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phar_350_20241030165923 Flashcards

1
Q

What is the problem with using 65 years as the marker for senior?

A

With increased diversity with age, protocols and guidelines are less useful in geriatric care than for younger ages
- Care must be individualized

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2
Q

What are some factors that affect health in older age? (5)

A
  1. Genetics
  2. SES
  3. Education
  4. Social engagement and support
  5. Lifestyle: Exercise, diet, smoking, and alcohol use
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3
Q

Define life expectancy

A

To what proportion of the max age a person may live

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4
Q

Define health span

A

Number of years that are spent free from functional limitations, morbidity, and pain

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5
Q

The goal of most geriatric models of care is to _______ the ______ ____

A

prolong the health span

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6
Q

Functional capacity is an indicator of ability to carry out everyday tasks. What are the 2 groups of activities?

A
  1. Activities of Daily Living (ADLs)
    - Dressing, toileting, eating, bathing, walking
  2. Instrumental Activities of Daily Living (IADLs)
    - Shopping, housekeeping, food preparation, medication management, financial management
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7
Q

A helpful mnemonic for activities of daily living (ADLs) is BATTED - should know it

A

Bathing
Ambulation
Toileting
Transfers
Eating
Dressing

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8
Q

A helpful mnemonic for instrumental activities of daily living (IADLs) is SCUM - should know it

A

Shopping
Cooking/cleaning
Using telephone or transportation
Managing money and medications

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9
Q

What is functional reserve?

A

Body systems generally have capabilities beyond what is needed for everyday activities
- e.g., average adult’s cardiac output ~5L/min. Trained athlete’s cardiac output ~40-50L/min

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10
Q

How does functional reserve compare in older adults vs. younger adults

A

Older adults have decreased functional reserve compared to younger adults
- Increased risk of decline when faced with illness or injury
- E.g., older adult with dementia is more likely to experience post-operative delirium

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11
Q

What is functional decline?

A

Reduction in ability to perform ADLs and IADLs due to decreased physical and/or cognitive function

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12
Q

Age is a factor in functional decline and health resource utilization, but not the only factor. What else plays a role?

A

Higher healthcare utilization was reported among those with more chronic medical conditions, regardless of age

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13
Q

What changes in absorption are associated with aging? (4)

A
  1. Decreased gastric acid secretion
  2. Slower gastric emptying
  3. Delayed intestinal transit
  4. Decreased blood flow
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14
Q

Generally speaking when aging there is decreased rate of drug absorption (first-dose, prns) but no change in extent of drug absorption. What are the exceptions (that is, decreased gastric acid secretion may decrease the extent of absorption of which meds)? (3)
How might we combat this? (2)

A
  1. Iron supplements
  2. Ketoconazole/intraconazole
  3. Calcium carbonate
    Suggestions to combat:
  4. Empty stomach with iron supplements
  5. Use citrate form of calcium
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15
Q

How is percutaneous absorption affected due to aging? Give 3 medication examples

A

Decreased rate of percutaneous absorption of lipophyllic meds
1. Fentanyl
2. Testosterone
3. Estradiol

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16
Q

How does body composition change with aging? (2)

A
  1. 25-30% increase in body fat
  2. 25-30% decrease in muscle mass/body water
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17
Q

What are 2 highly lipophilic meds whose distribution is altered in older adults?

A
  1. Diazepam
  2. Amiodarone
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18
Q

What are 2 highly hydrophillic meds whose distribution is altered in older adults?

A
  1. Lithium
  2. Aminoglycoside antibiotics
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19
Q

How do albumin levels change in older adults? What are 2 examples of meds which would be affected by this?

A

Decreased albumin levels in frail/malnourished older adults decreases protein-binding of highly-protein-bound medications
- Phenytoin
- Warfarin

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20
Q

How does liver size and blood flow change with age?

A

Liver size and blood flow decrease significantly with age
- 20-40% decrease in liver mass
- ~35% decrease in hepatic blood flow

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21
Q

Drugs with high first-pass extraction will have _________ bioavailability in older adults

A

increased

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22
Q

What are some drugs with high first-pass extraction to be aware of? (5)

A
  1. Morphine
  2. Metoprolol, propranolol, labetalol
  3. Verapamil
  4. Amitriptyline
  5. Levodopa
    (Start low go slow)
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23
Q

What changes in Phase I metabolism do we see in aging? What does that mean for the pt?

A

Some reduction in Phase I (CYP-450-mediated) metabolism with aging
- Longer half-lives - decreased dose requirements or increased dosing intervals

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24
Q

What changes in Phase II metabolism do we see in aging?

A

Gotcha - there are none

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25
Q

What are some meds that are metabolized via Phase II? (4)

A
  1. Acet
  2. Lorazepam, oxazepam, temazepam
  3. Zaleplon
  4. VPA
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26
Q

How does elimination change with age?

A

Decreased renal size, blood flow, GFR, and tubular secretion
- ~10% decrease in GFR per decade after age 30

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27
Q

Serum creatinine alone is not reliable to estimate kidney function in older adults. Why? (2)

A
  1. Muscle mass tends to decrease with age, so SCr may be falsely low
  2. Does not account for the effect of age on kidney function
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28
Q

What are some of the equations that can be used to estimate kidney function? (3)

A
  1. CKD-epi
  2. MDRD
  3. Cockroft-Gault
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29
Q

When does the Cockroft-Gault equation underpredict and overpredict renal function?

A
  1. Underpredicts renal function for those weighing less than their ideal body weight (IBW)
  2. Overpredicts renal function for those weighing more than their IBW
    - If overweight/obese - use IBW to calculate CrCl
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30
Q

Mrs. G is an 87 year old woman being started on digoxin, which is a very water-soluble medication. How would we expect the volume of distribution of digoxin to be altered in Mrs. G based on her age?
a. Vd would increase
b. Vd would decrease
c. Vd would not be expected to change

A

b.

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31
Q

Based on the anticipated pharmacokinetic alterations of digoxin in Mrs. G, we should choose an initial digoxin dose that is:
a. Higher than usual
b. Lower than usual
c. The same as usual

A

b.

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32
Q

Lorazepam is mainly metabolized by Phase II hepatic metabolism (glucuronidation). In older adults, we would expect the metabolism of lorazepam to be:
a. Decreased (slower) than in younger adults
b. Increased (faster) than in younger adults
c. Unchanged compared to younger adults

A

c.

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33
Q

Mr. A is a 79 year old man with a serum creatinine of 100mcmol/L (normal range is 45-90mcmol/L). He is starting gabapentin, a medication that requires dosage adjustment for renal impairment. Based on this information, you:
a. Start at half the usual recommended dose of gabapentin
b. Recommend a BID dosing regimen instead of the usual TID
c. Check his weight and calculate his CrCl to determine if dosage adjustment is needed
d. Calculate his eGFR using the MDRD, and use this to determine if dosage adjustment is required

A

c.

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34
Q

Changes in medication response associated with aging is due to what?

