Pharmacology Of Older Adults Flashcards
Antidepressants and antipsychotic medications that have anticholinergic burden?
“TO PACC”
TCAs
Olanzapine
Paroxetine
Antipsychotics/antidepressants
Chlorpromazine
Clozapine
Incontinence medications that have an anticholinergic burden?
“SOFTi”
Solifenacin
Oxybutynin
Fesoterodine
Tolterodine
Incontinence
Antihistamine medications that have an anticholinergic burden?
“MD ACHe”
Meclizine
Diphenhydramine
Antihistamines
Chlorphreniramine
Hydroxyzine
Anti-Parkinson’s medications that have an anticholinergic burden?
“TAB”
Trihexyphenidyl
Anti-Parkinson’s
Benztropine
Antispasmodic medications that have an anticholinergic burden?
“DASH”
Dicyclomine
Antispasmodics
Scopolamine
Hyoscyamine
Medication classes that have medication-causing sedative burden?
Antidepressants/antipsychotics
Antiseizure
Antihistamines (1st gen > 2nd gen)
Sedative hypnotics
Muscle relaxers
Opioids
Other (prazosin, terazosin, doxazosin, clonidine, levodopa, donepezil, atenolol, benztropine, indomethacin, metoclopramide)
Cardiovascular medication points to keep in mind for older adults
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
Preferred agents for HTN
DHP calcium channel blockers (ex: amlodipine)
Thiazide diuretics (chlorthalidone preferred)
ACEi/ARB (when indicated)
Other agents for HTN
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
Medications that commonly cause orthostatic HoTN (test Q per Dr. Wonderful)
Alpha blockers
Beta blockers
Calcium channel blockers
Tricyclic antidepressants
Antipsychotics
Diuretics
Direct vasodilators
Opioids
Atrial fibrillation recommendations
EAST-AFNET 4 (2020): rhythm control preferred in new onset, high CV risk pts
Amiodarone for afib
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
Digoxin for afib
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
HF checklist: things on the “yes” list
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
HF checklist: things on the “no” list
Fluid retention/HF exacerbation: verapamil, diltiazem, NSAIDs/COX-2 inhibitors, pioglitazone
Increased mortality: cilostazol, dronedarone
QT-prolongation risk: dextromethorphan-quinidine
STOPP criteria relevant recommendations for HTN/HF/Afib: beta blockers
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)
STOPP criteria relevant recommendations for HTN/HF/Afib: loops
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)
STOPP criteria relevant recommendations for HTN/HF/Afib: thiazides
With current significant: hypokalemia, hyponatremia, hypercalcemia
With a hx of gout (can be precipitated by thiazide)
STOPP criteria relevant recommendations for HTN/HF/Afib: RAAS agents
ACEi or ARBs in pts w/ hyperkalemia
Aldosterone antagonists w/ concurrent K-conserving drugs (w/o monitoring serum K)
STOPP criteria relevant recommendations for HTN/HF/Afib: others
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)
Antithrombotic recommendations: DOACs
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
Antithrombotic recommendations: antiplatelets
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
STOPP criteria for antithrombotics
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
Statins in older adults?
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
Endocrine pharmacotherapy points to keep in mind for older adults
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
Diabetes medication points to keep in mind
Increased incidence of hypoglycemia w/ sulfonylureas
Increased sensitivity/decreased clearance of insulin
Monitor GFR w/ metformin, SGLT2 use
Issues w/ transitions of care
SGLT21 safety points
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
Hormone therapy safety points
Avoid estrogen/testosterone HRT (there are exceptions)
Thyroid, growth hormone
General points when considering insomnia medication
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
Insomnia medications that are NOT recommended
Benzodiazepines, Z-drugs, TCAs (except doxepin <6 mg), first gen antihistamines (diphenhydramine), antipsychotics (quetiapine)
Alternatives for insomnia medications
Suvorexant/lemborexant, melatonin/ramelteon, trazodone, mirtazapine ≤15 mg, low dose doxepin
Insomnia non-pharmacological treatment options
CBT-I, sleep education, sleep hygiene, sleep restriction therapy, stimulus control therapy, counter-arousal measures
NSAIDs for pain?
Not recommended
Significant AEs: GI bleeding, peptic ulcer, increased BP, worsening HF, CV events, kidney injury
Alternatives to NSAIDs for pain management
Non-pharm tx, APAP, diclofenac gel (Voltaren)
Skeletal muscle relaxants for pain?
Not recommended (ex: cyclobenzaprine, carisoprodol, methocarbamol)
Generally poorly tolerated by older adults
Can lead to dependence
Alternatives: non-pharm tx
Medications for GERD/upper GI issues that are not recommended
PPIs >8 weeks (unless for gastric protection or high-risk pts)
Metoclopramide
Antispasmodics
Alternative medications for GERD/upper GI issues
Non-pharm tx, H2 blockers (not appropriate for gastric protection; can contribute to delirium), antacids for intermittent issues
Medications for constipation that are not recommended
Mineral oil, saline containing osmotic laxatives
Alternative medications for constipation
Alternatives: prevent cause, fiber (metamucil, benefiber), polyethylene glycol (Miralax), senna
Medications for incontinence that are not recommended
Anticholinergics (ex: oxybutynin, tolterodine)
Exception: trospium
Alternative medications for incontinence
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)
UTI medication considerations
Remember that UTI in older adults can present differently
Caution w/ abx for prophylaxis – make sure to monitor (SMX-TMP)
Avoid long-term nitrofurantoin
What to use for UTI?
