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Pharmacology > Pharmacology Of Older Adults > Flashcards

Pharmacology Of Older Adults Flashcards

1
Q

Antidepressants and antipsychotic medications that have anticholinergic burden?

A

“TO PACC”

TCAs
Olanzapine
Paroxetine
Antipsychotics/antidepressants
Chlorpromazine
Clozapine

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2
Q

Incontinence medications that have an anticholinergic burden?

A

“SOFTi”

Solifenacin
Oxybutynin
Fesoterodine
Tolterodine
Incontinence

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3
Q

Antihistamine medications that have an anticholinergic burden?

A

“MD ACHe”

Meclizine
Diphenhydramine
Antihistamines
Chlorphreniramine
Hydroxyzine

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4
Q

Anti-Parkinson’s medications that have an anticholinergic burden?

A

“TAB”

Trihexyphenidyl
Anti-Parkinson’s
Benztropine

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5
Q

Antispasmodic medications that have an anticholinergic burden?

A

“DASH”

Dicyclomine
Antispasmodics
Scopolamine
Hyoscyamine

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6
Q

Medication classes that have medication-causing sedative burden?

A

Antidepressants/antipsychotics
Antiseizure
Antihistamines (1st gen > 2nd gen)
Sedative hypnotics
Muscle relaxers
Opioids
Other (prazosin, terazosin, doxazosin, clonidine, levodopa, donepezil, atenolol, benztropine, indomethacin, metoclopramide)

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7
Q

Cardiovascular medication points to keep in mind for older adults

A

Downregulation of catecholamine receptors=decreased effectiveness of alpha/beta receptor antagonists

Increased sensitivity to QT-prolonging meds=increased risk of torsades de pointes

In pts >85 yo, strict control of HTN may not lead to improvement in outcomes; risk of death may be higher in individuals w/ BP <140/90 mmHg

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8
Q

Preferred agents for HTN

A

DHP calcium channel blockers (ex: amlodipine)

Thiazide diuretics (chlorthalidone preferred)

ACEi/ARB (when indicated)

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9
Q

Other agents for HTN

A

Beta blockers (decreased beta-adrenergic receptor function in older adults; appropriate when indicated)

Peripheral alpha-1 blockers/centrally-acting alpha agonists: doxazosin/prazosin/terazosin/clonidine; response does not appear to be diminished

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10
Q

Medications that commonly cause orthostatic HoTN (test Q per Dr. Wonderful)

A

Alpha blockers

Beta blockers

Calcium channel blockers

Tricyclic antidepressants

Antipsychotics

Diuretics

Direct vasodilators

Opioids

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11
Q

Atrial fibrillation recommendations

A

EAST-AFNET 4 (2020): rhythm control preferred in new onset, high CV risk pts

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12
Q

Amiodarone for afib

A

Avoid as first-line for afib d/t toxicities (thyroid disease, hepatic dysfunction, lung disease, neurologic abnormalities, and bradycardia)

May be appropriate if: pt has comorbid HF or left ventricular hypertrophy AND rhythm control is preferred to rate control

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13
Q

Digoxin for afib

A

Should not be used first-line for afib or HF (lacking evidence, narrow therapeutic window and reduced clearance in older adults is concerning)

Reserve for pts w/ HFrEF still symptomatic after maximizing BB, ACEi, and diuretic

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14
Q

HF checklist: things on the “yes” list

A

Tx fluid overload w/ loop diuretic (furosemide, torsemide, bumetanide)

HFpEF NYHA Class II/III + increased BNP: SGLT2i, MRA, can consider ARNI (sacubutril-valsartan)

HFrEF NYHA: BB (carvedilol, metoprolol succinate, or bisoprolol), ARNI/ACEi/ARB, MRA, SGLT2i

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15
Q

HF checklist: things on the “no” list

A

Fluid retention/HF exacerbation: verapamil, diltiazem, NSAIDs/COX-2 inhibitors, pioglitazone

Increased mortality: cilostazol, dronedarone

QT-prolongation risk: dextromethorphan-quinidine

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16
Q

STOPP criteria relevant recommendations for HTN/HF/Afib: beta blockers

A

In combo w/ verapamil or diltiazem (risk of heart block)

With symptomatic bradycardia (< 50/ min), type II heart block or complete heart block (risk of profound hypotension, asystole)

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17
Q

STOPP criteria relevant recommendations for HTN/HF/Afib: loops

A

As first line tx for HTN (there are safer and more effective alternatives available)

For LE edema w/o: HF, liver failure, nephrotic syndrome or renal failure (use leg elevation/ compression hosiery)

For tx of HTN w/ concurrent urinary incontinence (may exacerbate)