A

Changes in receptor sensitivity, or altered homeostatic mechanisms

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35
Q

How might cardiovascular medication response change in older adults? (4)

A
  1. Decreased blood pressure-lowering response to beta-blockers
  2. Decreased arterial compliance and decreased baroreceptor reflex
    - Predispose to orthostatic hypotension
  3. Increased stiffness of large blood vessels –> isolated systolic hypertension
  4. Increased susceptibility to QT prolongation
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36
Q

How might CNS medication response change in older adults? (3)

A
  1. Increased permeability of BBB with age
  2. Increased susceptibility to CNS adverse effects of medications
    - Anticholinergics
    - Benzodiazepines
    - Dopaminergic medications
  3. Decreased dopaminergic neurons in substantia-nigra –> increased susceptibility to EPS side effects of dopamine-blocking meds
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37
Q

How does fluid and electrolyte homeostasis change in older adults? (4)

A
  1. Decreased thirst response
  2. Decreased GFR
  3. Decreased response to antidiuretic hormone
  4. Decreased response to aldosterone
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38
Q

In terms of fluid and electrolyte homeostasis, older adults are more susceptible to: (4)

A
  1. Dehydration
  2. Hyponatremia
  3. SIADH
  4. Hyperkalemia
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39
Q

How does hematopoietic reserve change in older adults? What does that do?

A

Decreases
- Increased risk of hematological toxicities associated with chemotherapeutic drugs

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40
Q

In older adults, there is a(n) _________ response to antiepileptic drugs at a lower serum concentration

A

increased
(also increased susceptibility to adverse effects)

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41
Q

What is immunosenescence? (3)

A
  1. Reduced ability to fight infections
  2. Reduced immune response following vaccination
  3. Increased susceptibility to malignancy
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42
Q

In older adults there is _________ regenerative capacity of gastric mucosa which leads to?

A

decreased
- leads to increased risk for GI bleeds

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43
Q

How does therapeutic window change for older adults?

A

It narrows, which can be a problem for some medications

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44
Q

What is polypharmacy? (2 - 3+2)

A
  1. High number of meds
    - No universally agreed-upon cutoff
    - Literature supports 5 or more meds as being associated with increased risk
    - More than 10 meds = hyperpolypharmacy
  2. Lack of appropriateness of meds
    - Meds with no indication
    - Use of inappropriate meds
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45
Q

True or False? Under-utilization of meds is never an issue in older adults

A

False - common in older adults

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46
Q

List some meds/conditions that are not prescribed (under-utilization) (4)

A
  1. Bisphosphonates for osteoporosis
  2. Anticoagulation for afib
  3. Pain meds
  4. COPD treatment
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47
Q

The task for the clinician is not to determine whether too many or too few meds are being taken, but to determine if the patient is taking the _____ meds

A

right

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48
Q

__% age 65-74 taking 5+ meds
__% age 85+ taking 5+ meds

A

58
80

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49
Q

Why are older adults using such a disproportionate amount of meds?

A

They tend to be a population that has 2 to 4+ chronic conditions which require meds

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50
Q

Why should we be concerned about polypharmcy?

A

Number 1 risk factor for adverse drug reactions = number of medications taken

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51
Q

Adverse drug reactions account for __-__% of hospitalization in older adults. Of which __% are considered preventable

A

10-30
65

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52
Q

Older adults are particularly vulnerable to polypharmacy and ADRs because? (4)

A
  1. Altered medication response
  2. More comorbidities
  3. Altered homeostatic mechanisms
  4. Limited EBM
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53
Q

What are the 3 sections of the BEERS criteria that we should know?

A
  1. Medications generally considered inappropriate for older adults
    - Unfavorable risk/benefit profile + better alternatives available
    - e.g., first-gen antihistamines, warfarin
  2. Medications inappropriate for older adults with certain medical conditions
    - Drug-disease interactions
    - e.g., NSAIDs in HF
  3. Medications to be used with caution in older adults
    - Some evidence of potential harm, or increased monitoring required in older adults
    - E.g., dabigatran, prasugrel, ticagrelor
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54
Q

What is the utility of the BEERS criteria?

A

Useful tool to assist in identifying PIMs for older adults
- Identify medications that may warrant reevaluation or closer monitoring

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55
Q

While the BEERS criteria is a useful tool, what should we be aware of when optimizing medications? (2)

A
  1. Absence of a BEERS medication does not mean an older adult’s medications are optimized
  2. Most ADR-related hospitalizations in older adults are not due to BEERS drugs
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56
Q

What are the top 10 drug classes most commonly associated with seniors’ ADR-related hospitalizations?

A
  1. Anticoagulants
  2. Other antineoplastic drugs
  3. Opioids and related analgesics
  4. Glucocorticoids and synthetic analogues
  5. Beta-adrenoreceptor antagonists, not elsewhere classified
  6. NSAIDs (excluding salicylates)
  7. Loop (high-ceiling) diuretics
  8. Benzothiadiazine derivatives
  9. Other diuretics
  10. ACEis
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57
Q

What are explicit prescribing tools? (2)
What are the pros and cons?

A
  1. Usually consensus criteria developed by a panel of experts
  2. Lists of medications to either use or avoid
  3. Pros: Easy to use and implement
  4. Cons: Miss other types of DTPs
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58
Q

What are implicit prescribing tools?
What are the pros and cons?

A
  1. Outline a process for the clinician to follow to identify DTPs
  2. Pros: Very comprehensive approach to identifying DTPs
  3. Cons: Require clinician knowledge/expertise, time-consuming
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59
Q

Give 3 examples of explicit prescribing tools

A
  1. BEERS criteria
  2. STOPP/START criteria
  3. STOPP FRAIL
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60
Q

Give 2 examples of implicit prescribing tools

A
  1. Medication Appropriateness Index
  2. Good Palliative-Geriatric Practice Algorithm
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61
Q

What is the Medication Appropriateness Index?

A
  1. Can be used as a research tool to evaluate a patient’s medication regimen
  2. More useful in clinical practice as a series of questions to ask
    - As part of a comprehensive medication review to assess the appropriateness of each drug
    - Before starting a new medication
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62
Q

What is the problem with the Medication Appropriateness Index and the Good Palliative-Geriatric Practice Algorithm?

A

They do not help identify untreated conditions

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63
Q

What is deprescribing?

A

The process of tapering, reducing, or stopping medications to improve clinical outcomes

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64
Q

What are some common meds that have deprescribing guidelines associated with them? (4)

A
  1. PPIs
  2. BZDs and Z-drugs for insomnia
  3. Cholinesterase inhibitors for dementia
  4. Glyburide and other hypoglycemics
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65
Q

The Canadian Deprescribing Network is developed patient information about the risks of certain medications. Such as? (7)

A
  1. NSAIDS
  2. Antipsychotics
  3. First-generation antihistamines
  4. Sulfonylureas like glyburide
  5. Opioids for chronic non-cancer pain
  6. Sleeping pills and anti-anxiety medications
  7. PPIs
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66
Q

What are the 5 steps you should be going through when approaching polypharmacy?

