Geriatrics, Supplements, pain2

Question 1

T or F: in palliative care, the goal is to minimize the number of medications in order to improve quality of life, and no longer “CURE” the disease

Answer 1

True

Question 2

what can you do to your patient’s medications if they can no longer swallow their medications?

Answer 2

use liquids, crush tabs, injections, rectal administration

Question 3

What classes of medications can be used to treat anxiety in palliative care?

Answer 3

Benzodiazepines
SSRI
Antipsychotics
Haloperidol

Question 4

When is Haloperidol the best choice in treating anxiety associated with palliative care?

Answer 4

if the patient has anxiety AND delirium

Question 5

When treating delirium in palliative care, which of the following medications should you avoid:

• Antipsychotics
• Haloperidol
• Benzodiazepines
• Chlorpromazine

Answer 5

Benzodiazepines - may worsen delirium

Question 6

you are seeing a patient who is on palliative care, and she is suffering from dyspnea. After attempting to treat the cause without success, you prescribe _____

Answer 6

opioids

first line for dyspnea

Question 7

T or F: use a high dose opioids for respiratory depression to alleviate dyspnea at end of life

Answer 7

FALSE - low dose is effective enough to suppress respiratory awareness

Question 8

T or F: may need a high dose opioids for pain related to palliative care.

Answer 8

True - may need higher dose of short-acting opioid for breakthrough pain.

Question 9

what must you be cautious of with opioids used for treating pain at end of life?

Answer 9

Respiratory depression, constipation, neurotoxicity

Question 10

when do you start treatment of terminal secretions in the lungs?

Answer 10

At the FIRST sign of secretions - they do not help existing secretions, only prevent it

Question 11

what is the standard of therapy for pulmonary secretions?

Answer 11

Anticholinergic Drugs (atropine, hyoscyamine, scopolamine, glycopyrrolate)

Question 12

Atropine
Hyoscyamine
Scopolamine
Glycopyrrolate

are used for what?

Answer 12

anticholinergics, used to dry up terminal pulmonary secretions

Question 13

How could you change medications with someone who has hypotension and is at the end stage of their life with heart failure?

Answer 13

decrease ACE Inhibitor

taper off Beta blockers

Question 14

Your patient has end stage heart failure and is experiencing volume overload. You decide to carefully increase their diuretic, but you must be cautious of what?

Answer 14

Dehydration

Question 15

what kind of urinary incontinence is characterized by an underactive urethra leading to a lack or resistance to outflow.

Answer 15

Stress incontinence - when intra-abdominal pressure > intra-urethral pressure

Question 16

What are some risk factors to stress incontinence?

Answer 16

Pregnancy, vaginal delivery, menopause, obesity, increased age.

Question 17

which type of urge incontinence is characterized by an overactive detrusor muscle?

Answer 17

urge incontinence

Question 18

which medication will you reach for first when treating Stress incontinence?

Answer 18

Duloxetine

Question 19

which 2 adverse effects do you need to watch for with Duloxetine used to treat stress incontinence?

Answer 19

increase in BP

increase in suicide risk

Question 20

this class of medication is sometimes used to treat stress incontinence, but is not recommended due to adverse effects and many contraindications

Answer 20

alpha-agonists (pseudoephedrine and phenylephrine)

estrogen

Question 21

this choice of treating stress incontinence might be a good option if patient has estrogen deficiency

Answer 21

estrogen

Question 22

Darifenacin
Fesoterodine
Soilfenacin
Trospium
Oxybutynin
Tolterodine

Answer 22

Anticholinergic/antimuscarinic drugs (treating urge incontinence)

Question 23

what is the first line treatment of urge incontinence

Answer 23

anticholinergic/antimuscarinic drugs

Question 24

you start your patient on Fesoterodine for urge incontinence, and tell her that she should wait _____ to see the full effect

Answer 24

4 weeks for full effect

Question 25

What are the adverse effects of the anticholinergics?