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18
Q

STOPP criteria relevant recommendations for HTN/HF/Afib: thiazides

A

With current significant: hypokalemia, hyponatremia, hypercalcemia

With a hx of gout (can be precipitated by thiazide)

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19
Q

STOPP criteria relevant recommendations for HTN/HF/Afib: RAAS agents

A

ACEi or ARBs in pts w/ hyperkalemia

Aldosterone antagonists w/ concurrent K-conserving drugs (w/o monitoring serum K)

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20
Q

STOPP criteria relevant recommendations for HTN/HF/Afib: others

A

Amiodarone as first-line antiarrhythmic in SVT (BB, CCB safer)

Digoxin in HFpEF

Verapamil/ diltiazem in NYHA Class III/V HF (may worsen)

PDE5 inhibitors (in severe HF, w/ nitrates)

Centrally-acting agents (less well tolerated by older people)

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21
Q

Antithrombotic recommendations: DOACs

A

First-line: apixaban

Avoid rivaroxaban for long-term tx of afib or VTE

Dabigatran “potentially” inappropriate

Warfarin: avoid for afib or VTE unless long-term use w/ >70% time-in-range

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22
Q

Antithrombotic recommendations: antiplatelets

A

Evaluate whether indicated, especially for primary prevention

Use caution w/ dual antiplatelet therapy (ASA + clopidogrel)

Few reasons to use regular-strength ASA or antiplatelet + anticoagulant

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23
Q

STOPP criteria for antithrombotics

A

Long-term aspirin at doses greater than 160mg per day

Aspirin w/ a past hx of peptic ulcer disease w/o concomitant PPI

Aspirin + clopidogrel as secondary stroke prevention (there are some exceptions; no evidence of added benefit over clopidogrel monotherapy)

Aspirin in combo w/ vitamin K antagonist, direct thrombin inhibitor or factor Xa inhibitors in pts w/ chronic afib

Antiplatelet agents w/ vitamin K antagonist, direct thrombin inhibitor or factor Xa inhibitors in pts w/ stable coronary, cerebrovascular or peripheral arterial disease

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24
Q

Statins in older adults?

A

Often appropriate to continue

Fine-tuning – consider changing simvastatin to another agent

D/c can be considered to reduce pill burden in late life

Initiation at a late age (e.g. 90 yo) may not provide benefit

Confusion/memory loss

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25
Q

Endocrine pharmacotherapy points to keep in mind for older adults

A

Older pts may have decreased hypoglycemia awareness

Different symptoms than typical in younger pts

Older adults are more likely to need emergency tx for hypoglycemic episodes

Consider relaxing goals when appropriate

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26
Q

Diabetes medication points to keep in mind

A

Increased incidence of hypoglycemia w/ sulfonylureas

Increased sensitivity/decreased clearance of insulin

Monitor GFR w/ metformin, SGLT2 use

Issues w/ transitions of care

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27
Q

SGLT21 safety points

A

Ex: canagliflozin, dapagliflozin, empagaflozin

Increased incidence of urogenital infections in older adults (Fournier’s gangrene) - skin checks extra important

Renal monitoring

Fluid balance

Euglycemic ketoacidosis

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28
Q

Hormone therapy safety points

A

Avoid estrogen/testosterone HRT (there are exceptions)

Thyroid, growth hormone

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29
Q

General points when considering insomnia medication

A

Older adults have higher risk of AEs from hypnotics

Excessive sedation, cognitive impairment, night wandering, agitation, balance issues/falls

Risk of “hangover” effects from sleep meds

Continually assess effectiveness - avoid stacking

Important to determine underlying cause: anxiety/depression, pain, sleep apnea, restless leg syndrome, meds (both sedating and stimulating), urination urges, poor sleep hygiene

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30
Q

Insomnia medications that are NOT recommended

A

Benzodiazepines, Z-drugs, TCAs (except doxepin <6 mg), first gen antihistamines (diphenhydramine), antipsychotics (quetiapine)

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31
Q

Alternatives for insomnia medications

A

Suvorexant/lemborexant, melatonin/ramelteon, trazodone, mirtazapine ≤15 mg, low dose doxepin

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32
Q

Insomnia non-pharmacological treatment options

A

CBT-I, sleep education, sleep hygiene, sleep restriction therapy, stimulus control therapy, counter-arousal measures

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33
Q

NSAIDs for pain?

A

Not recommended

Significant AEs: GI bleeding, peptic ulcer, increased BP, worsening HF, CV events, kidney injury

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34
Q

Alternatives to NSAIDs for pain management

A

Non-pharm tx, APAP, diclofenac gel (Voltaren)

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35
Q

Skeletal muscle relaxants for pain?