A
  1. Identify patients at risk of/experiencing polypharmacy or adverse drug reactions
  2. Obtain an accurate medication history
    - Evaluate adherence to medications
  3. Are any symptoms or problems the patient is experiencing potentially caused or worsened by a drug they are taking?
    - Need to know medication’s pharmacology and side effects
    - Also need to consider the time of onset of symptoms in relation to starting the drug
  4. Match medical conditions with medications
  5. Align drug therapies with the patient’s goals and priorities
    - Life expectancy
    - Time to benefit of the med
    - Pt preferences
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67
Q

What is time to benefit activity? (3)

A
  1. Refers to how long someone needs to take or be on a med before they’re likely to receive the anticipated benefit from it.
  2. Helps us evaluate appropriateness of different therapies within the context of how likely a particular patient is to receive benefit
  3. Geriatric meds towards people who are older and frailer
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68
Q

What are 2 considerations for determining time to benefit?

A
  1. Patient’s individual risk of event
    - Secondary prevention will have greater magnitude of benefit (lower NNT) than primary prevention
  2. Clinical trial data
    - How long was the study?
    - When was impact of intervention seen?
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69
Q

What are some tips for successful deprescribing? (5)

A
  1. Patient/caregiver buy-in is key
  2. Taper/stop one medication at a time if possible
  3. Watch for/try to break up prescribing cascades
  4. Consider whether any drug interactions may be unmasked when stopping a medication
  5. Anticipate and manage potential adverse drug withdrawal reactions
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70
Q

What are adverse drug withdrawal reactions? (3)

A

Clinically significant signs or symptoms on discontinuing a drug
1. Physiologic withdrawal
2. Recurrence of underlying condition
3. Discontinuation symptoms

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71
Q

When in doubt (for an ADWR) what should be done?

A

Taper a medication off slowly - particularly if on a higher dose and/or have been taking chronically

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72
Q

What are the acute ADWRs seen with antidepressants (SSRIs, SNRIs, TCAs)? (4)

A
  1. Insomnia
  2. Agitation
  3. Sweating
  4. Malaise
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73
Q

What is the chronic ADWRs seen with antideprssants?

A

Depression recurrence

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74
Q

What are the ADWRs seen with hypnotics (BZDs, zopiclone, zaleplon) (4)

A
  1. Rebound insomnia
  2. Agitation
  3. Anxiety
  4. Tremor
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75
Q

What are the ADWRs seen with narcotics? (6)

A
  1. Increased pain
  2. Mobility changes
  3. Insomnia
  4. Agitation
  5. Anxiety
  6. Diarrhea
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76
Q

What are the ADWRs seen with antipyschotics? (4)

A
  1. Hallucinations
  2. Restlessness
  3. Agitation
  4. Insomnia
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77
Q

What are the ADWRs seen with beta-blockers? (3)

A
  1. Increased HR
  2. Increased BP
  3. Angina
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78
Q

What are the ADWRs seen with digoxin? (2)

A
  1. Palpitations
  2. Increased HR
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79
Q

What are the ADWRs seen with diuretics (furosemide, HCTZ)? (4)

A
  1. Increased BP
  2. Edema
  3. Weight gain
  4. SOB
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80
Q

What are the ADWRs seen with PPIs/H2RAs? (3)

A
  1. Nausea
  2. Weakness
  3. Decreased BP
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81
Q

What are the ADWRs seen with corticosteroids? (3)

A
  1. Nausea
  2. Weakness
  3. Decreased BP
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82
Q

What are the ADWRs seen with anticholinergic agents? (5)

A
  1. Anxiety
  2. Nausea
  3. Vomiting
  4. Diarrhea
  5. Dizziness
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83
Q

What are the ADWRs seen with antiparkinsonian agents? (3)

A
  1. Rigidity
  2. Tremor
  3. Hypotension
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84
Q

What are some medications to know that are NOT associated with ADWRs? (5)

A
  1. Bisphosphonates and denosumab
  2. Aspirin
  3. Anticoagulants
  4. Statins
  5. Vitamin and mineral supplements
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85
Q

What antihistamines should you be aware of on the BEERS list? (4)

A

First generations
e.g.,
1. Brompheniramine
2. Chlorpheniramine
3. Dimenhydrinate
4. Hydroxyzine

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86
Q

What anti-infective should you be aware of on the BEERS list? (1)

A

Nitrofurantoin

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87
Q

What cardiovascular and antithrombotic meds should you be aware of on the BEERS list? (8)

A
  1. Aspirin for primary prevention of CVD
  2. Warfarin for the treatment of nonvalvular atrial fibrillation or VTE
  3. Rivaroxaban
  4. -zosin meds
  5. Clonidine, guanfacine
  6. Nifedipine
  7. Amiodarone
  8. Digoxin
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88
Q

Which antidepressants are on the BEERS list that you should be aware of? (2)

A

Strong anticholinergic effects
1. TCAs
2. Paroxetine

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89
Q

What antiparkinsonian med should you be aware of on the BEERS list? (2)

A
  1. Benztropine
  2. Trihexyphenidyl
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90
Q

What APs should you be aware of on the BEERS list? (5)

A
  1. Aripip
  2. Haloperidol
  3. Olanzapine
  4. Quetiapine
  5. Risperidone
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91
Q

What barbituates should you be aware of on the BEERS list? (1)

A

Phenobarbitol

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92
Q

What benzos should you be aware of on the BEERS list?

A

Basically all of them are on there

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93
Q

What Z drugs should you be aware of on the BEERS list? (3)

A
  1. Eszopiclone
  2. Zaleplon
  3. Zolpidem
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94
Q

What androgen should you be aware of on the BEERS list?

A

Testosterone

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95
Q

Is insulin on the BEERS list? Why or why not?

A

Yes - risk of hypoglycemia

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96
Q

What sulfonylureas should you be aware of on the BEERS list? (2)

A
  1. Gliclazide
  2. Glyburide
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97
Q

What PPIs should you be aware of on the BEERS list?

A

Basically all of them
Omeprazole etc.

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98
Q

Is metoclopramide on the BEERS list. Why or why not?

A

Yes - can cause EPS

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99
Q

What pain meds should you be aware of on the BEERS list? (6)

A
  1. Aspirin
  2. Diclofenac
  3. Ibuprofen
  4. Indomethacin
  5. Ketorolac
  6. Naproxen
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100
Q

What skeletal muscle relaxants should you be aware of on the BEERS list? (2)

A
  1. Cyclobenzaprine
  2. Methocarbamol
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101
Q

What are geriatric syndromes? (2)

A
  1. Common health conditions in older adults that have multifactorial causes and do not fit into discrete disease categories
  2. Predispose older adults to poor health outcomes, decrease function and QoL
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102
Q

What are 6 examples of geriatric syndromes?