Can use vaginal estrogen
Medications for BPH that are not recommended
Alpha-1-adrenergic antagonists
Alternative medications for BPH
Alternatives: tamsulosin, finasteride
NEED to take tamsulosin w/ food - if not can cause drop in BP and very high risk for falling
Supplements considerations
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
Medications for allergies that are not recommended
1st gen antihistamines (diphenhydramine)
Alternative medications for allergies
Nasal corticosteroids, 2nd gen antihistamines (loratadine), saline nasal spray
Asthma/COPD pearls
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
Antimicrobial considerations
Nitrofurantoin: avoid if CrCl <30
Fluoroquinolones: older adults more susceptible to tendon rupture
How to treat delirium in general?
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)
What to avoid in treatment of delirium
Benzodiazepines
Name some cholinesterase inhibitors for dementia
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
When to discontinue ACh inhibitors?
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
Memantine (Namenda)
Is considered neuroprotective, can be added to donepezil
Generally well-tolerated
AEs: dizziness, rare agitation
How to manage behavioral and psychological symptoms in dementia
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
Antipsychotics for severe behavioral/psychological dementia symptoms
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
Antipsychotic medication points to consider
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
Other agents for severe behavioral/psychological dementia symptoms
Citalopram, dextromethorphan-quinidine
What medication class is first line treatment for depression in older adults?
SSRIs
No major differences in efficacy between agents; minimization of AEs should drive drug choice
Sertraline, citalopram, escitalopram are best choices for older adults
SSRI AE consideration points
Parkinsonism, akathisia, anorexia, sinus bradycardia, hyponatremia, sedative, anticholinergic burden, suicide risk
Benzodiazepines
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
Warfarin
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
Rivaroxaban
AVOID in long term treatment of afib or VTE in favor of safer alternatives
May cause higher risk of major bleeding and GI bleeding
Alpha blockers (prazosin, doxazosin, terazosin)
AVOID for treatment of HTN due to high risk of HoTN and other associated harms in older adults
Clonidine and guanfacine (central alpha-agonists)
AVOID as first line treatment for HTN in older adults
Nifedipine (CCB)
AVOID in older adults d/t potential for HoTN and risk of MI
Amiodarone
AVOID as first line treatment for afib unless pt has HF or substantial LVH
Digoxin
AVOID this rate-control agent as first line therapy for afib
AVOID as first line therapy for HF
T/ F - Quetiapine is an antipsychotic that should be avoided EXCEPT for use in schizophrenia, Bipolar disorder, Parkinson’s disease psychosis
True
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
Barbituates
Butalbital
Phenobarbital
Primidone
Why should benzodiazepines be avoided in older adults?
Risk of abuse, misuse, addiction
May cause sedation, respiratory depression, coma, and death
What are non-benzodiazepine benzodiazepine receptor agonist hypnotics and have AEs similar to benzodiazepines in older adults?
Z-drugs
Eszopiclone
Zaleplon
Zolpidem
_____ should be avoided in older adults unless indicated for confirmed hypogonadism w/ clinical symptoms
Androgens
What medication is recommended by the BEERs list for dyspareunia, recurrent lower UTI, and other vaginal symptoms?
Vaginal estrogen
Insulin is to be avoided according to the BEER’s list, however, it only applies to a certain kind of insulin, which kind?
Short term or rapid-acting regimens
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
Sulfonylureas (gliclazide, glimepride, glipizide, glyburide)
Why can we not prescribe growth hormone to our older patients?
Associated w/ edema, arthralgia, carpal tunnel syndrome, gynecomastia, and impaired fasting glucose
What GI medication class should generally be avoided for scheduled use >8 weeks? Why?
PPIs
Can cause Cdiff infection, pneumonia, GI malignancies, bone loss
Avoid this medication (unless for use in gastroparesis with duration not to exceed 12 weeks) as it can cause extrapyramidal effects (ex: tardive dyskinesia)
Metoclopromide
Name some GI antispasmodic medications. Why should they be avoided in older adults?
Atropine, clidinium, dicyclomine, hyoscyamine, scopolamine
Highly anticholinergic
T/F - oral mineral oil should be avoided in older adults d/t risk of aspiration
True
_____ should NOT be used for treatment of nocturia or nocturnal polyuria (due to a high risk of hyponatremia)
Desmopressin (DDAVP)
These should be avoided for chronic use unless other alternatives can be used along with gastroprotective agent
Non-COX-2 NSAIDs
Also not recommended for short term scheduled use in combo w/ steroids, anticoagulation, antiplatelets
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)
Indomethacin
Name some skeletal muscle relaxants. Why are they to be avoided in older patients?
Carisoprodol, chlorzoxazone, cyclobenzaprine, metaxalone, methocarbamol, orphenadrine
Anticholinergic AEs: sedation –> increased risk of falls –> increased risk of fractures
