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Peds and Geriatrics > Week 5 > Flashcards

Week 5 Flashcards

1
Q

Normal Bladder function physiology

A

Normal micturition occurs when bladder contraction is coordinated with urethral sphincter relaxation.

storage phase:
micturition phase:

SYMPATHETIC NERVOUS SYSTEM:
beta activity relaxes the detrusor muscle
alpha activity contracts smooth muscle sphincter

PARASYMPATHETIC NERVOUS SYSTEM:
contracts the bladder detrusor muscle through cholinergic fibers from the pelvic nerve. (muscarinic receptors)

SOMATIC NERVOUS SYSTEM:
contracts the striated muscle sphincter thorugh cholinergic fibers from the pudendal nerve

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2
Q

Common causes if incotinence

A

urethral obstrucction (BPH)

impair bladder contraction

incompetent sphincter

bladder inflammation

bladder stones

malignancy

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3
Q

common meds affecting incontinence

A

alpha agonists/antagoinsts

alcohol

anticholinergics

CCB

diuretics

narcotics

antidepressants

antiphysicotics

sedative/hypnotics

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4
Q

urinerary incotinance examination

A

physical exams
*digital rectal or pelvic exam
*neurologici exam
*PVR
cystoscopy/cystometroghram?

labs
*U/A w. micro
serum bun/Cr
*PSA

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5
Q

Drug: DESMOPRESSIN nasal spray (Noctiva) aka ADH

Indication
warnings:
monitoring:
CI:
Dosing:
How supplied

A

Drug

Indication: nocturnal polyrucia (awaken >/2x/night to void
warnings: fluid retention, hyponatremia, nasal conditions
monitoring: Na+ levels

CI: hyponatremia, polydypsia, primary nocturnal enuresis, concamminant use of loop diuretics or systemic or inhaled glucocorticouids, egfr<50, SIADH, during illness that can cause fluid retention or rlectrolyte imbalance, NYHA CLASS ii-iV CHF, uncontrolled HTN

Dosing: age 50-65>1 spray (1.66 mcg) either nostril~30 min before bed
age >65-: 1 spray (0.83 mcg) either nostril~30 min before bed

How supplied

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6
Q

Types of incontinance

Urge incontinance (Overactive bladder)

A

what is it: involentary leakage of urine and involentary contraction of bladder

causes: detrusor hypperreflexia
*neurologic
stones
tumor
cystitis

mechanism to treat: anti-muscarinic with atropine like effects
*antispasmodics

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7
Q

TREATMENT OF OAB

list of drugs that work on PSNS (micturition phase) ( antimuscarinics/ antispasmodics)

A

oxybutinin

tolteridine

trospium (sanctura)

Darifenacin (Enablex)

Solifenacin (Vesicare)

Fesoterodine (Toviaz)

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8
Q

oxybutinin

moa:
dose:
notes:

A

moa: anti-musc, anti spasmodic
dose: 5mg big-tid
notes: oxytrol patch

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9
Q

Tolderidine

moa: anti-muscarinic
dose: 1-2 bid ER
notes: decrease bbb crossing, decreased lipo and salivery

A

moa:
dose:
notes:

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10
Q

Trospium

moa:
dose:
notes:

A

moa: antimuscarinic
dose: 20 mg bid
notes: decreased bb crossing

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11
Q

Darifenacin(Enablex) AND Solifenacin(Vesicare)
moa:
dose:
notes:

A

moa: both M3 specific
dose: 7.5 mg, 5 mg
notes: decreased side effects due to m3 specificity

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12
Q

Fesoteridine
moa:
dose:
notes:

A

moa:
dose:
notes:

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13
Q

Adverse effects of SM- relaxants

A

dry mouth

dry eyes/blurred vision

urinary retention

palpitations

constipation

dizziness/ drowsiness

confusion/delerium/dementia

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14
Q

which anticholinergic drug for OAB in adults

A

ER tolteridine solifenacin, and derafenicin have increased efficacy and decreased risk for adverse effects
dry mouth

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15
Q

other agents for OAB

A

imipramine or other TCA
*CONTRAINDICATED IN ELDERLY. risk for orthostasis, cardiac arrythmia, and other anticholinergic effects

Botox: detrusor overasctivity associated w. neurologic condition in adults with an inadequate response or intolerance to an anticholinergic medication