Answer 25

``` dry mouth constipation blurred vision flushing orthostatic hypotension sedation ```

Question 26

Bethanecol and alpha antagonists (silodosin, prazosin, terazosin) are sometimes used to treat what?

Answer 26

overflow incontinence

Question 27

your patient has BPH, which is obstructing the urethra and causing overflow incontinence. What can you treat him with?

Answer 27

either bethenacol or alpha antagonists (silodosin, prazosin, terazosin)

Question 28

which class of medications is the worst culprit of losing bone mass density?

Answer 28

Glucocorticoids

Question 29

your patient asks you what they can do NONPHARMACOLOGICALLY to increase bone mass density and you tell them to eat foods that contain which nutrients?

Answer 29

foods with calcium and vitamin D

Question 30

T or F: your patient should exercise doing NON-weight bearing activity to reduce tension on the bones

Answer 30

False - weight bearing activities are best along with muscle strengthening

Question 31

Alendronate Ibandronate Risedronate Zoledronic Acid

Answer 31

Bisphosphonates - first line therapy for osteoporosis

Question 32

how long do you treat a person with bisphosphonates?

Answer 32

5 years

Question 33

why shouldn't you treat with bisphosphonates longer than 5 years?

Answer 33

risk of jaw osteonecrosis, subtrochanteric fractures

Question 34

how long before eating breakfast should you take bisphosphonates?

Answer 34

30-60 minutes prior, and don't lay down after

Question 35

what is the most common adverse effects associated with bisphosphonates?

Answer 35

GI effects (n/v, diarrhea, esophagitis)

Question 36

you are about to administer Zoledronic acid IV - how can you reduce the flu-like symptom AE that is common?

Answer 36

pre-treat with APAP

Question 37

bisphosphonates ok for pregnancy?

Answer 37

NO

Question 38

what should you prescribe your patient who has osteoporosis but cannot tolerate bisphosphonates

Answer 38

Denosumab

Question 39

only use this medication for osteoporosis if the patient has VERY HIGH FRACTURE RISK

Answer 39

Teriparatide (not first line!)

Question 40

most of the osteoporosis medications block osteoclast activity, but this one specifically enhances osteoblastic activity

Answer 40

Teriparatide (caution if pre-existing hypercalcemia)

Question 41

Black box warning for teriparatide

Answer 41

Osteosarcoma

Question 42

what is the maximum recommended time frame for teriparatide

Answer 42

2 years (daily injections)

Question 43

What is the medication under the class Selective Estrogen Receptor Modulator (SERM)

Answer 43

Raloxifine

Question 44

what is the MOA of Raloxifine

Answer 44

estrogen-like activity

Question 45

raloxifene contraindications

Answer 45

pregnancy, if could become pregnancy, nursing

Question 46

what fraction of patients do not reveal their supplement use to providers

Answer 46

2/3

Question 47

why do people take CoQ10

Answer 47

improve outcomes in heart failure and improve ejection fraction, myocardial energy

Question 48

Why do people take fish oil?

Answer 48

reduce triglycerides

Question 49

AE of fish oil

Answer 49

GI reflux, fishy taste, bleeding risk if > 5 mg

Question 50

Why do people take Ginkgo Biloba?

Answer 50

improves cognition in dementia (enhancement of cerebral blood flow)

Question 51

what is the risk with ginkgo biloba

Answer 51

increased bleeding risk due to antiplatelet and antithrombotic effects

Question 52

why do people take St. John's Wort?

Answer 52

mild to moderate depression

Question 53

does St johns wort work with all types of depression?

Answer 53

not severe.

Question 54

Your patient notes that she wants to start an antidepressant medication to help with her depression. She mentions that she is already on St. John's Wort. What medication should you worry about

Answer 54

NO SSRI! risk of serotonin syndrome

Question 55

this supplement is often combined with caffeine and has a high risk of hypertension, arrhythmias, MI, stroke, seizure

Answer 55

Ephedra Alkaloids

Question 56

This supplement is found in herbal supplements and teas and can cause liver toxicity, cirrhosis, fibrosis

Answer 56

Pyrrolizidine Alkaloids

Question 57

This supplement is used to self-treat opioid withdrawal, but has a risk of overdose, addiction, and salmonella contamination

Answer 57

Kratom

Question 58

this supplement is a chines herb used for weight loss, but can cause nephrotoxicity

Answer 58

Aristolochia

Question 59

which chronic conditions have the highest risk of interactions with supplements and why?

Answer 59

Seizures Arrhythmias CHF these patients take more Rx medications with NARROW therapeutic indexes

Question 60

what happens when you take St. John's Wort with Warfarin

Answer 60

increased metabolism of warfarin = decreased warfarin and lower INR

Question 61

Cardiovascular medications interact the most with what supplement?

Answer 61

St Johns Wort

Question 62

What should you educate your patient on if she takes St Johns Wort with her Oral contraceptives?

Answer 62

It interacts, and can cause contraceptive failure

Question 63

St. John's Wort + cyclosporine can cause what?

Answer 63

transplant failure!

Question 64

T or F: most of palliative treatment is off label

Answer 64

True

Question 65

what are the FDA approved cannabinoids

Answer 65

Dronabinol | Nabilone

Question 66

of the cannabinoids used, which one is best for AIDS associated wasting?

Answer 66

Nabilone

Question 67

Which case is NOT an example of a good time to use medical marijuana chemo-induced n/v, painful spasms not tolerated by opioids, chronic RA pain, Acute pain, AIDS wasting

Answer 67

acute pain

Question 68

THC is highly protein bound, so caution when taking with ____

Answer 68

warfarin

Question 69

THC has additive effects when combined with ___

Answer 69

sedatives, psychotropics, hypnotics, alcohol

Question 70

Contraindications THC

Answer 70

