Polypharmacy

Question 1

What are the 5 frailty syndromes in the elderly? [5]

Answer 1

Falls: Such as collapse, legs giving way, or being found on the floor

Immobility: Such as a sudden change in mobility, or being “stuck in the toilet”

Delirium: Such as acute confusion, sudden worsening of confusion, or “muddledness”

Incontinence: Such as a change in continence, or new onset or worsening of urine or faecal incontinence

Susceptibility to side effects of medication: Such as confusion with codeine, or hypotension with antidepressants

Question 2

Which medications increase the risk of falls? [6]

Answer 2

• Sedatives
• Antihypertensive medications
• Drugs that prolong QT interval
• Drugs that cause delirium
• Drugs that reduce vision
• Postural hypotension
• Drugs causing Hypoglycaemia

Question 3

What are the three types of anticholinergics? [3]

Answer 3

Blocks action of Acetylcholine at synapses in CNS + PNS

Divided into 3 categories:
* Antimuscarinic agents
* Ganglionic blockers (nicotinics)
* Neuromuscular blockers

Question 5

What are common (unwarranted) anticholinergic effects? [3]

Answer 5

• Dry mouth, constipation and urinary retention
• Linked to poor cognition and physical decline
• Associated with falls, and increased mortality and cardiovascular events.

Question 6

Name 5 medications that can cause constipation

Answer 6

Antacids
Antimuscarinics
Antidepressants
Anti-epileptic medications
Antipsychotics
Calcium supplements
Diuretics
Iron supplements
Opioids
Paracetamol
Amlodopine

Question 7

The most common medications to cause delirium are: [3]

Answer 7

Opiates

Benzodiazipine medications
- Given to older patients due to insomnia

Anti-cholinergic medications

Question 8

What are BP targets in over 80s? [1]

Answer 8

< 150/90 if over 80

Question 9

What are common drug ADRs of B blockers? [3]

Answer 9

Bradycardia
Heart block
Hypotension
Wheezing

Question 10

What are common drug ADRs of opiates? [3]

Answer 10

Constipation
Vomiting
Confusion
Urinary retention

Question 11

What are clinic [1] and ABPM [1] BP targets in over 80s?

Answer 11

Clinic: < 150/90
ABPM: < 145/85

Question 12

Why do you need to be careful about codeine / opiates with a patient who is had vomiting / diarrhoea? [1]

Answer 12

Opiates are renally excreted.

If fluid loss, might be in AKI - in which case need to change medication away from opiates

Question 13

How would you alter the below if a patient has become renally impaired?
- Morphine
- Enoxaparin
- Co-amoxiclav
- DOAC

Answer 13

• Morphine to oxycodone
• Enoxaparin - reduce dose to 20mg if CrCl is 15-30
• Co-amoxiclav - reduce dosing
• DOAC - not licensed below CrCl 15; reduce dosing -

Question 14

Why are the elderly more susecptible to anticholinergic effects of drugs? [1]

Answer 14

Increased perm. of BBB

Question 15

Which drug could you use instead of oxybutynin? [1]
E.g. in the elderly

Answer 15

Mirabegron

Question 16

A patient with dx PD becomes NBM.

Why is this critical and how would you treat them? [1]

Answer 16

Time critcal to ensure that get PD tx
- if NBM can give via NG tube or switch to rotigotine patch

Question 17

For each of the following, state a side effect [5]

Answer 17

Question 18

When calcuting Anticholinergic Burden Scale (ACB), a score of [] or more is considered clinically relevant

Answer 18

3 +

Question 19

START

Start [] in patients taking maintenance oral
corticosteroid therapy

GM

Answer 19

 Bisphosphonates in patients taking maintenance oral
corticosteroid therapy

Question 20

Which hypertensive levels should you stop NSAIDs on in the elderly?

Answer 20

with moderate-severe hypertension (moderate: 160/100mmHg –
179/109mmHg; severe: ≥180/110mmHg) (risk of exacerbation of
hypertension).

Question 21

Diclofenac is associated with
[body system] risks that are higher than the other non-selective NSAID

Answer 21

Diclofenac is associated with
cardiovascular risks that are higher than the other non-selective NSAID

Question 22

Urogenital System BNF Chapter 7

Do NOT offer [] (immediate release) to frail older
women.

Answer 22

Do NOT offer oxybutynin (immediate release) to frail older
women.

Question 23

In whcih conditions are bladder antimuscarinic drugs recommended to stop in CoE? [4]

Answer 23

STOP:
Bladder antimuscarinic drugs
 with dementia (risk of increased confusion, agitation).
 with chronic angle-closure glaucoma (risk of acute
exacerbation).
 with chronic constipation (risk of exacerbation)
 with chronic prostatism (risk of urinary retention).

Question 24

When should alpha blockers be stopped in CoE? [1]

Answer 24

in males with frequent incontinence i.e. one or more episodes
of incontinence daily (risk of urinary frequency and worsening
of incontinence).

Question 25

Which drugs are potentially inappropriate in persons aged ≥65 years of age with Parkinsoniasim, which regards to the GI system [2]

Answer 25

Prochlorperazine or metoclopramide with Parkinsonism (risk
of exacerbating Parkinsonism).

NB: both are dopamine agonists

Question 26

During an acute illness, which DMT2 medications should be withheld? [1]
Why? [1]

Answer 26

If hospitalised for major surgery or acute serious illnesses
- Treatment may be restarted once the patient’s condition has stabilised and they are
eating normally for at least 24 hours

Question 27

Stop BB x which drug to minimise risk of symptomatic heart block [1]

Answer 27

Beta-blocker in combination with verapamil

Question 28

The three acetylcholinesterase (AChE) inhibitors donepezil,
galantamine and rivastigmine are recommended as options for managing
mild to moderate Alzheimer’s disease. Start with treatment of lowest
acquisition cost (currently []).

Answer 28

The three acetylcholinesterase (AChE) inhibitors donepezil,
galantamine and rivastigmine are recommended as options for managing
mild to moderate Alzheimer’s disease. Start with treatment of lowest
acquisition cost (currently donepezil).