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16
Q

Drugs that treat SNS (storage phase) for OAB

A

B3 adrenergic receptor agonists

Mirabegron

Vibegron

Solabegron

Ritobegron

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17
Q

Drug: Mirabegron ER

Indication
warnings:
monitoring:
CI:
Dosing:
How supplied

A

Drug:

Indication: OAB
moa: detrusor muscle relaxation through agonism of b3 adrenergic receptor

pk: ~50 hrs half life

AE: nausea, headache, HTN, diarrhea, constipation, dizziness, and sinus tachycardia

warnings: uncontrolled HTN (sbp?180 mmhg or DBP?110
monitoring:
CI:
Dosing:
How supplied

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18
Q

Drug:Vibegron

Indication
warnings:
monitoring:
CI:
Dosing:
How supplied

A

Indication: OAB
moa: detrusor muscle relaxation through agonism of b3 adrenergic receptor

half life:

AE: nausea, headache, HTN, diarrhea, constipation, dizziness, and sinus tachycardia

warnings:

monitoring:

CI:

Dosing:
*no

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19
Q

AUA guidelines on OAB

A

1st line: behavioral therapies (bladder training, bladder control strategies, pelvic floor muscle training, fluid managemnt)

2nd line
oral antimuscarinics or oral b3 agonists
ER>IR
transdermal oxybutinin may be offered
combo anti-muscarinic and b3 agonist refractory to monotherapy
manage constipatio and dry mouth before abandoing effective antimuscariinic therapy
caution anti-m w. ther

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20
Q

Stress incontinance

A

involentary leakage with stress
*increased intra-abdominal pressure

decrease pelvic wall musculature

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21
Q

treatment of stress incontinance

A

alpha receptor agonists

  1. increase intra-urethral pressure
    *pseudoephedrine
    *midodrine

2.Estrogen replacement
*causes proliferation of urethral mucosa
*improves mucosal “outflow resistance”
AE: pap/mammogram, bleeding, DVT

Duloxetine
supresses bladder activity thorugh 5ht receptors and enhances external urethral sphincter activity

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22
Q

Overflow incontinence

A

Leak urine thoughout the day

due to “weight of urine”
r/t
BPH
neuropathies
anticholinergics

treatment: Bethanechol (urecholine)
stimulates muscarinic receptors to increase bladder tone

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23
Q

BPH (benign prostatic hyperplasia

A

proliferation of smooth muscle cells in prostate which increases size

proliferation of stromal and epithelial cells (static)

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24
Q

BPH patho

A

increase in smooth muscle tone (dynamic phase)

DYNAMICA bladder obstructiondue to alpha adrenergic receptors
*a1A, 70% of a receptors in prostate
*a1b
*a1d

sttaic bladder obstruction
*5a-reductase enzymes

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25
Q

symptoms of bph

A

incomplete emptying

frequency

intermittency

urgency

weak stream

straining

nocturia

boyardsky index

AUA symptom index

international prostate index score

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26
Q

nonpharm bph mangement

A

incontinance pads

TURP(transurethral resection of th eprostate)

urethral dilation

foley catheters

other (TUIP, TUDP, VLAP, microwave hyperthermia, enzyme injection

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27
Q

general meds used for bph

A

black a-1 in prostae to reduce muscle tone
terazosin>doxazosin>prazosin

howveer, ALLHAT trial: these meds were orginally used for htn. trial showed these meds did not reduce risk of heart events when used. should not be ysed for bp reduction, only bph. however need to monitor for bp lowering

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28
Q

alpha blockers AE for bph

A

POStural htn

dizziness/vertigo

blurred vision

drowsiness

asthenia

first doe effect , added effect with other htn meds)

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29
Q

a1-A specific blockers

A

selective for a-1a
Silodosin (38x)»lfuzosin~tamsulosin

Tamsulosin(flomax): 0.4-0.8 mg daily

alfusozin
10 mg daily w. food

sildosin (8mg daily)

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30
Q

adverse effects of a-1a specific blockers

A

rarely htn, vertigo, drowsiness

floppy iris synrome

ejaculatory dysfunction (sildosin>tamsulosin>

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31
Q

treatment of cellularity portion of bph

A

5-a-reductase inhibitor

finasteride
inhibits types II 5-a1 reductase
decrease dht
3-6 MONHS OF THERAPY, TAKES TIME
5 MG PO QD