A
  1. Falls
  2. Frailty
  3. Cognitive impairment
  4. Delirium
  5. Urinary Incontinence
  6. Iatrogenesis (including polypharmacy)
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103
Q

Define a fall

A

An event which results in a person coming to rest inadvertently on the ground or other lower level

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104
Q

Why do we care about falls? (4)

A

Common in older adults
1. 20-30% fall each year
2. Best predictor of future falls = having a previous fall
3. Risk of falls increases with age
4. On average, every 10 minutes an older Canadian is hospitalized due to a fall

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105
Q

Falls are number 1 in what 2 things in older adults?

A
  1. # 1 mechanism of injury causing death in older adults
  2. # 1 cause of traumatic hospitalizations/non-fatal injuries in older adults
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106
Q

Falls account for 95% of hip fractures in older adults. What can that lead to? (2)

A
  1. 20% of those who suffer a hip fracture die within a year
  2. Another 20% will never live independently again
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107
Q

What is fear of falling syndrome?
What does that lead to? (3 total)

A
  1. When individuals restrict their activities due to the fear of falling
  2. Activity avoidance –> deconditioning –> increased fall risk
  3. Also leads to social isolation, low mood, decreased QoL
108
Q

What are the complications of falls in older adults? (6)

A
  1. Injuries
    - Painful soft tissue
    - Fractures
  2. Subdural hematoma
  3. Hospitalization
    - Complications of immobilization
    - Risk of iatrogenic illness
  4. Disability
  5. Increased risk of institutionalization
  6. Increased risk of death
109
Q

What are the 5 classes of risk factors for falls?

A
  1. Medical/biological
  2. Pharmacological
  3. Environmental
  4. Social/economic
  5. Behavioural
110
Q

What are the medical/biological risk factors for falls? (9)

A
  1. Deconditioning
    - Decreased muscle strength, decreased balance, poor gait pattern
  2. Vision impairment
  3. Hearing Impairment
  4. Orthostatic hypotension
  5. Heart rate or rhythm abnormalities
  6. Dizziness/syncope
  7. Pain
  8. Neuropathy
  9. Medical conditions
    - Dementia, Parkinson’s disease, previous strokes, depression, diabetes
    - Risk of falling is at least 2x higher in older adults with ≥ 4 chronic conditions
111
Q

What are the environmental risk factors for falls? (3)

A
  1. Home hazards
    - Clutter, pets, throw rugs, lighting, lack of handrails or other supports
  2. Community hazards
    - Snow/ice, uneven pavement, curbs, potholes, slippery floors, obstacles or tripping hazards
  3. Lack of familiarity with surroundings
112
Q

What are some easy ways to avoid falls at home (that is, how can the environment in the home be optimized?) (6)

A
  1. Non-slip floors
  2. Grab bars
  3. Better lighting
  4. Remove clutter
  5. Repair flooring
  6. Hand rails
113
Q

What are the social/economic risk factors for falls? (5)

A
  1. Social isolation
  2. Living alone
  3. Lack of community or family supports
  4. Lack of transportation
  5. Low income
114
Q

______ _________ has the same mortality and risk factors as smoking a pack of cigarettes a day

A

Social isolation

115
Q

What are the behavioural risk factors for falls? (6)

A
  1. Improper footwear choices
  2. Rushing
  3. Impulsivity/risk-taking
  4. Fear of falling/activity restriction
  5. (Lack of) use of assistive devices
  6. Alcohol use
116
Q

Drugs may contribute to falls in various ways. Such as? (6)

A
  1. Cognitive changes
  2. Movement disorders (secondary Parkinsonism)
  3. Gait and balance changes
  4. Muscles weakness
  5. Dizziness, drowsiness
  6. Vision changes
117
Q

Medications may contribute indirectly to falls. How so? (2)

A
  1. Example: diuretic –> urinary urgency/frequency –> fall rushing to the bathroom
  2. Polypharmacy (4+ concurrent meds) = increased fall risk
118
Q

Absence of appropriate drug therapy may also increase fall risk indirectly. Give an example as to how

A

E.g., lack of appropriate treatment for pain or COPD –> decreases activity tolerance –> increased fall risk

119
Q

How do benzos contribute to falls? (3)

A
  1. Muscle weakness, ↓ balance and coordination
  2. Drowsiness, dizziness
  3. Cognitive changes/confusion
120
Q

What antipsychotics have increased fall risk? (2 groups, 2 and 3 examples)

A
  1. Typical
    - Haloperidol
    - Chlorpromazine
  2. Atypical
    - Risperidone
    - Quetiapine
    - Olanzapine
121
Q

Which of the antidepressants are more anticholinergic and contribute to fall risk in older adults? (2)

A
  1. TCAs
    - AmiTRIPtyline
  2. Paroxetine
122
Q

What antiemtic is more anticholinergic and contributes to fall risk in older adults?

A

Dimenhydrinate

123
Q

What antihistamines are more anticholinergic and contribute to fall risk in older adults? (3)

A
  1. Dimenhydrinate
  2. Diphenhydramine
  3. Hydroxyzine
124
Q

What is an antimuscarinic that contributes to fall risk?

A

Oxybutynin

125
Q

What is an antiparkinsonian drug that contributes to fall risk?

A

Amantadine

126
Q

What are 2 antiseizure drugs that are anticholinergic and contribute to fall risk?

A
  1. Carbamazepine
  2. Oxcarbazepine
127
Q

What are some GI agents that are more anticholinergic and contribute to fall risk? (2)

A
  1. Loperamide
  2. Ranitidine
128
Q

What are some muscle relaxants that are more anticholinergic and contribute to fall risk? (3)

A
  1. Baclofen
  2. Cyclobenzaprine
  3. Methocarbamol
129
Q

What are some CV meds that increase fall risk? (2)

A
  1. Digoxin
  2. Type I antiarrhythmic meds (e.g., procainamide, disopyramide)
130
Q

Insulin has been associated with increased fall risks why?

A

Because of potential hypoglycemia, duh

131
Q

Do opioids contribute to fall risk?

A

Mixed results from studies

132
Q

Multifactorial risk assessment is recommended for: (3)

A
  1. Individuals that have fallen 2+ times in the past 12 months
  2. After an acute fall
  3. Gait or balance difficulties
133
Q

What are some multifactorial interventions for fall prevention? (8)

A
  1. Ambulatory assistive devices and protective equipment
  2. Clinical disease management
  3. Education
  4. Environmental modification
  5. Exercise programs
  6. Medication review and modification
  7. Nutrition and supplements
  8. Vision referral and correction
134
Q

Vitamin D for fall prevention. Yay or nay?

A

Mixed results, but it’s low risk low cost so might as well

135
Q

Fracture prevention does not prevent falls, but what is it good for?

A

Assessment and treatment of osteoporosis may help decrease fractures from falls, especially hip fractures

136
Q

What is frailty?
What is it characterized by?

A
  1. Medical syndrome that increases an individual’s vulnerability to loss of independence and/or death
  2. Characterized by decreased strength, endurance and functional reserves –> ↑ vulnerability to stressors
137
Q

Frailty is associated with: (4)

A
  1. Increased age
  2. Increased number of medical comorbidities
  3. Women > men
  4. Lower SES
138
Q

The best single-item predictor for frailty is?

