Witches and Wizards: Safe Med Use Flashcards
geriatric syndromes (example)
- dementia, delirium
- urinary incontence
- falls
- dizziness
- syncope
- malnutrition
- pressure ulcers
- sleep problems
- polypharmacy
- iatrogenesis
- frailty
bolded syndromes are the classic geriatric syndromes
geriatric syndrome definition
multiple factors, organs, systems going wrong -> hard to get an exact dx -> treat te s/sx
delirium vs dementia onset
- delirium: sudden, definite beginning point
- dementia: slow, gradual, uncertain begining point
delirium vs dementia duration
- delirium: days to weeks
- dementia: permanent
delirium vs dementia cause
- delirium: almost always another condition (infection, dehydration, withdrawal)
- dementia: chronic brain disorder (AD)
delirium vs dementia course
- delirium: usually reversible
- dmeneita: permament
delirium vs dementiav effect at night
- delirium: almost alwas worse at night
- dementia: usually worse
delirium vs dementia attention
- delirium: greatly ipaire
- dementia: unimpaired until severe disease
delirium vs dementia level of consiousness
- delirum: variably ipaired
- dmenttia: unimpaired until severe disese
delirium vs dementia orientaiton to time and place
- delirium: varies
- dementia: impaired
delirium vs dementia use of language
- delirium: slow, often incoherent and inapprorpatie
- dementia: difficulty finding right word
delirium vs dementia memory
- delirium: vaires
- dementia: lost, esp for recent events
delirium vs dementia need for medical attnetion
- delirium: immediate
- dementia: required, but less urgently
frailty
- wt loss > 4.5 kg or 5% of wt per year
- self-reported exhaustion
- low energy expenditure
- slow gait
- weak grip strength
5 Ms of geriatrisc
- mentation/mind
- mobility
- meds
- multicoplexity
- matters most
Table 2 drugs: first-gen antihistamines - why bad
- highly anticholinergic -> falls, delirium, dementia, dry mouth,, consitpation
- diphenhydramine acceptable for acute treamtent of severe allergic reaction
Table 2 drugs: nitrofurantoin - why bad
- avoid specifically in CrCl <30 or for long term suppression
- potential for pulm tox, hepatotox, peripheral neuropathy
- safer options available
Table 2 drugs: asa for primary prevention - why bad
- bleed risk and not a ton of evidence for benefit
Table 2 drugs: warfarin - why bad
- bleed risk > > DOACs
- acceptable in: pts with CI or substantial barriers to DOACs AND pts who have been on warfarin long term
Table 2 drugs: xarelto - why bad
- bleed > > > other DOACs, esp eliquis (still better than warfarin tho)
- reasonable if: reasonable if QD dosing necessary for adherence
Table 2 drugs: dipyridamole - why bad
- ADR oorthostatic hypotension
- more effective altneratives available
- acceptable in IV form acceptable for sue in stress testing AND PO combo version with asa for secondary prevention
Table 2 drugs: non-selective peripheral alpha blockers - why bad
-azosin
- big no no for treatment of hypertension
- ADR orhtostatic hypotension
- alt agents aviailable with better risk/benefit profile
Table 2 drugs: central alpha agonst - why bad
clonidine, guanfacine
- big no no for treatment of hypertension (clonidine acceptable but not as firsft line)
- ADR CNS effects
- may worsen brady cardia and orthostatic hypotension
Table 2 drugs: nifedipine IR - why bad
- hypotension
- risk of precipitating MI
Table 2 drugs: amiodarone - why bad
- greatter tox than other agents (do NOT use as first line)
- acceptable in pts with HF or substantial left ventricualr hypertrophy
Table 2 drugs: dronederone - why bad
- worse outcomes in pts with afib or severe HF
- acceptable but cautioned use in pts with HfrEF
Table 2 drugs: digoxin - why bad
- acceptable but NOT as firsst line for afib orr HF (if using avoid TDD >0.125mg)
- safer and more effet alts
- decreased renal clearance -> tox
Table 2 drugs: antidepressants with strong anticholinergic activity - why bad
- highly anticholinergic
- sedating
- orthsotatic hypotension
doxepin safety comparable to placebo at TDD < 6mg
Table 2 drugs: antiparkinsonian agents with strong anticholinergic - why bad
benztropine, trihexyphenidyl
- anticholinergic
- more effective agents available
Table 2 drugs: antipsychotics (first AND second gen) - why bad
- risk of stroke
- greater rate of cognitie decline
- mortality in persons with dementia
- acceptable in FDA approed indications (schizophrenia etc)
Table 2 drugs: barbituates - why bad
butalbital, phenobarnital, primidone
- high rate of physical dpendence
- tolerance to sleep benefits
- greater risk of overdose at low doses
Table 2 drugs: benzos - why bad
- risk of abuse, misuse, addition
- conmittant use of opioids -> resp depression, coma, death
- increased sensitivty and decreased metabolism ) physical dependence
- risk of cog impairment, falls, fractures, and MVA
- acceptable in seizure disorders, REM disorders, benzo withdrawal, EtOH withdrwal, severe GAD, periprocedural anesthesia
Table 2 drugs: z-drugs - why bad
eszopiclone, zaleplon, zolpidem
- ADR similar to benzos (delirium falls, fractures, increased visit to ER, hospitalzations, MVA)
- miminal improvement in sleep latency and durtion
Table 2 drugs: meprobamate - why bad
- high rate of physical dependence
- very sedaatng
Table 2 drugs: ergot alkalids - why bad
lack of efficacy
Table 2 drugs: androgens/testosterone - why bad
- cardiac problems
- risks in men with prosate cancer