A

Not recommended (ex: cyclobenzaprine, carisoprodol, methocarbamol)

Generally poorly tolerated by older adults

Can lead to dependence

Alternatives: non-pharm tx

36
Q

Medications for GERD/upper GI issues that are not recommended

A

PPIs >8 weeks (unless for gastric protection or high-risk pts)

Metoclopramide

Antispasmodics

37
Q

Alternative medications for GERD/upper GI issues

A

Non-pharm tx, H2 blockers (not appropriate for gastric protection; can contribute to delirium), antacids for intermittent issues

38
Q

Medications for constipation that are not recommended

A

Mineral oil, saline containing osmotic laxatives

39
Q

Alternative medications for constipation

A

Alternatives: prevent cause, fiber (metamucil, benefiber), polyethylene glycol (Miralax), senna

40
Q

Medications for incontinence that are not recommended

A

Anticholinergics (ex: oxybutynin, tolterodine)

Exception: trospium

41
Q

Alternative medications for incontinence

A

Non-pharm tx

D/c diuretics

Beta-3 adrenoreceptor agonists (mirabegron (Myrbetriq)/vibegron (Gemtesa) –> avoid w/ severe/uncontrolled HTN)

Trospium (does not appreciably penetrate the CNS)

42
Q

UTI medication considerations

A

Remember that UTI in older adults can present differently

Caution w/ abx for prophylaxis – make sure to monitor (SMX-TMP)

Avoid long-term nitrofurantoin

43
Q

What to use for UTI?

A

Can use vaginal estrogen

44
Q

Medications for BPH that are not recommended

A

Alpha-1-adrenergic antagonists

45
Q

Alternative medications for BPH

A

Alternatives: tamsulosin, finasteride

NEED to take tamsulosin w/ food - if not can cause drop in BP and very high risk for falling

46
Q

Supplements considerations

A

Good place to reduce pill burden in pts w/ generally healthy diet, if pt is taking random supplements

Consider initiating/screen for deficiency in: calcium/vitamin D, vitamin B12, iron, magnesium

47
Q

Medications for allergies that are not recommended

A

1st gen antihistamines (diphenhydramine)

48
Q

Alternative medications for allergies

A

Nasal corticosteroids, 2nd gen antihistamines (loratadine), saline nasal spray

49
Q

Asthma/COPD pearls

A

Simplify the regimen

Ensure the regimen is appropriate and guideline-driven

Ensure the pt knows what each device is for

Watch for expired inhalers

Nebulizers - Medicare Part B

50
Q

Antimicrobial considerations

A

Nitrofurantoin: avoid if CrCl <30

Fluoroquinolones: older adults more susceptible to tendon rupture

51
Q

How to treat delirium in general?

A

Use non-pharm options first

May need to tx w/ meds if severe, there is little evidence to guide use

Low dose haloperidol has most evidence (0.5 -1 mg/dose, <5 mg/day; PO, IM, or IV) - REMEMBER IV use associated w/ QT-prolongation

Use another antipsychotic in pts w/ Parkinson disease (pimavanserin)

52
Q

What to avoid in treatment of delirium

A

Benzodiazepines

53
Q

Name some cholinesterase inhibitors for dementia

A

Donepezil (MC), rivastigmine, galantamine

AEs: n/v, weight loss, vivid dreams, bradycardia, HoTN

CI in pts w/ bradycardia/cardiac conduction disease (increases risk of syncope –> falls –> fractures)

Caution when combined w/ beta blocker/CCBs

54
Q

When to discontinue ACh inhibitors?

A

If no improvement in 6 months after initiation

If decline seen upon d/c, may resume

D/c upon progression to severe dementia

Reasonable to continue if well-tolerated

Taper, do not abruptly d/c

55
Q

Memantine (Namenda)

A

Is considered neuroprotective, can be added to donepezil

Generally well-tolerated

AEs: dizziness, rare agitation

56
Q

How to manage behavioral and psychological symptoms in dementia

A

No meds are truly “safe” for behavioral/psychological symptoms in dementia

Evaluate and address the underlying cause

Start first with behavioral approaches (calming activities, misdirection)

Antipsychotics can be used for severe symptoms

Avoid benzodiazepines

57
Q

Antipsychotics for severe behavioral/psychological dementia symptoms

A

Risperidone, olanzapine, quetiapine most widely studied (remember BBW for increased risk of mortality in older adults)

Pimavanserin (Nuplazid) for Parkinson’s related psychosis

Only use for severe symptoms/other methods not effective; ideal to limit use to shortest duration possible

58
Q

Antipsychotic medication points to consider

A

Anticholinergic, sedating, QTc prolongation, metabolic effects; orthostatic HoTN w/ risperidone

Attempt d/c at regular intervals

Avoid in pts w/ Lewy body dementia or Parkinson’s disease (except pimavanserin)

Avoid long acting injectables

59
Q

Other agents for severe behavioral/psychological dementia symptoms

A

Citalopram, dextromethorphan-quinidine

60
Q

What medication class is first line treatment for depression in older adults?

