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Fall 2020: Therapeutics 2 > Geriatrics (Introduction and Incontinence) > Flashcards

Geriatrics (Introduction and Incontinence) Flashcards

1
Q

What age bracket is the fastest growing in the US population?

A

Adults >75 years

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2
Q

Who has greater longevity: men or women?

A

Women

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3
Q

What are some advantages of being a consultant pharmacist in LTC?

A
  • Flexible schedule
  • Work independently
  • Work with multiple disciplines at a variety of facilities
  • LTC regulations clearly describe pharmacist role
  • Educational component for facility staff
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4
Q

What are some disadvantages of being a consultant pharmacist in LTC?

A
  • Travel time
  • Rely on facility staff for follow-up
  • Communication with providers often written, asynchronous
  • Frustration when recommendations are not accepted
  • Limited patient interaction
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5
Q

How do we define healthy aging?

A

“The process of developing and maintaining the functional ability that enables wellbeing in older age.”

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6
Q

What is functional ability?

A

Having the capabilties to engage in activities that patients find valuable

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7
Q

What are some activities of daily living (ADLs)?

A
  • Dressing
  • Bathing
  • Transferring
  • Feeding
  • Toileting
  • Walking/ambulation
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8
Q

What are some instrumental activities of daily living (IADLs)?

A
  • Handling finances
  • Shopping for groceries
  • Meal preparation
  • Using a telephone
  • Housekeeping/laundry
  • Handling medications
  • Using transportation
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9
Q

What are the two largest contributors to functional decline in older adults?

A

Musculoskeletal and cardiovascular

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10
Q

Functional limitations increase with age for nearly all categories except for what?

A

Lung

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11
Q

What medication classes can increase fall risk in older adults?

A
  • Sedatives/hypnotics
  • Neuroleptics/antipsychotics
  • Antidepressants
  • Opioids (especially long-acting)
  • Loop diuretics
  • Alpha-blockers
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12
Q

List the three most prevalent medication problems in older adults.

A
  1. Polypharmacy
  2. Nonadherence
  3. Altered pharmacokinetics
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13
Q

Is aging a barrier to adherence?

A

No!

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14
Q

How is total body water influenced by aging?

A

Decreased

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15
Q

How is lean body mass influenced by aging?

A

Decreased

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16
Q

How is body fat influenced by aging?

A

Increased

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17
Q

How is baroreceptor response/activity influenced by aging?

A

Decreased

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18
Q

How is heart rate variability influenced by aging?

A

Reduced

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19
Q

How is hepatic blood flow influenced by aging?

A

Decreased

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20
Q

How is renal blood flow influenced by aging?

A

Decreased

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21
Q

How is neurotransmitter volume influenced by aging?

A

Decreased

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22
Q

How are Vd and concentration of water-soluble drugs such as atenolol affected by aging?

A

↓ Vd and ↑ concentration

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23
Q

How are Vd and T1/2 of lipid-soluble drugs such as rifampin affected by aging?

A

↑ Vd and ↑ T1/2

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24
Q

How are clearance and T1/2 of most hepatically-cleared drugs like propranolol affected by aging?

A

↓ Clearance and ↑ T1/2

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25
Q

How are the clearance and T1/2 of most renally-cleared drugs like atenolol affected by aging?

A

↓ clearance and ↑ T1/2

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26
Q

What are the Beers Criteria?

A

Criteria for potentially inappropriate medication use in older adults (65+)

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27
Q

What medication classes should be avoided/used with caution according to Beers Criteria?

A
  • Anticholinergics (cognitive impairment)
  • Sedatives and other medications with CNS effects (falls)
  • Diabetic agents (sliding scale insulin, long-acting SUs)
  • Medications that may exacerbate chronic conditions (heart failure)
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28
Q

What factors should be considered when choosing medications for older adults?

A
  • Life expectancy
  • Goals of care
  • Treatment targets
  • Time required to benefi (i.e. DCCT trials for tight FBG control, bisphosphonates in osteoporosis)
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29
Q

What is palliative care?

A

After diagnosis of terminal illness, disease is not responsive to curative treatment or treatment doesn’t exist; holistic care for patient and family with the goal to optimize QOL

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30
Q

What is hospice care?

A

Care provided at home, in LTC, or in an independent facility where most patients have a life expectancy of 6 months or less (certified by an MD); diagnostic tests, hospitalizations, and labs are no longer covered

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31
Q

Advanced Care Directives are supported by which act?