DUTASTERIDE
*Selective inhibitor of type I and II 5-a-reductase
dose: 0.5 mg po qd

Jalyn (0.5 mg dutasterise/0.4 mg tamsulosin)

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32
Q

drugs o avoid in bph

A

TCA
diphenhydramine
disopyrimaide
psuedoehedrine
ephedrine
ACH drugs (including otc)

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33
Q

other bph treatments

A

tadalafil
*moa not established
*pde5 inhibitor
* this in combo w. alpha blocker can causesymptomtic hypotension

entadafi (finasteride 5 mg and tadalfil 5 mg

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34
Q

otc treatment of bph

A

SAW PALMETTO

been found it did not improve sympoms or objective measures of bph

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35
Q

guidelines for treatment of bph

A

initial: alpha blockers
*if t has bph and ed, pde5 can be started

lock or incomplete response…. consider pde5

if size is >30cc, 5 alpha reductase inhibiot can be added

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36
Q

erectil dysfunction patho

A

normal
“penal flaccidity
*penile erction

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37
Q

risk factors for ED

A

MEABOLIC SYNDROME

LOWER UTI OF BPH

tobacco smoking

neurologic ocnditions

spina cord injury

depression

endocrine conditions

dm

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38
Q

drugs that can cause erectile dysfunction

A

diuretics

htn meds (only betablockers except nebivolol)

cardiac and cholesteral

antidepressants

tranquilizes

h2 antagonists
cytotoxic agents

opioids

nsaids

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39
Q

drug therapy for ED

A

androgens

pde5

adrenergic receptor antagonists

apomorphine

trazodone

transurethral therapy

intracavernous

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40
Q

pde5 in ed

A

inhibits pde5 results in SM relaxation and inflroof blood into corpus cavinosum

pk: cyp3a4

CI: dont use inpts using nitrate therapy

additive effects c/ a-blockers

41
Q

pde5 moa

A

pde5 prevent break down of cGMP(produces erection) and prevents conversion to gmp which is inactive

42
Q

cardiac risks of pde5

A

low risk:Risk
Category Description of Patient’s Condition Management ApproachLow risk
Has asymptomatic cardiovascular disease with <3
risk factors for cardiovascular disease
Has well-controlled hypertension
Has mild congestive HF (NYHA class I or II)
Has mild valvular heart disease
Had a MI >8 weeks ago
Patient can be started on phosphodiesterase inhibitor

Intermediate
risk
Has ≥3 risk factors for cardiovascular disease
Has mild or moderate, stable angina
Had a recent MI or stroke within the past 2-8 weeks
Has moderate congestive HF (NYHA class III)
History of stroke, transient ischemic attack, or
peripheral artery disease
Patient should undergo complete cardiovascular workup and treadmill stress test to determine tolerance to increased myocardial energy consumption associated with increased sexual activity. Reclassify in low or high risk category

High risk
Has unstable or refractory angina, despite treatment
Has uncontrolled hypertension
Has severe congestive heart failure (NYHA class IV)
Had a recent MI or stroke within past 2 weeks
Has moderate or severe valvular heart disease
Has high-risk cardiac arrhythmias
Has obstructive hypertrophic cardiomyopathy
Phosphodiesterase inhibitor is contraindicated; sexual intercourse should be
deferred

43
Q
A

Sildenafil
(Viagra®)

Vardenafil
(Levitra®,
Staxyn)

Tadalafil
(Cialis®)

Avanafil
(Stendra)

Dose(Range)
50mg/day
(25-100mg)
10mg
(5-20mg)
(Staxyn ODT)
10mg
(5-20mg)
2.5mg daily
100 mg
(50-200mg)50mg if stable -blockerOnset 30 - 60 min 60 min 30-45 min 15 minDuration 2-4 hours 4-6hrs 24-36 hrs 4-6 hoursfat meal  Tmax & Cmax Cmax No effect c/ or s/ foodVision
changes
Blurred/blue
(3-11%)
<2% <0.1% <2%Wait time
Nitrates
24h 24h 48h 12h? (24h)Nickname “little blue pill”,
“Vitamin V”
“the
weekender”
“the
quickie”

