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