A

Patient Self-Determination Act

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32
Q

What are Advanced Care Directives (ACDs)?

A
  • Verbal/written instructions about future medical care and treatment
  • Elective and do not take away a patient’s right to make current care decisions
  • Include Health Care Representative, Psychiatric Advance Directive, and Power of Attorney
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33
Q

What does it mean to designate a Health Care Representative?

A

Naming someone to make decisions if you are unable (or prevents someone from making decisions for you)

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34
Q

What is a Psychiatric Advance Directive?

A

Sets preferences regarding mental illness during periods of incapacity

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35
Q

What is a Power of Attorney?

A

Can be financial or healthcare-based; grants power to others you choose

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36
Q

Physician Orders for Scope of Treatment (POST) is a legal document declaring what four things?

A
  1. Preferences for resuscitation
  2. Medical interventions (intubations, dialysis, hospitalization)
  3. Antibiotics
  4. Artificial nutrition
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37
Q

What must occur for a Physician Orders for Scope of Treatment (POST) document to be valid?

A

Must be signed and dated

38
Q

What is the preferred alternative to the term “geriatric”?

A

“Older adult”

39
Q

What sex is urinary incontinence more common in?

40
Q

Rank the types of UI by the frquency that they occur in women.

A
  1. Urge
  2. Stress
  3. Overflow
  4. Mixed
41
Q

Rank the types of UI by the frquency that they occur in men.

A
  1. Urge
  2. Overflow
  3. Mixed
  4. Stress (0%)
42
Q

Explain the process of urine release in a normally-functioning bladder.

A
  1. Stretch receptors notify the brain that the bladder is full (B3 receptors in the dome support detrusor relaxation/filling)
  2. Neurologic stimulation initiates contraction (ACh receptors in the dome and alpha-adrenergic receptors in base and proximal urethra)
  3. Sphincter relaxes to allow urine release
43
Q

List the three age-related changes to the bladder and urethra.

A
  • Decreased bladder capacity/elasticity
  • Increased spontaneous detrusor contractions
  • Decreased sphincter compliance
44
Q

What is Urge UI (AKA overactive bladder)?

A

Hyperactivity of destrusor muscle = sudden, frequent, and unpredictable urination

45
Q

What are the two possible causes of Urge UI?

A
  • Neurologic
  • Medications (i.e. ACh inhibitors for Alzheimer’s)
46
Q

What is Stress UI?

A

Outlet incompetence (external urethral sphincter) + abdominal pressure

47
Q

Describe the volume of Urge UI accidents.

A

Can be large or small

48
Q

Describe the volume of Stress UI accidents.

A

Usually small volume

49
Q

What are the two risk factors for Stress UI?

A
  • Multiple childbirths
  • Estrogen deficiency
50
Q

What medication class can exacerbate or cause Stress UI?

A

Alpha-antagonists

51
Q

What is Overflow UI?

A

Abdominal discomfort/pain paired with increased freqency and need to void shortly following last urination, resulting from outlet obstruction or inability to/uncoordinated detrusor constriction.

52
Q

Overflow UI is most commonly caused by what condition?

A

BPH or prostatic blockage of the urethra

53
Q

True or false: in Overflow UI, urine builds up in the bladder.

54
Q

What is Neurogenic (Atonic) Bladder?

A

Disruption in neurologic innervation of the bladder, usually characterized by inability/uncoordinated detrusor constriction.

55
Q

Beyond inability/uncoordinated detrusor constriction, how else may Neurogenic (Atonic) Bladder occur?

A

Atony of bladder muscle from stroke, neuropathy, or spinal cord injury

56
Q

Describe the volume of accidents from Neurogenic (Atonic) Bladder.

A

Small volume

57
Q

Neurogenic (Atonic) Bladder increases the risks of what two conditions?

A

UTI and kidney stones

58
Q

What is Functional Incontinence?

A

The inability to get to the bathroom in a timely fashion.

59
Q

What are the four most common causes of Functional Incontinence?

A
  • Impaired mobility
  • Change in mental status (dementia)
  • UTI
  • Medications (sedating)
60
Q

What are the five non-pharmacological treatment options for urinary incontinence?