A

Gait speed
- Predicts functional decline and mortality
- Gait speed < 0.8 m/s (usually measured over 20m) correlates with frailty

139
Q

Medication adverse effects may contribute to frailty. How so? (2)

A
  1. Medication –> nausea/GI upset –> ↓ appetite and weight loss
  2. Medication –> fatigue –> ↓ activity –> deconditioning
140
Q

How might frailty be managed? (4)

A
  1. Multifactorial causes –> multifactorial approaches
    - Comprehensive geriatric assessment
  2. Exercise programs
    - Aerobics, balance, and strength training
  3. Optimize health status
    - Treat underlying conditions as per goals of care
  4. Streamline medications as much as possible
141
Q

Use of ≥_ medications is associated with increased fall risk

A

4

142
Q

How are number of meds associated with cognitive impairment?

A

Impaired cognition in 22% of older adults taking <5 meds vs. 54% of those taking ≥10 meds

143
Q

Half of patients taking ≥__ medications were found to be malnourished

A

10

144
Q

What is delirium according to the DSM-5? (4)

A
  1. Acute onset
  2. Disturbances in attention, awareness, and cognition
  3. Fluctuates in severity
  4. Attributable to an underlying cause
145
Q

Delirium is an _____ ___________ state

A

acute confusional

146
Q

What are 3 other features of delirium?

A
  1. Psychomotor disturbance
  2. Altered sleep-wake cycle
  3. Emotional lability
147
Q

What is the significance of delirium? (4)

A
  1. Poor prognostic indicator
  2. Delirium is associated with:
    - 2x increased risk of death
    - 2.5x increased risk of discharge to higher level of care
    - 12.5x increased risk of developing dementia
  3. Increased length of hospitalization (5-10 days)
  4. Sustained functional decline 6 months after admission
148
Q

What underlying vulnerabilities can cause delirium? (4)

A
  1. Cognitive dysfunction
  2. Frailty
  3. Age
  4. Stressor(s)
    - Hypoxia
    - Infection
    - Drugs
    - Pain
    - Hypoglycemia
    - Dehydration
149
Q

What are some predisposing factors of delirium? (5)

A
  1. Increased age
  2. Dementia
  3. Functional impairment (baseline)
  4. Multimorbidity
  5. Others
    - Decreased vision and/or hearing
    - Mild cognitive impairment
    - Depression
    - Alcohol or drug use/withdrawal
150
Q

What are some precipitating factors of delirium? (7)

A
  1. DRUGS
  2. Surgery/trauma
  3. Pain
  4. Anemia
  5. Infection
  6. Exacerbation of chronic illness
  7. Bedridden
151
Q

What are the worst drugs in terms of causing delirium? (3 groups)

A
  1. Anticholinergics
    - TCAs
    - 1st gen antihistamines
    - 1st gen antipsychotics
    - Muscle relaxants
    - Antimuscarinics
    - Benztropine
  2. BZDs/Z-Drugs
  3. Opioids
152
Q

What are the bad, but not worst drugs in terms of causing delirium? (4 groups)

A
  1. Anticonvulsants
    - Carbamazepine
    - Phenytoin
    - Topiramate
    - Gabapentin/pregabalin
  2. Dopamine agonists
  3. Amantadine
  4. Cannabis (THC/dose-related)
153
Q

What drugs are less likely but can still possibly cause delirium? (4)

A
  1. Corticosteroids
  2. Psychoactive NSAIDs
  3. Digoxin
  4. Cannabis (CBD-based)
154
Q

What is the most useful bedside tool used for diagnosing delirium?

A

Confusion Assessment Method (CAM)

155
Q

The confusion assessment method (CAM) requires 1+2 with either 3 or 4. List 1 through 4 symptoms on the list

A
  1. Acute change in mental status with fluctuations
  2. Inattention
  3. Disorganized thinking
  4. Altered level of consciousness
156
Q

What are the 3 delirium subtypes?

A
  1. Hyperactive delirium
  2. Mixed delirium
  3. Hypoactive delirium
157
Q

What are the general symptoms of hyperactive delirium? (3)

A
  1. Combative
  2. Agitated
  3. Restless
158
Q

What are the general symptoms of hypoactive delirium? (3)

A
  1. Drowsy
  2. Somnolent
  3. Unarousable
159
Q

Delirium vs. Dementia: Onset

A

Delirium - acute (hours-days)
Dementia - chronic (months)

160
Q

Delirium vs. Dementia: Course

A

Delirium - fluctuating
Dementia - slowly progressive

161
Q

Delirium vs. Dementia: Decreased level of consciousness

A

Delirium - may be present
Dementia - absent

162
Q

Delirium vs. Dementia: Attention

A

Delirium - impaired
Dementia - preserved until end-stage

163
Q

Delirium vs. Dementia: Hallucinations

A

Delirium - common
Dementia - rare until later stages

164
Q

What are 4 strategies to help prevent delirium?

A
  1. Orientation
  2. Mobilization
  3. Medication review
  4. Hydration and nutrition
165
Q

Give examples of orientation in terms of preventing delirium (4)

A
  1. Use calendars, clocks
  2. Encourage use of glasses, hearing aids
  3. Accommodate visitors
  4. Promote regular sleep-wake cycle
166
Q

Give examples of mobilization in terms of preventing delirium (2)

A
  1. Physical therapy
  2. Avoid unnecessary lines, catheters, restraints
167
Q

Give examples of medication review in terms of preventing delirium (3)

A
  1. Reassess use of high-risk meds
  2. Medication/substance withdrawal?
  3. Pain control, bowel + bladder function
168
Q

Give examples of hydration and nutrition in terms of preventing delirium (1)

A

Maintain or optimize

169
Q

What is the hierarchy of methods to manage delirium? (3)

A

Base of the pyramid = identify and manage underlying causes
Middle = initiate or continue supportive strategies
Top = medication only if necessary

170
Q

When it comes to identifying and managing underlying cause(s) of delirium, what are some categories to be looking out for? (9)

A
  1. Readily reversible causes - e.g., hypoglycemia
  2. Infection
  3. Neurologic
  4. Medication-induced adverse effects, intentional or unintentional overdose, supratherapeutic levels because of renal or liver disease
  5. Toxicologic
  6. Metabolic
  7. Cardiopulmonary
  8. Environmental factors
  9. Other factors
171
Q

What are some examples of providing supportive care for delirium management? (7)

A
  1. Treat the underlying condition
  2. Manage pain and other symptoms
  3. Encourage mobilization
  4. Re-orientation cues
  5. Maintain sleep-wake schedule
  6. De-escalation for agitated individuals
  7. System-level interventions:
    - Minimize time spent in ER
    - Trained volunteers to calm, provide re-orientation
    - Low beds
    - Non-slip floors or socks
172
Q

We do pharmacological management of delirium ONLY IF: (3)

A
  1. The patient is in significant distress from their symptoms
  2. The patient poses a safety risk to self or others
  3. The patient is impeding essential aspects of medical care
173
Q

What is first line in pharmacological management of delirium?