44
Q

algorithm for selecting treatment for ED

A

pt w. ed

  1. treat underlying cause
  2. d/c meds that could contribute
  3. remove risk factors
  4. if pt has hypogonadism, give testosterone supplements

once all of those done.. can ocnsider pde5

a)if effective, continue.
if not, pt should have 7-8 doses before deemed non effective, dosage is titrated up

b)if CI or pt prefers use vaccume erecction device

45
Q

pde5 therapy counseling points

A

taking med will not result in an erection in the absence of sexual stimulation

7-8 doses needed to analyse efficacy

need sufficient time to take before engaging in intercoursw

46
Q

asessment of neuropsychiatric symptoms(NPS) in dementia

A

mild depression anxiety, irritability, apathy

severe (agitation, aggregasion, vocalizations, hallucinations, delusions, disinhibition

differential dx
(acute vs gradual, pain, environment, drugs)

medical causes of agitation in dementia
(medication, infection, cva, trauma, pain

assessments and diagnostic tests
(PE (w/ cognitive testing), labs, drug levels

47
Q

general approack to behavior mgt

A

define target symptoms

establish or revisit medical dx

establish or revist established neuropsychiatric dx

assess and reverse ggravating factors

adapt to specific cognitive defecits

identify relevant psychosocial

educate care givers

employ behavior mgt principles

use psychotropics for specific psychiatric syndrome

48
Q

consider symptomatic pharmacotherapy

A

use “psychobehaviorial metaphor” (eg. features of psychosis or depression)

startlow, go slow

avoid toxicity

use lowest effective dose

withdraw after appropriate period, observe for relapse

serial trials someitmes needed

49
Q

evaluating the pt w. hallucinations or dellusions

A
  1. peprform cognitive exam
    a: abnormal: and no multiple cognitive effects: evaluate for focal brian syndrome
    b: if normal…

eva;uate for neurologic disorder/opthamologic disorder
present: assess and treat
absent…

evaluate for mood disorder
a: if absent: dx delusional disorder
if prresent: dx schizophrenia

50
Q

BBW for APS used in elderly

A

increased risk of death in elderly patients being treated with APS for use in dementia related psychosis

risky agents: Jaloperidol>olanzapine>quetiapine

quetiapine is the saferrrrr agent to use, not just safe

51
Q

d/c of aps in elderly

A
52
Q

Neuropsychiatric symptoms of dementia

A

psychotic symptoms (delusions, hallucinations)

depressive symptoms

apathy

manic like behavioral symptoms

agitation or aggregasion (differential anxiety)

“sundowning”

insomnia

53
Q

environmental interventions

A

general: family and caregivers
structureing hte physical and psychosocial environment
behavioral interventions

milg: environment and interventions

severe: constant supervision

54
Q

non pharm trt ofNPS

A

care givers
*scheduled toileting and promted toileting
*offer graded assitance (little as possible to performing adls
*avoid adversiarial debates
*maintain calm demeaner
*use services of caregiver support groups

problem behaviors
*music during meals
*walking or light exercise
*simulate family presence w. video or audio tapes
*pet therapy
*speak at pts comprehensive levels
*bright light, “white”noise

55
Q

abpout schizophrenia and schizophrenia like syndromes

A

positive SS (hallucinations, delusions, and htought disorders)
negative SS

85% of oldr adults w. schizophrenia experiences onset of illness in adult early in life

late onset schizo “40-60 y.o

very late onset >60

56
Q

psychotic symptoms of AD

A

seen in about 20% alzheimers disease patients

delusions

halucinations

d2/d3 receptor

57
Q

psychotic disorder caused by general medical conditions

A

parkinsons

*secondary dopiminergic agent, visual hallucinations before any medications are started
*educateion and support
*significant emotional distress or gangerous or upsetting behavior
*QUETIAPINE or OLANZAPINE may be beneficial

Lewy body dementia
*cognitive decline accompanied by motor features of parkinsonism. prominant visual hallucinations
*avoid conventional APS

58
Q

depressive symptoms: okay meds to use

A

SSRI’s, SNRI’s

mirtazipine
trazadone

59
Q

depressive symptoms, meds not to use to treat

A

paroxetine, despiramine, nortriptyline (ach effects)