A
  1. Scheduled voiding
  2. Kegels 30-60x a day
  3. Avoiding irritants (coffee, alcohol, caffeine, water at bedtime)
  4. Absorbent products
  5. Catheters
61
Q

What is the main goal when treating Urge UI?

A

Reducing detrusor contraction frequency

62
Q

What are the three medication classes that may be used to treat Urge UI?

A
  • Anticholingeric/antimuscarinic
  • B3-antagonists
  • Combination
63
Q

What is the single UI type that cannot be managed with injections or surgery?

A

Functional UI

64
Q

List the six anticholinergic/antimuscarinic medications.

A
  1. Oxybutynin (Ditropan, Oxytrol OTC patch, Gelnique)
  2. Tolterodine (Detrol)
  3. Solifenacin (Vesicare)
  4. Darifenacin (Enablex)
  5. Trospium (Sanctura)
  6. Fesoterodine (Toviaz)
65
Q

What is the only B3-agonist option to treat Urge UI?

A

Mirabegron (Myrbetriq)

66
Q

What are the most common adverse effects of anticholineric/antimuscarinic medications?

A
  • Dry mouth
  • Constipation
  • Fatigue
  • Confusion (acute or chronic)
  • Tachycardia
67
Q

What are the most common adverse effects of mirabegron?

A
  • Minor increase in BP
  • UTI
68
Q

When treating Urge UI pharmacologically, how long does it usually take to receive max benefit?

69
Q

When talking to patients taking medications for Urge UI, why would you advise against stopping a medication too quickly?

A

May cause recurrence of symptoms that is worse than baseline

70
Q

How often should oxybutynin patches be applied?

A

Every 3-4 days

71
Q

What medication is most clinically similar to oxybutynin?

A

Tolterodine

72
Q

What anticholinergic/antimuscarinic medication is selective to the M3 receptor?

A

Solifenacin

73
Q

What anticholinergic/antimuscarinic medication is a CYP2D6 inhibitor, CYP3A4 sub?

A

Darifenacin

74
Q

What anticholinergic/antimuscarinic medication’s absorption is decreased by food and should be taken on an empty stomach?

75
Q

What anticholinergic/antimuscarinic medication is a prodrug and CYP3A4 sub?

A

Fesoterodine

76
Q

What is the most important counseling point for patients taking mirabegron?

A

Do not crush

77
Q

What pharmacologic treatment options are available for Stress UI management?

A
  • Duloxetine 40 mg BID
  • Topical estrogen 21 days on, 7 days off
  • Alpha-agonists like pseudoephedrine (rare)
  • Vaginal pessaries
78
Q

In what order do you address Overflow UI treatment?

A
  1. Address obstruction
  2. Alpha-adrenergic blockers (if BPH)
  3. Catheterization
79
Q

What two alpha-adrenergic blockers can be used in Overflow UI management?

A
  • Doxazosin 1-4 mg daily
  • Tamsulosin 0.4 mg daily
80
Q

Which alpha-adrenergic blocker is slightly more selective for bladder neck subtypes of alpha receptors, and also has less of a hypotensive effect?

A

Tamsulosin 0.4 mg once daily

81
Q

Since pharmacologic management is not routinely effective for Neurogenic UI, what other treatment options are?

A
  • Non-pharmacologic like scheduled voiding
  • Intermittent catheterization
  • Botox injections in the bladder or urinary sphincter
  • Augmentation cystoplasty
82
Q

What is augmentation cystoplasty?

A

Bladder walls and intestinal walls are connected to improve storage capacity

83
Q

What catheter type is this?

A

Intermittent straight

84
Q

What can intermittent straight catheters be made from?

A
  • Rubber latex
  • Silicone
  • PVC
85
Q

What catheter type is this?

A

Foley (indwelling) catheter

86
Q

Are Foley catheters used chronically or acutely?

A

Chronically

87
Q

What catheter type is this?

A

Condom catheter

88
Q

What catheter type is this?

A

Suprapubic catheter

89
Q

What is an appropriate follow-up time for UI treatment efficacy?

90
Q

What is the mechanism of anticholinergic adverse cognitive effects?

A
  1. Central muscarinic antagonism
  2. Increased central amyloid
  3. Loss of total cortical and temporal lobe thickness
  4. Lower performance in processing/memory/executive function
  5. Cognitive impairment

Fall 2020: Therapeutics 2 (11 decks)

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