A

Antipsychotics
- Similar efficacy among agents
- Choice based on side effect profile, patient factors, availability
- Start with low doses and titrate to effect ~q30min
- Prn doses thereafter

174
Q

What group of meds should be avoided in delirium management? (What is the exception)

A

Avoid benzos
- Except in alcohol-withdrawal delirium, terminal delirium

175
Q

The conventional drug of choice for delirium management is?

A

Haloperidol
- Note: if longer treatment duration is required, switch to atypical to reduce risk for EPS

176
Q

Of the atypical antipsychotics, which is most anticholinergic?

A

Olanzapine

177
Q

Which atypical AP is the agent of choice for individuals with Parkinson’s disease or Lewy Body Dementia?

A

Quetiapine

178
Q

Degree of sedation for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine

A

Haloperidol - low
Risperidone - low
Olanzapine - moderate
Quetiapine - high

179
Q

Risk of EPS for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine

A

Haloperidol - high
Risperidone - high
Olanzapine - moderate
Quetiapine - low

180
Q

Adverse effects for the following:
Haloperidol
Risperidone
Olanzapine
Quetiapine

A

Haloperidol - risk of EPS increases if daily dose exceeds 3mg
Risperidone - slightly less risk of EPS than with haloperidol at low doses
Olanzapine - more sedating than haloperidol
Quetiapine - much more sedating than haloperidol; risk of hypotension

181
Q

Atypical APs have a black-box warning for use in individuals with dementia. What is that warning?

A

Increased risk of mortality (~1.6x)
- Not seen in studies of short-term use for delirium (3-7 days)

182
Q

What is the role of the pharmacist in delirium prevention and management? (3)

A
  1. Deprescribe medications known to increase delirium risk
  2. Assess for and manage pain, constipation
  3. Ensure judicious use of antipsychotics for delirium
    - ≥25% of APs started in hospital are continued after discharge
183
Q

Define dementia

A

A clinical syndrome characterized by progressive cognitive decline that interferes with the individual’s ability to function independently

184
Q

What is mild cognitive impairment?
How does it compare to dementia?

A

Modest decline in cognition from previous
- May be subjective or may be observable on cognitive testing
- This decline does NOT interfere with the ability to function independently
- Greater effort of compensatory strategies may be necessary to maintain function
- May or may not progress to dementia

185
Q

How are delirium and dementia linked? (2)

A
  1. Individuals with dementia are particularly vulnerable to developing delirium
  2. Individuals that have experienced delirium are at higher risk of developing subsequent dementia
186
Q

Dementia is a diagnosis of _________

A

exclusion

187
Q

A helpful mnemonic for dementia when it comes to potentially reversible contributors to cognitive dementia is DEMENTIA. Should know it

A

Drugs (including alcohol)
Emotional (depression)
Metabolic, electrolytes, endocrine (hypothyroidism, hyponatremia, uremia)
Eyes and ears declining
Nutritional (e.g., vitamin B12 deficiency)
Tumor or other space-occupying lesion
Infection (neurosyphillus, HIV)
Anemia

188
Q

Anticholinergics may impact cognitive function in three ways:

A
  1. May cause or contribute to delirium
  2. May cause cognitive impairment that is reversible upon discontinuing the anticholinergic agent(s)
  3. There is evidence that cumulative anticholinergic exposure increases risk for subsequent dementia
189
Q

What are 5 types of dementia?

A
  1. Alzheimer’s disease
  2. Vascular dementia
  3. Frontotemporal dementia
  4. Parkinson disease dementia
  5. Lewy body dementia
    First 3 listed are the most common
190
Q

Alzheimer’s disease is the most common form of dementia. What is it characterized by? (progression, and physically)

A
  1. Slow and progressive
    - Short-term memory –> all areas of functioning
  2. Associated with characteristic beta-amyloid plaques and neurofibrillary tangles on autopsy
    - Head CT: cerebral atrophy
191
Q

Although the etiology of alzheimer’s is unclear, what are some risk factors? (6)

A
  1. Increased age
  2. Family history/genetics (APOE4 increases risk)
  3. Rare genetic mutations –> early onset-Alzheimer’s disease (<1%)
  4. History of severe head trauma
  5. Mild cognitive impairment
  6. Lifestyle - decreased exercise, smoking, obesity, HTN, poorly controlled diabetes, dyslipidemia
192
Q

What are some protective measures against alzheimer’s disease? (3)

A
  1. Educational attainment
  2. Social engagement
  3. Lifelong learning
193
Q

The main difference between dementia and mild cognitive impairment is:
a. Mild cognitive impairment develops quickly (hours-days)
b. With dementia, scores on cognitive tests are impaired (testing is normal in MCI)
c. Dementia impairs ability to perform functional activities
d. Mild cognitive impairment is the same as early dementia

A

c.

194
Q

Which of the following medications would you be concerned about in a patient complaining of cognitive decline?
a. Sertraline 100mg daily
b. Dimenhydrinate 25mg daily
c. Aspirin 81 mg daily
d. A and B
e. All of the above

A

b.

195
Q

What is vascular dementia?

A

Results from interrupted blood flow in parts of brain
- May or may not have a history of overt strokes - vascular damage usually visible on MRI and CT + CV risk factors

196
Q

What are CV risk factors associated with vascular dementia? (5)

A
  1. HTN
  2. High cholesterol
  3. Smoking
  4. Diabetes
  5. Heart disease
197
Q

Describe onset of vascular dementia

A

May be abrupt (after an event) OR gradual
- May have periods of relative stability interspersed with periods of more rapid decline (“stepwise” decline)

198
Q

How do symptoms of vascular dementia compare to alzheimer’s disease? (2)

A
  1. Complex thinking and planning, personality changes, agitation, and moodiness are more common early on that in AD
  2. Insight into deficits may be more preserved in vascular dementia vs. AD
199
Q

What is unique about frontotemporal dementia? (2)

A
  1. Strong genetic component
  2. Earlier onset (40-50 years) and no increased prevalence with age
200
Q

In frontotemporal dementia, damage is initially limited to the frontal and temporal lobes…hence the name. What are the characteristics symptoms (3)

A
  1. Changes in speech, language, personality occur BEFORE memory changes
  2. Speech is more unusual, choppy, repetitive
  3. Poor judgement, disinhibited behaviour
    - Over time, progresses to global impairment
201
Q

What is the main diagnostic criteria for parkinson’s dementia?

A

Dementia that develops AFTER a clinical diagnosis of Parkinson disease
- Increased prevalance of PD dementia in older people with PD

202
Q

What are the early symptoms of parkinson’s dementia?

A

Impairment in attention, visuospatial skills, and planning and completing complex tasks

203
Q

What are the problems with parkinson’s disease treatment and parkinson’s dementia?