- acceptable in confirmed hypogonaidsm with clincal s/s
Table 2 drugs: estrogens - why bad
- carcinogenic potential
- lack of cardioprotectie effect and lack of cognitive protection
- increased risk of heart disease, stroke, blood clots, dementia
- acceptable as low dose vaginal cream or tablets for treatment of vaginal s.s
Table 2 drugs: insulin ss WITHOUT basal or long actig insulin - why bad
hypoglycemia
Table 2 drugs: sulfonylureas - why bad
glimepiride, glipizide, glyburide
- risk of CV events, all cause mortality, hypoglycemia (longer acting agents glyburide and glimepiride have a higher risk of hypoglycemia)
Table 2 drugs: desiccated thyroid - why bad
armour thyroid
- cardiac effects
- safer alts
Table 2 drugs: megestrol - why bad
- minimal effect on weight
- increased risk of thrmbotic events and death
Table 2 drugs: growth horrmone - why bad
- small impact
- associaaed with edema, arthralgia, carpal tunnel gynecomastia, impaire fasting glucose
- acceptable in pts rigorously dxed with evidence-based criteria with growth hormone deficiency
Table 2 drugs: PPIs - why bad
- specically avoid: scheduled use > 8 weeks
- risk of c. diff infection, pneumonia, GI malignances, bone loss, fractures
- acceptable chronic CS or NSAId use, Barrett’s or other conditions that demonatrate need for PPI
Table 2 drugs: metoclopramide - why bad
- ADR: EPS including tardive dyskinesia
- acceptable in gastroparesis with an LOT < 12 weeks
Table 2 drugs: GI antispasmodics with strong anticholinergic - why bad
dicyclomine, scopolmine, hyoscyamine
- highlly anticholinergic
- uncertain effectiveness
Table 2 drugs: PO mineral oil - why bad
- potential for aspiration and other ADR
- safer alts
Table 2 drugs: desmopressin - why bad
antidiuretic
- specifcially avoid for treatment of nocturia
- high risk of hyponatremia
- safer alts
hypoNa=confusion,brain swelling, coma,death
Table 2 drugs: NSAIDs - why bad
including asa TDD > 325mg
- PUD and bleed risk (increased in pts: >75, CS use, anticoag, or antiplatelet use)
- CV risk (increased bp, increased risk of MI, heart attack and stroke -> avoid in pts with hx of stroke or CAD)
- kidney injury (decreased blood flow, Na and H2O retention -> avoid in HF)
- short term scheduled use (while on interacting med) or chronic use acceptable if no other alternatives available and pt can take a stomach protective agent
ketorolac and indomethacin are a hard no
stomach protective agents for NSAIDs use
- misoprostol: high dose needed for efficacy but ADR
- H2RA: double standard dose needed
- PPI: gold standard
hgih risk pts: try COX-2 selectie (celebrex) + PPI
Table 2 drugs: mepiridine - why bad
opioid pain med (demerol)
- not effective in commonly used doses
- high risk of neurotx (including delrium)
- safer alts
Table 2 drugs: skeletal muscle relaxants - why bad
cyclobenzaprine, metaxalone, methocarbamol
- anticholinergic ADR
- sedation
- increased risk of fractures
does NOT apply to baclofen or tizanidine (even tho they have substantial ADR)
consequencces of poly pharmacy
- ADR
- DDI
- cog impairment
- functional decline
- non adherance
- increased healthcaare cost
- falls
which two anticholingeric medications have very similar structures despite being used for two very very different indicaions
cyclobenzaprine and amitriptyline
anticholingergic ADRs
- vision impairment (blind as a bat) -> falls
- dry mouth (dry as a bone) -> nutrition, communicaton, nfection
- CV -> disease worsening (hot as a hare, red as a beet)
- GU -> incontinence, infection, loss of independence
- CNS -> cognition (mad as a hatter)
T/F: all antidepressants carry a fall risk
T, but not all are anticholingergic, anticholinergics have additional ADR
barriers to deprescribing
- individual/patient factors: personal uncertanity, “md knows best”, impaired cognition
- sociocultural factors: med culture of prescribing
- personal and relational factors: fear/accountability, not wanting to mess with another provider’s work
- organizational factors: not enough time or funding, fragmented care
facilitators of deprescribing
- individual/patient factors: awareness of potetnial harm, disccusion of goals of care
- sociocultural factors: less is mroe, acknowledging complexity of multimorbidity and frailty
- personal and relational factors: continuatiion of care, communication between providers
- organizational factors: reimmbursement, access to support resources
process of describing
- comprehensive med hx (if med stopped, why stopped)
- identifiy PIMs
- determine eligibility for deprescrbing and prioritize
- greatest harm and least benefit
- easiest to dc without rebound s/s or withdrawal
- what is pt most willing to dc - plan and initiate withdrawal
- monitor, support, document
meds that are good canditates for dc include
- no valid indication
- part of prescribing cascade
- harm clearly outweighs benefit
- preventative med unlikely to confer benefit in pt remaining lifespan
- drug imposes unacceptable treatment burden
intense glucose cotrol in DM ttb and tth
- ttb(time to benefit): 10 yrs
- tth (time to harm: minutes
bisphosphanates for osteoporisis TTB
8-19 months
statins for primary prevention TTb
time to benefit
2-5 yrs
HTN primary preention TTB
1-2 yrs
asa for primary prevention TTB
10 yrs
how to taper off a benzo
reduce by 25% of original dose q2w with 12.5% reductions towards end if possible
- incoporate drug free days at end if possible
