Safe Medication Use Flashcards
Any symptom in an elderly patient should be considered as what until proven otherwise?
A drug side effect
High-risk elderly: polypharmacy
Use of multiple drugs by a single patient for one or more conditions
≥9 meds, ≥12 doses
High-risk elderly: high-risk drugs
BZDs, hypnotics, APs, anticholinergics, narcotics, long-acting sulfonylureas, insulins, anticoagulants
High-risk elderly: patient characteristics
decreased weight, ≥85 years old, decreased renal function
High-risk elderly: drugs with a narrow TI
warfarin, digoxin, phenytoin, CBZ, VPA, Li
Other characteristics of high-risk elderly patients
History of prior ADRs
≥6 comorbidities
Effect of anticholinergics in the elderly
Confusion, which may lead to delirium +/- dementia
Anticholinergic effects on vision and potential outcome
Impaired ADL, falls and accidents
ACh effects on oral cavity and potential outcome
Decline in nutritional status, increased risk of infection
ACh effects on GI tract and potential outcome
Decline in nutritional status, worsening of disease, anxiety, pain
ACh effects on CV system and potential outcome
Worsening disease, anxiety
ACh effects on UT and potential outcome
Incontinence, infection, loss of independence
ACh effects on CNS and potential outcome
Cognitive dysfunction, impaired ADLs
ACh muscle relaxant examples
cyclobenzaprine, methocarbamol, carisoprodol, oxybutynin
ACh TCA example
amitriptyline
ACh antispasmodic examples
dicyclomine, hyoscyamine, propantheline
ACh antihistamine examples
diphenhydramine, chlorpheniramine, cyproheptadine, hydroxyzine, promethazine
Most anticholinergic medications
Amitriptyline, paroxetine, atropine, oxybutynin, tolterodine
How to reduce ACh risk from meds
D/C them
Effects of BZDs in the elderly
Increased risk of cognitive impairment, delirium, falls/fractures, motor vehicle crashes
Uses for BZDs in the elderly
May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, BZD withdrawal, severe generalized anxiety disorder, periprocedural anesthesia
How to reduce BZD risk in the elderly
Use a short-acting BZD at the lowest dose
If you have to treat anxiety, use an SSRI
ADs risk in the elderly
falls, anticholinergic ADRs (paroxetine, amitriptyline). Increased risk of hip fractures
How to reduce AD risk in the elderly
Start the patient on lower doses, start low and go slow
NSAID risks of the elderly
GI toxicity, CV risks, renal considerations
GI toxicity with NSAIDs
Ulcer risk is 4-5x higher than nonusers
~4-fold increased mortality related to PUD
Highest risk early
Risks increase ~4%/year of age >65
Study on NSAID-induced GI toxicity: ALL NSAIDs increase risk of GI complications compared to ibuprofen as a control
CV risks with NSAIDs
All NSAIDs increase risk of AMI
Worsening HF
Renal effects with NSAIDs
Reductions in renal blood flow
Sodium and water retention
Concern for combinations with ACEIs or diuretics commonly used in elders
How to reduce NSAID risk in the elderly
Misoprostol: 800mcg/day needed; lower doses decrease diarrhea, but less effective
H2RA: standard doses shouldn’t be used for prophy, but double doses are effective
PPI: standard doses effective
High-risk GI patients: COX-2 alone or NSAID + PPI offer similar but potentially insufficient protection, so consider COX-2 + PPI