A

Dopaminergic treatments for PD may exacerbate behavioural and psychological symptoms of dementia

204
Q

What are Lewy bodies?

A

Abnormal deposits of alpha-synuclein protein in neurons

205
Q

What is lewy body dementia?

A

Parkinson disease in reverse
- Present with cognitive impairment and visual hallucinations FIRST or CONCURRENTLY with PD motor symptoms

206
Q

What are the 4 distinctive clinical features of lewy body dementia?

A
  1. Early postural instability and repeated falls are common
  2. Detailed, recurrent visual hallucinations
  3. Pronounced fluctuations in cognition
  4. Extremely sensitive to antipsychotics
207
Q

While dementia is a diagnosis of exclusion, what should be assessed during the process of diagnosis? (4)

A
  1. Neuroimaging (MRI or CT) may be supportive but is not diagnostic
  2. Rule out reversible causes for cognitive changes, including medications
  3. Detailed history
    - Collateral information is very important to assess functional status
  4. Cognitive assessment
208
Q

What is the most commonly used cognitive assessment tool used in diagnosing dementia?

A

Mini-Mental Status Examination (MMSE)

209
Q

What does the mini-mental status exam assess?
What score are we looking for?

A
  1. Multiple cognitive domains: orientation, attention, language, recall, calculation, visual reconstruction
  2. Highly sensitive and specific to dementia (≤26/30 considered abnormal)
210
Q

What does the functional activity questionnaire asses?
What does a higher score equal?
Who does it?

A
  1. Developed to assess functional impairment
  2. Higher score = poorer function
  3. Designed to be completed by a caregiver or close support
211
Q

Define BPSD (behavioural and psychological symptoms of dementia)

A

Non-cognitive symptoms of disturbed thoughts, preceptions, mood, or behaviour that may occur with dementia (particularly in the later stages)
- May be frustrating or distressing to caregivers
- Also may pose safety concerns

212
Q

Remember - all behaviour has meaning. Responsive behaviours are _____________ _________

A

communicating something

213
Q

What are some of the behavioural aspects of BPSD? (8)

A
  1. Agitation
  2. Aggression (may be verbal or physical)
  3. Wandering
  4. Disinhibition
  5. Repetitive behaviours
  6. Hoarding
  7. Vocalizations
  8. Nocturnal restlessness
214
Q

What are some of the psychological aspects of BPSD? (7)

A
  1. Apathy
  2. Emotional lability
  3. Paranoia
  4. Hallucinations
  5. Delusions
  6. Involuntary laughing or crying
  7. Depression
215
Q

What are the 4 classes of triggers for BPSD?

A
  1. Psychological
  2. Environmental
  3. Medical
  4. Medication
216
Q

What are some psychological triggers of BPSD? (5)

A
  1. Fear of danger or being abandoned
  2. Distress
  3. Loss of autonomy/control
  4. Paranoia
  5. Misinterpretation
217
Q

What are some environmental triggers of BPSD? (7)

A
  1. Not liking who is around
  2. Boredom
  3. Confusing surroundings
  4. Change in routine
  5. Loneliness
  6. Noise/sounds
  7. Low lighting
218
Q

What are some medical triggers of BPSD? (8)

A
  1. Pain
  2. Constipation
  3. Dehydration
  4. Hunger
  5. Hypothyroidism
  6. Infection
  7. Urinary retention
  8. Metabolic or electrolyte disturbances
219
Q

What are some medication groups that can trigger BPSD? (7)

A
  1. Anticholinergics
  2. Benzos, sedatives, hypnotics
  3. Opioids
  4. Cannabinoids
  5. Anticonvulsants
  6. Some antibiotics (fluoroquinolones, clarithromycin)
  7. Psychoactive NSAIDs (indomethacin, diclofenac)
220
Q

How should we approach dementia management? (6)

A
  1. Optimize management of co-morbid conditions
  2. Attempt to decrease/stop meds that may be contributing to cognitive impairment
  3. Refer to Alzheimer Society of Saskatchewan (or local)
  4. Encourage regular exercise and a healthy diet
  5. Encourage cognitive and social activity
  6. Caregiver support
221
Q

What are the 2 categories of pharmacological treatment of dementia?

A
  1. Treatment of dementia
    - Cholinesterase inhibitors
    - N-methyl-D-aspartate (NMDA) antagonist
    - ? emerging treatments
  2. Management of BPSD
    - Antipsychotics
    - Other meds as indicated e.g., antidepressants, pain meds
222
Q

What is the goal of treatment in dementia? (3)

A
  1. To improve the QoL for the individual and caregivers
  2. Maintain optimal function
  3. Provide maximum comfort
223
Q

What are 3 examples of cholinesterase inhibitors?

A
  1. Donepezil
  2. Galantamine
  3. Rivastigmine
224
Q

What is the MOA of cholinesterase inhibitors?

A

Prevent breakdown of ACh
- ACh is the main NT involved in memory and learning

225
Q

How effective are cholinesterase inhibitors? (2)

A
  1. May show small improvements in measures of cognition
    - Less frequently see improvements in functional abilities
  2. May slow progression (by months, not years) (~1 in 12)
226
Q

How long to see any benefits in cholinesterase inhibitors?
Long-term benefits?

A
  1. If benefit, seen in 3-6 months
  2. Long-term clinical benefit not clear
227
Q

What are the common adverse effects of cholinesterase inhibitors? (6)

A
  1. Nausea
  2. Loss of appetite
  3. Vomiting
  4. Diarrhea
  5. Insomnia
  6. Urinary urgency/frequency +/- incontinence
228
Q

What are the less common ADEs of cholinesterase inhibitors? (7)

A
  1. Weight loss
  2. Agitation
  3. Bradycardia
  4. Syncope
  5. GI bleed
  6. Behaviour disturbances
  7. Nightmares
229
Q

Cholinesterase inhibitors ADEs are ____-________

A

dose-related

230
Q

What are 2 contraindications to cholinesterase inhibitors?

A
  1. Uncontrolled/severe asthma or severe COPD
  2. Cardiac conduction abnormalities, bradycardia (HR < 55 bpm)
231
Q

What are 4 precautions to using cholinesterase inhibitors?

A
  1. Peptic ulcer disease or uncontrolled GERD
  2. Urinary incontinence
  3. Seizure history
  4. Concurrent anticholinergics
232
Q

What are the cardiovascular specific ADEs seen with cholinesterase inhibitors? (3)

A
  1. ↓ Heart rate and velocity of conduction
  2. ↓ Blood pressure
  3. Vasodilation of arterioles
233
Q

What is the respiratory specific ADE seen with cholinesterase inhibitors?

A

Increased bronchoconstriction

234
Q

What is the GI tract specific ADE seen with cholinesterase inhibitors?

A

Increased GI motility and peristalsis

235
Q

What is the urinary specific ADE seen with cholinesterase inhibitors?

A

↑ Contraction of ureter and bladder smooth muscle relaxation of sphincter

236
Q

What is the eye specific ADE seen with cholinesterase inhibitors?