60
Q

apathy

A

high overlap w. depressive symptoms but lacks depressive mood, guilt, and hopelessness

treatment: a) DIVALPROEX SODIM (better tolerated and can be sprinkled on to food)methylphenidate, dextroamphetamine, modafinil

61
Q

Agitstion and regression

A

determine whether delusions or hallucinations are interfering w. function
selct med agent on the basis of symptoms

62
Q

non pharm trt for agitation and aggresion

A

exclude underlying physical discomfort

positive reinforcement

try not to physically restraint

63
Q

meds for agitation and aggresion

A

agitation in context of psychosis: 2nd gen aps

agitation in depression: SSRI’s

ANCIETY: buspirone

sexual aggression: seocnd gen APS

64
Q

sundowning

A

forgetfullness, confused, delerius, agitated that occurs late afternoon-early evening

non pharm: nightlights, check ins

acute meds: trazadones, first gen and second gen APS

long term: trazadone, melatonin

65
Q

insomnia

A

principles of sleep hygeine
caffeine, fluid intale, light activity, time inbed

acute: trazadone, melatonin, bzds

long term, trazadone, melatonin

66
Q

Patho of pain

A

nociceptive pain:
atimulation, transmission, perception, modulation (pain caused by injury to bosy tissues)

Neuropathic pain
*spontaneous transmission
hyperalgesia
allodynia
(pain initiated or caused by a primary lesion or dysfunction in nervous system)

67
Q

acute vs chornic pain

A

acute: trauma
surgery

chronic pain: muskuloskelatal (arthritis, RA, OA, low back disorders
*neuropathy
*vascular
*cancer

68
Q

consequences of lack of knowledge of pain mgt

A

overuse of inappropriate meds

failure to use multimodal approach

failiure to target mechanism of pain

failure to treat neuropahthic pain w. adjunctive meds

heavy us ofe SA-opioids instead of long acting

69
Q

assessment of pain

A

patient interview:
PQRST
*palliative
quality
radiation
severity

Painscales
(UNIVERSAL PAIN ASSESSMENT TOOLS)
Flacc Scale

pain diaries

70
Q

non pharm pain mgt in older pts

A

physical activity

pt education

CBT

adjuncts like heat, colf, massage, ligaments, spirituality

71
Q

approach to the mgt of pain

A

mild pain:
non opioid + adjuvent (adjuvent used for neurologic pain)

mild
opioid for mild-mod pain
_/= nonopioid
+/- adjuvent

mod-severe
*opioid
+/- nonopioid
+/- adjuvent

72
Q

pros and conc of non opioid APAP

A

pros
*selder safe
*adjunctive
*useful to mild-mod pain
*starting point)

concs
*very few
*watch total apap 4g MDD
*need to counsle pt if started on opioid/apap combo before

73
Q

pros an d cons of nsaids

A

pros
*useful in mild-mod pain
*may be ocnsidered rarely and should be used w. extreme caution after other safer meds have failes

Cons
*ceiling effect
CI: peptic ulcer disease, ckd, HF
*cardiac risk (CHF, MI risk)

note: topical diclofenac safer than other nsaids, esp oral

evalute risk vs. beengit

use lowest effective dos epossible

analgesic vs anti inflammatory (cox2 may be safer)

74
Q

adjunctive pain agents

A

all pts w. neuropathic pain are candidates for adjunctive analgesics ( it could even be first line)

first line: a2 ligands (pregablin, gabapentin), SNRI’s
second line: (topical agents)

ex: duloxetine
lidocaine
avoid tertiary TCAs

75
Q

pros and cons of opioids for pain

A

pros
*no celing dose
mod-severe pain
*many diff routes of admin

76
Q

side effects of opioids

A

AE:
respiratory depression (esp. w. concaminnat disease(asthma, copd, sleep apnea)

lethargy/sedation

miosis

constapation

fears of addiction or dependence

77
Q

signs of opioid toxicity

A

severe resp, depression, apnea
decreased LOC, unarousable
ocular: “pinpoint pupils

78
Q

preferred opioids in elderly

A

morphine
hydrocodone
oxycodone
hydromorphone
fentanyl

less preffered:
codeine
methadone?

