Witches and Wizards: Safe Med Use Flashcards

1
Q

geriatric syndromes (example)

A
  • dementia, delirium
  • urinary incontence
  • falls
  • dizziness
  • syncope
  • malnutrition
  • pressure ulcers
  • sleep problems
  • polypharmacy
  • iatrogenesis
  • frailty

bolded syndromes are the classic geriatric syndromes

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2
Q

geriatric syndrome definition

A

multiple factors, organs, systems going wrong -> hard to get an exact dx -> treat te s/sx

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3
Q

delirium vs dementia onset

A
  • delirium: sudden, definite beginning point
  • dementia: slow, gradual, uncertain begining point
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4
Q

delirium vs dementia duration

A
  • delirium: days to weeks
  • dementia: permanent
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5
Q

delirium vs dementia cause

A
  • delirium: almost always another condition (infection, dehydration, withdrawal)
  • dementia: chronic brain disorder (AD)
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6
Q

delirium vs dementia course

A
  • delirium: usually reversible
  • dmeneita: permament
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7
Q

delirium vs dementiav effect at night

A
  • delirium: almost alwas worse at night
  • dementia: usually worse
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8
Q

delirium vs dementia attention

A
  • delirium: greatly ipaire
  • dementia: unimpaired until severe disease
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9
Q

delirium vs dementia level of consiousness

A
  • delirum: variably ipaired
  • dmenttia: unimpaired until severe disese
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10
Q

delirium vs dementia orientaiton to time and place

A
  • delirium: varies
  • dementia: impaired
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11
Q

delirium vs dementia use of language

A
  • delirium: slow, often incoherent and inapprorpatie
  • dementia: difficulty finding right word
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12
Q

delirium vs dementia memory

A
  • delirium: vaires
  • dementia: lost, esp for recent events
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13
Q

delirium vs dementia need for medical attnetion

A
  • delirium: immediate
  • dementia: required, but less urgently
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14
Q

frailty

A
  • wt loss > 4.5 kg or 5% of wt per year
  • self-reported exhaustion
  • low energy expenditure
  • slow gait
  • weak grip strength
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15
Q

5 Ms of geriatrisc

A
  • mentation/mind
  • mobility
  • meds
  • multicoplexity
  • matters most
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16
Q

Table 2 drugs: first-gen antihistamines - why bad

A
  • highly anticholinergic -> falls, delirium, dementia, dry mouth,, consitpation
  • diphenhydramine acceptable for acute treamtent of severe allergic reaction
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17
Q

Table 2 drugs: nitrofurantoin - why bad

A
  • avoid specifically in CrCl <30 or for long term suppression
  • potential for pulm tox, hepatotox, peripheral neuropathy
  • safer options available
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18
Q

Table 2 drugs: asa for primary prevention - why bad

A
  • bleed risk and not a ton of evidence for benefit
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19
Q

Table 2 drugs: warfarin - why bad

A
  • bleed risk > > DOACs
  • acceptable in: pts with CI or substantial barriers to DOACs AND pts who have been on warfarin long term
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20
Q

Table 2 drugs: xarelto - why bad

A
  • bleed > > > other DOACs, esp eliquis (still better than warfarin tho)
  • reasonable if: reasonable if QD dosing necessary for adherence
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21
Q

Table 2 drugs: dipyridamole - why bad

A
  • 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
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22
Q

Table 2 drugs: non-selective peripheral alpha blockers - why bad

-azosin

A
  • big no no for treatment of hypertension
  • ADR orhtostatic hypotension
  • alt agents aviailable with better risk/benefit profile
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23
Q

Table 2 drugs: central alpha agonst - why bad

clonidine, guanfacine

A
  • big no no for treatment of hypertension (clonidine acceptable but not as firsft line)
  • ADR CNS effects
  • may worsen brady cardia and orthostatic hypotension
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24
Q

Table 2 drugs: nifedipine IR - why bad

A
  • hypotension
  • risk of precipitating MI
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25
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
26
Table 2 drugs: dronederone - why bad
- worse outcomes in pts with afib or severe HF - **acceptable** but cautioned use in pts with HfrEF
27
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
28
Table 2 drugs: antidepressants with strong anticholinergic activity - why bad
- highly anticholinergic - sedating - orthsotatic hypotension ## Footnote doxepin safety comparable to placebo at TDD < 6mg
29
Table 2 drugs: antiparkinsonian agents **with strong anticholinergic** - why bad | benztropine, trihexyphenidyl
- anticholinergic - more effective agents available
30
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)
31
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
32
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
33
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
34
Table 2 drugs: meprobamate - why bad
- high rate of physical dependence - very sedaatng
35
Table 2 drugs: ergot alkalids - why bad
lack of efficacy
36
Table 2 drugs: androgens/testosterone - why bad
- cardiac problems - risks in men with prosate cancer - **acceptable in** confirmed hypogonaidsm with clincal s/s
37
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
38
Table 2 drugs: insulin ss WITHOUT basal or long actig insulin - why bad
hypoglycemia
39
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)
40
Table 2 drugs: desiccated thyroid - why bad | armour thyroid
- cardiac effects - safer alts
41
Table 2 drugs: megestrol - why bad
- minimal effect on weight - increased risk of thrmbotic events and death
42
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
43
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
44
Table 2 drugs: metoclopramide - why bad
- ADR: EPS including tardive dyskinesia - **acceptable in** gastroparesis with an LOT < 12 weeks
45
Table 2 drugs: GI antispasmodics with strong anticholinergic - why bad | dicyclomine, scopolmine, hyoscyamine
- highlly anticholinergic - uncertain effectiveness
46
Table 2 drugs: PO mineral oil - why bad
- potential for aspiration and other ADR - safer alts
47
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
48
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) - k*idney 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 ## Footnote ketorolac and indomethacin are a hard no
49
stomach protective agents for NSAIDs use
- misoprostol: high dose needed for efficacy but ADR - H2RA: double standard dose needed - PPI: gold standard ## Footnote hgih risk pts: try COX-2 selectie (celebrex) + PPI
50
Table 2 drugs: mepiridine - why bad | opioid pain med (demerol)
- not effective in commonly used doses - high risk of neurotx (including delrium) - safer alts
51
Table 2 drugs: skeletal muscle relaxants - why bad | cyclobenzaprine, metaxalone, methocarbamol
- anticholinergic ADR - sedation - increased risk of fractures ## Footnote does NOT apply to baclofen or tizanidine (even tho they have substantial ADR)
52
consequencces of poly pharmacy
- ADR - DDI - cog impairment - functional decline - non adherance - increased healthcaare cost - falls
53
which two anticholingeric medications have very similar structures despite being used for two very very different indicaions
cyclobenzaprine and amitriptyline
54
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**)
55
T/F: all antidepressants carry a fall risk
T, but not all are anticholingergic, anticholinergics have additional ADR
56
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
57
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
58
process of describing
1. comprehensive med hx (if med stopped, why stopped) 2. identifiy PIMs 3. 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 4. plan and initiate withdrawal 5. monitor, support, document
59
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
60
**intense** glucose cotrol in DM ttb and tth
- ttb(time to benefit): 10 yrs - tth (time to harm: minutes
61
bisphosphanates for osteoporisis TTB
8-19 months
62
statins for primary prevention TTb | time to benefit
2-5 yrs
63
HTN primary preention TTB
1-2 yrs
64
asa for primary prevention TTB
10 yrs
65
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