A

Increased contractility of ciliary muscle and iris

237
Q

What are the secretions specific ADEs seen with cholinesterase inhibitors? (5)

A
  1. ↑ Salivation
  2. ↑ Lacrimation
  3. ↑ GI secretions
  4. ↑ Bronchial secretions
  5. ↑ Sweating
238
Q

True or False? Cholinesterase inhibitors are EDS

A

True
- Must NOT be taking concurrent anticholinergic meds at any time

239
Q

What is the NMDA antagonist medication?

A

Memantine (Ebixa)

240
Q

What is the MOA of memantine?

A

Block glutamate at NMDA receptor (Theory: persistent activation of NMDA contributes to symptoms)
- No effect on ACh

241
Q

True or False? NMDA antagonists are less tolerated than cholinesterase inhibitors?

A

False - better tolerated

242
Q

What are the ADEs of NMDA antagonist? (10)

A
  1. Dizziness
  2. Constipation
  3. Confusion
  4. Insomnia
  5. Headache
  6. Hypertension
  7. Restlessness
  8. Akathisia
  9. Nausea
  10. QT prolongation (<1%)
243
Q

When might we discontinue dementia pharmacological treatment?

A

General consensus - loss of ability to perform ADLs independently
- Dementia has progressed to a stage where there would be no meaningful benefit remaining

244
Q

True or False? There are no meds, vitamins, herbals etc. to help prevent cognitive decline or dementia

A

True - well, no evidence of anything at the moment

245
Q

What are some non-pharmacological ways to prevent dementia? (6)

A
  1. Usual CV risk reduction strategies
  2. Educational attainment/ongoing cognitive challenges
  3. Social engagement
  4. Exercise
  5. Healthy Diet
  6. Hearing/vision checks and use of aids as needed
246
Q

What is the basic MOA of new dementia -mab drugs?

A

Increase clearance of beta-amyloid, reducing beta-amyloid plaques in the brain
- Only indicated for alzheimer’s disease (early)

247
Q

Name the mab drugs being used for dementia

A

Lecanemab and donanemab - not yet approved in Canada but being reviewed

248
Q

Go through the steps of management of BPSD (4)

A
  1. Assess for and treat any medical/medication causes or contributors
  2. Explore and minimize psychological and environmental triggers
  3. Pharmacotherapy ONLY if behaviour is causing harm or significant distress to individual, caregivers, or others AND is persistent or recurrent
  4. Re-evaluate drug regimen after 3 months
249
Q

Which of the behavioural and psychological symptoms of BPSD may be amenable to pharmacotherapy? (5)

A
  1. Aggression
  2. Paranoia
  3. Hallucinations
  4. Delusions
  5. Depression
250
Q

When managing BPSD how do we assess and treat medical causes? (4)

A
  1. Taper/stop any medications that may be contributing
  2. Look for and manage any underlying medical issues
    - Infection
    - Endocrine (thyroid, diabetes, etc.)
    - Electrolyte abnormalities
    - Urinary retention
    - Assess for and treat pain**
  3. Offer food/drink often to prevent hunger and thirst
  4. Manage constipation proactively
251
Q

When managing BPSD, how do we assess for and manage psychological triggers? (5)

A
  1. Avoid social isolation; consider impact of environment/company on mood
  2. Allow individual to make decisions whenever possible
    - Give simple, clear choices
  3. Provide simple instructions
  4. Show a warm, kind, manner; do not infantilize or speak as if the individual is not present
  5. Do not argue; reassure and redirect
252
Q

When managing BPSD, how do we assess for and manage environmental triggers? (6)

A
  1. Encourage use of glasses/hearing aids
  2. Provide regular, structured daily routine
  3. Comfortable, familiar environment
  4. Avoid overstimulation (noises, crowds)
  5. Engaging activities, social opportunities
  6. Sun/bright light exposure during the day, dark at evening and nighttime
253
Q

What antidepressants do we want to be using in the management of BPSD? (3)

A
  1. SSRIs minus fluoxetine and paroxetine
  2. SNRIs
  3. Bupropion
254
Q

What classes of antidepressants do we want to avoid in the management of BPSD? (2)

A
  1. TCAs and paroxetine
  2. Fluoxetine
255
Q

Which class of antipsychotics is preferred in the management of BPSD?

A

Atypical
- Risperidone
- Olanzapine
- Quetiapine

256
Q

When do we give APs in the management of BPSD?

A

Given only if behaviour is causing harm and/or has not responded to non-pharmacological methods

257
Q

What are some ADEs to watch out for when using APs? (8)

A
  1. Weight gain
  2. ↓BP
  3. Anticholinergic effects
  4. Sedation
  5. Falls
  6. EPS
  7. Tardive dyskinesia
  8. Urinary retention
258
Q

Typically, in Saskatchewan, what AP is actually used in BPSD?

A

Quetiapine

259
Q

Using >1 antipsychotic at a time in BPSD. Yay or nay?

A

Nay - no evidence for it

260
Q

When is haloperidol specifically used in BPSD?

A

To manage acute delirium - PRN only
- Not recommended in Parkinson’s pts due to EPS

261
Q

When MIGHT stimulants (methylphenidate) be used in BPSD?
What would we prefer?

A
  1. Very occasionally used to treat apathy and loss of motivation
  2. External activity and environmental stimulation is
    more effective
262
Q

Why do we prefer not to use stimulants in BPSD? (2)

A
  1. Stimulant adverse effects usually outweigh any potential benefit
  2. ↑ blood pressure and heart rate, ↓ appetite, dizziness, insomnia, agitation
263
Q

When MIGHT sedatives be used in BPSD?

A

Considered when behaviour is thought to be directly correlated with lack of sleep OR behaviours are during night

264
Q

What sedatives should be avoided in BPSD? What to watch for? (3 item)

A
  1. Avoid antihistamines, sedating OTCs
  2. Watch for dependence and tolerance
  3. Increase risk of delirium and falls!!
265
Q

What is the pharmacist’s role in BPSD and dementia in general? (5)

A
  1. Communication is key
  2. Re-assessment of pharmacological treatments frequently as clinical status, function, goals of care change
  3. Advertise/refer to the Alzheimer Society; a support for both patient and caregiver(s)
  4. Recognize non-obvious presentations of other conditions in individuals with dementia
    - A change in behaviour could be due to many underlying factors (e.g. UTI, pain, change in routine, etc.)
  5. Be a calm, patient resource for both patient and caregiver for drug information, advice
    - Supplement with written information when possible
266
Q

What analgesics are appropriate to use in BPSD? (3)

A
  1. Acet
  2. NSAIDs
  3. Opioids
267
Q

Talk about analgesic use in BPSD (3)

A
  1. When pain is thought to be cause of behaviour
  2. A good trial of acetaminophen for pain is often overlooked
  3. Re-assess and increase dosage, or switch to opioids if necessary
    - Expect and manage constipation, sedation

350 again (1 decks)

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