``` psychotic illness schizophrenia bipolar anxiety mood disorder substance disorder ```

Question 71

T or F: caution using medical marijuana with Rx opioid use

Answer 71

True

Question 72

This vaccine is found in dirt, soil and part of a combination vaccine

Answer 72

Tetanus

Question 73

Which vaccine in DTap is responsible for the vaccine against bacteria that causes membranous pharyngitis

Answer 73

Diphtheria

Question 74

How many DTaP vaaccinations necessary

Answer 74

3 (with Td booster every 10 years)

Question 75

which trimester do you give a pregnant woman DTaP

Answer 75

3rd

Question 76

how many doses of hepatitis A do we give?

Answer 76

2 doses

Question 77

How many doses of hepatitis B do we give?

Answer 77

3

Question 78

How are Hepatitis A and B different regarding transmission?

Answer 78

A - fecal/oral | B - Blood/bodily fluids

Question 79

How many doses of MMR do we give?

Answer 79

2

Question 80

which specific population should we avoid giving the MMR vaccine to, and why?

Answer 80

Immunocompromised - risk of measles (the vaccine is live-attenuated) HIV infected is ok if not immunocompromised

Question 81

This vaccine's common Adverse effect is a fever >1 week later (increased risk of epilepsy)

Answer 81

MMR

Question 82

this vaccine prevents a highly contagious progressive paralytic disease, that is now eradicated

Answer 82

Polio (inactivated)

Question 83

How many doses of the rotavirus vaccine do we give?

Answer 83

2-3 doses (BOTH LIVE - ATTENUATED)

Question 84

what is a major adverse effect of the rotavirus (given to kids <5 yearS)

Answer 84

Intussusception

Question 85

T or F: the rare case of seizures that happen after MMR vaccine are life-threatening

Answer 85

FALSE - they are rare, temperature related, and do NOT cause lasting damage

Question 86

What element of vaccines causes all the hype about autism?

Answer 86

Thimerosal (ethyl mercury)

Question 87

what type of vaccinations should you avoid in immunocompromised?

Answer 87

live-attenuated

Question 88

which 2 vaccinations should you give pregnant women in the second half of their pregnancy

Answer 88

Tdap Influenza (avoid live vaccines)

Question 89

what delayed adverse effect can happen with the varicella vaccine?

Answer 89

mild rash 20 days later

Question 90

Which medication is best for migraine pain?

Answer 90

Sumatriptan

Question 91

Which type of meds treat neuropathic pain

Answer 91

Tricyclics and Gabapentin

Question 92

Duloxetine treats what type of pain?

Answer 92

fibromyalgia

Question 93

Dexamethasone is used to treat what type of pain

Answer 93

post operative n/v

Question 94

what do you treat the pain from gout?

Answer 94

prednisone

Question 95

what medication treats pain from muscle spasm?

Answer 95

cyclobenzaprine

Question 96

which 2 opioids are less effective?

Answer 96

codeine | Tramadol - more interactions and risk of seizure

Question 97

which medication in pediatrics gives a high risk of kernicterus

Answer 97

sulfamethoxazole-trimethoprim

Question 98

Chloramphenicol in pediatric population has a risk of what?

Answer 98

Gray baby syndrome

Question 99

T or F: hepatic metabolism is slower at birth, allowing medications to build up and cause adverse effects

Answer 99

True

Question 100

benzyl alcohol and benzoic acid in babies can cause _____

Answer 100

gasping syndrome

Question 101

your patient is newly diagnosed with stress incontinence. What can you prescribe her?

Answer 101

Duloxetine

Question 102

the major risk of Ginkgo Biloba is ____

Answer 102

increased bleeding risk

Question 103

do you avoid Duloxetine in liver or kidney dysfunction?

Answer 103

Both (liver disease or CrCl < 30)

Question 104

Transdermal administration is not suggested in pediatrics, EXCEPT which?

Answer 104

methylphenidate for ADHD

Question 105

which vitamins are water soluble and excreted in urine

Answer 105

B and C