A

SSRIs

No major differences in efficacy between agents; minimization of AEs should drive drug choice

Sertraline, citalopram, escitalopram are best choices for older adults

61
Q

SSRI AE consideration points

A

Parkinsonism, akathisia, anorexia, sinus bradycardia, hyponatremia, sedative, anticholinergic burden, suicide risk

62
Q

Benzodiazepines

A

Increased effects in older adults

Increased sedative burden

AEs: unstable gait, falls, confusion/cognitive impairment, amnesia, dependence

Safest choices are lorazepam, oxazepam, and temazepam (hydrophilic, no active metabolites, shorter duration)

Taper upon d/c

63
Q

Warfarin

A

AVOID for initial therapy for treatment of non-valvular afib or VTE unless alternative options are contraindications

CAN be reasonable to continue on pts who have been on it long term with little AEs

64
Q

Rivaroxaban

A

AVOID in long term treatment of afib or VTE in favor of safer alternatives

May cause higher risk of major bleeding and GI bleeding

65
Q

Alpha blockers (prazosin, doxazosin, terazosin)

A

AVOID for treatment of HTN due to high risk of HoTN and other associated harms in older adults

66
Q

Clonidine and guanfacine (central alpha-agonists)

A

AVOID as first line treatment for HTN in older adults

67
Q

Nifedipine (CCB)

A

AVOID in older adults d/t potential for HoTN and risk of MI

68
Q

Amiodarone

A

AVOID as first line treatment for afib unless pt has HF or substantial LVH

69
Q

Digoxin

A

AVOID this rate-control agent as first line therapy for afib

AVOID as first line therapy for HF

70
Q

T/ F - Quetiapine is an antipsychotic that should be avoided EXCEPT for use in schizophrenia, Bipolar disorder, Parkinson’s disease psychosis

A

True

71
Q

These should be avoided in older pts d/t high risk of physical dependence, tolerance to sleep benefits, and greater risk of overdose at low dosages

A

Barbituates

Butalbital

Phenobarbital

Primidone

72
Q

Why should benzodiazepines be avoided in older adults?

A

Risk of abuse, misuse, addiction

May cause sedation, respiratory depression, coma, and death

73
Q

What are non-benzodiazepine benzodiazepine receptor agonist hypnotics and have AEs similar to benzodiazepines in older adults?

A

Z-drugs

Eszopiclone

Zaleplon

Zolpidem

74
Q

_____ should be avoided in older adults unless indicated for confirmed hypogonadism w/ clinical symptoms

A

Androgens

75
Q

What medication is recommended by the BEERs list for dyspareunia, recurrent lower UTI, and other vaginal symptoms?

A

Vaginal estrogen

76
Q

Insulin is to be avoided according to the BEER’s list, however, it only applies to a certain kind of insulin, which kind?

A

Short term or rapid-acting regimens

77
Q

This class of diabetes medication should be avoided as first or second monotherapy or even add on therapy unless there are substantial barriers to use safer more effective agents

A

Sulfonylureas (gliclazide, glimepride, glipizide, glyburide)

78
Q

Why can we not prescribe growth hormone to our older patients?

A

Associated w/ edema, arthralgia, carpal tunnel syndrome, gynecomastia, and impaired fasting glucose

79
Q

What GI medication class should generally be avoided for scheduled use >8 weeks? Why?

A

PPIs

Can cause Cdiff infection, pneumonia, GI malignancies, bone loss

80
Q

Avoid this medication (unless for use in gastroparesis with duration not to exceed 12 weeks) as it can cause extrapyramidal effects (ex: tardive dyskinesia)

A

Metoclopromide

81
Q

Name some GI antispasmodic medications. Why should they be avoided in older adults?

A

Atropine, clidinium, dicyclomine, hyoscyamine, scopolamine

Highly anticholinergic

82
Q

T/F - oral mineral oil should be avoided in older adults d/t risk of aspiration

A

True

83
Q

_____ should NOT be used for treatment of nocturia or nocturnal polyuria (due to a high risk of hyponatremia)

A

Desmopressin (DDAVP)

84
Q

These should be avoided for chronic use unless other alternatives can be used along with gastroprotective agent

A

Non-COX-2 NSAIDs

Also not recommended for short term scheduled use in combo w/ steroids, anticoagulation, antiplatelets

85
Q

This should be avoided for pain d/t increased risk of GI bleeding/peptic ulcer disease, and AKI (this medication also has the most AEs)

A

Indomethacin

86
Q

Name some skeletal muscle relaxants. Why are they to be avoided in older patients?

A

Carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine

Anticholinergic AEs: sedation –> increased risk of falls –> increased risk of fractures

Pharmacology (4 decks)

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