79
Q

equianalgesic intial doses of opioids

A

PO:
morphine, hydrocodone, oxycodone~30 mg
hydromorphone: 7.5 mg
fentanyl: 100mcg/hr

IV:
morphine: 10 mg
hydromorphone: 1.3-1.5
hydrocodone, oxycodone not available IV

80
Q

routes of admin for opioids

A

PO/SL/ transbuccal

inhaled

intranasal

rectal

topicals

(fentanyl, bupenorphine)

81
Q

considerations for opioid transdermal formulations

A

active ingredient may still be present after tpx obsolecense

improper disposal could lead to accidental/unintended exposure

extrnal heat, fever, and exertion could impact rate of absoprion

products w. meta lfoil backing preclude use if an MRI isn ecessar

82
Q

mgt of gi effects (n/v) in opioid use

A

butyrophines
phenothiazines
antihistamines
anticholinergic
seretonin antagonsits

83
Q

mgt of constipation in opioid use

A

softening agents (docusate)

stimulants (bisacodyl, senna)
osmotics
saline
opioid antagonists
lubricant

84
Q

prescribing opioids in pts w. chornic pain

A

selective and careful prescribing does not apply to pain caused by sickle cell disease, mgt of cancer related pain, or palliative care or end of life care.

85
Q

concept of palliative care and hospice

A

palliative care: the active total care of pts whose disease is not responsive to curative trtment

focus: control of pain, other symptoms, and psychologica, social, and spiritial problems. should be given in conjunction w.curative care

hospice:philosphy and program that delivers palliative care. centers around an interdisciplinRY TEAM

medicare deifnition: qualify for hospice if dx w. terminal illness w. a prognosis of 5 months or less as certified by the physician and the hospice medical director

86
Q

palliative care vs hospice

A

poallitive: improving quality of life for those w. serious illness. can be adminis

hospice: subset of palliative care for end of life care, requires a prognosis of 6 months or less. can occur in home, nursing home, hospice general unit, hospital. occurs when curative care has ceased

87
Q

the dying experience (1-3 mo)

A

withdrawal from the world an dppl

decreased food intake

increase in sleep

going inside seld

less ocmmunication

88
Q

changes during the dying process

A

fatigue and wekness (decreasing function, hygeine, inability to move aroundi nbed, inability to lift head from pillow

cutaneous ishamia (erythema over bony promminences, skin breakdown/wounds)

decreasing appetite food, intake

cardiac dysfunction: tachycardia, HTN followed by hypotension, peripheral cooling, peripheral and central cyanosis, mottling of slin, venous pooling

neurologic: decrease level of consiousness, decreased ability to communicate, terminal delerium

respiratory dysfunction

loss of abiolity to swallow

loss of sphincter control

pain

loff of ability to close eyes

89
Q

palliative care toolkit

A

intensol (concentrated liquid)

morphine liquid

lorazepam liquid

haloperidol liquid

atropine 1%

examethazone liquid

ondansetron odt

90
Q

symptoms in hospice and palliative care

N/V

causes:
treatments:

A

symptoms in hospice and palliative care

causes:
*gutwall: gastirc irratants, abdominal radiotherapy,intestinal distention,cytotoxic chemo

treatments:
step1 h2 antagonst
PPI

step2: metoclopramide

step3: ondansetron

91
Q

n/v due to area postrema

A

causes: morphine, digoxin, hypercalcemia/uremia, clonidine, cytotoxic chemo

treatments: haloperidol, metoclopramide

step1+metoclompramide

step 3: ondansetron+dexamethasone

92
Q

dyspnea

A

step 1:
step2: ipratropium/albuterol

step3: morphine

step4:

93
Q

dyspnea and opioids

A

help releieve sensations of sob

94
Q

treatment of cough

A

treat underlying cause

  1. supress cough (morphine, hydrocodone dextromethorphan

step: dexamethasone or glycopyrolate

95
Q

anxiety vs delerium

A

anxiety:
*treatments 1. non pharm
2. short term benzos

step2 long term: buspirone

deleriium (hallucinations, aggressive)
*step1: haloperidol (its okay to use veen the there is a BBW)
step2: haloperidol+lorazepam combo

96
Q

constipation prevention

A

opioid: senna or bisacodyl+/- docusate_/= metaclopramide

step2: sorbitol, lactulose

97
Q

bowel obstruction

A

metaclopramide

98
Q

depression

A

> 4 weeks survivial: SSRI

> 4 weeks w. other SS

Peds and Geriatrics (5 decks)

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