCPs and family members that often leads to prolong tx
-Reduce costs of tx at EOL
ACD laws may differ slightly from state to state
ACDs allow patients to preserve some level of control if they develop a life-threatening injury or terminal illness
Living will; durable POA for health care
Life-sustaining treatment: Ventilators, Feeding tubes, Dialysis, CPR, Hospitalizations
Do not resuscitate orders**
Withholding and withdrawing treatments
end of life care issues - palliative care
Total care of terminally-ill patient whose disease is not responsive to curative treatment
-Medical, psychological, social, spiritual care
-Control symptoms to maintain best possible QOL
-d/c unnecessary meds
-Focus on symptom control vs. disease mgmt
Hospice Care - Interdisciplinary palliative care
Active total care of patients whose disease is not responsive to curative treatment
The goal of palliative care is the achievement of the best possible quality of life for patients and their families.
Palliative care affirms life while providing optimal quality of life, neither hastening nor postponing death.
palliative care components
Medical, psychological, social, spiritual care of pt.
Psychosocial support and bereavement care of family.
Control symptoms to maintain best possible QOL
Discontinue unnecessary tests, treatments, and medications
Focus on symptom control vs. disease management
Focus on allowing the patient to be better informed of options and maintain more control of care.
Includes adults and peds.
palliative care common disease states
Cancer Heart failure ALS; MS COPD ESRD Liver failure Severe dementia fluyHIV/AIDS
pharmacist’s responsibilities in palliative care
Assessing appropriateness of medication orders.
Ensuring timely provision of effective medications for symptom control.
Educating other HCP and family regarding medication therapy.
Ensuring patients and caregivers comprehend and follow directions for use of medications.
Providing efficient means for compounding of nonstandard dosage forms.
Addressing financial concerns regarding meds.
Ensuring safe and legal disposal of meds, particularly following death.
Establishing and maintaining effective communication with regulatory and licensing agencies.
common condition and sxs that may need managed in EOL care
Pain Anxiety; depression; insomnia Anorexia Difficulty swallowing Fatigue Constipation / Diarrhea Bowel obstruction Delirium Dyspnea Nausea / Vomiting Edema/ascites Dry mouth Terminal restlessness Terminal respiratory congestion
hospice care
Provision of palliative care to individuals with terminal illnesses who have a life expectancy of six months or less.
Must be certified by MD.
May be provided at home, in LTCF, or in free standing facility.
Provides oversight of care but does not provide full-time caregivers. Patient must cover any caregiver expenses.
Focus on keeping the patient comfortable.
Patients and family must agree that life-sustaining interventions will not be continued.
Covered by Medicare, Medicaid, VA and most private insurances.
Diagnostic tests, hospitalizations for acute illness, labs, etc. are no longer considered.
history of hospice care
Modern hospice movement started in 1967 with the opening of St. Christopher’s Hospice in London.
Focus on allowing pts to live their final stages of life in dignity and comfort.
-Dr. Cicely Saunders -Nurse then Medical Social Worker then Physician
In 1963, Dr. Saunders visited Yale-New Haven Medical Center – Florence Wald (Dean of Nursing)
-Dr. Saunders was visiting faculty in 1965
Pharmacist: Arthur Lipman
In 1974, with the help of 2 physicians, Wald founded the Connecticut Hospice in Branford.
-First facility to offer home care.
-90% of hospice care is now delivered at home.
1.4 million pts received hospice care in 2007.
communicating with elderly patients
chronological age is not physiological age avoid stereotyping* Engage patient in decision making process regarding treatment decisions Speak to the patient, not the caregiver Reluctance or inability to communicate Physiologic barriers to effective communications - Vision, Hearing, Cognition Suggested strategies… -Use simple, direct wording -Use a slower pace -Repeat instructions +/- written -Allow ample time to respond -Give reasons for your advice -Use visual aids when possible -Follow-up
