Therapeutics 3 > Geriatrics > Flashcards

Geriatrics Flashcards

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1
Q

Define: Potentially Inappropiate Medications (PIMs)

A

risks associated with use of the medication outweighs the benefit

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2
Q

What is the purpose of the Beers Criteria?

A

identify potentially inappropiate medications that should be avoided in many older adults

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3
Q

What are the med classes that should raise alarm when used in the older patient population?

A
  • anticholinergics
  • antipsychotics
  • sulfonylurea
  • PPIs
  • benzodiazepines
  • NSAIDs
  • opioids
  • orthostatic agents

AND MORE

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4
Q

Why should first generation antihistamines be generally avoided in the elderly?

A

cognitive impairment, risk of confusion, dry mouth, constipation

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5
Q

What is the recommendation of antihistamines use in the elderly?

A

avoid use of first generation

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6
Q

What may be used in place of antihistamines in the elderly?

A
  • nasal steroids, second generation antihistamines, or saline nasal spray for allergies
  • sleep hygiene (non-pharmacologic) for insomnia use
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7
Q

Why should TCAs and paroxetine be avoided in the elderly?

A

sedation, orthostatic hypotension and anticholinergic side effects

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8
Q

What is the recommendation of antidepressants in elderly?

A

avoid use of TCAs and paroxetine

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9
Q

What is the alternative therapy in elderly for antidepressants?

A
  • depression: SSRIs (sertraline or escitalopram), bupropion
  • Neuropathic pain: gabapentin, pregabalin, or topical agents
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10
Q

When may benzodiazepines be used in the elderly?

A
  • seizures
  • withdrawal (EtOH and BZD)
  • severe/refractory anxiety
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11
Q

Why should benzodiazapines be generally avoided in the elderly?

A

risk of cognitive impairment, falls, delirium, fractures and motor vehicle crashes

sedative hypnotics should also be avoided for same reason

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12
Q

Why should PPIs be avoided in the elderly?

A

risk of C. diff infections and fractures

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13
Q

What is the recommendation for digoxin use the elderly?

A
  • avoid first line use in HF (use agents that decrease morbidity and mortality) and A Fib (ate control with BB or CCB)
  • avoid doses > 0.125mg/day
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14
Q

Why should alpha blockers (non-selective) be avoided as hypertensives in the elderly?

A

risk of orthostatic hypotension

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15
Q

Why should central alpha agonists (clonidine) be avoided in the elderly?

A

CNS effects, bradycardia, and orthostatic hypotension

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16
Q

What glucose lowering medication should be avoided in the elderly?

A
  • glyburide, glimepride, and short-acting sulfonylureas (glipizide)
  • sliding scale insulin
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17
Q

What is the recommendation of SGLT2 use in the elderly?

A

use with caution due to increased risk of urogenital infections

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18
Q

What is the recommendation of NSAID use in elderly?

A

avoid chronic use unless patient has failed safer therapy and is on PPI due to increased risk of bleeding or peptic ulcer disease in high risk patients (>75 yo, corticosteroid use, anticoagulant use, antiplatelet use)

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19
Q

Urinary Incontinence

What are the types of urinary incontinence?

A
  • overactive bladder (OAB) or urge (UUI)= bladder overactivity; urgency, frequency, large amount of urinary leakage, may be unable to reach toilet, frequent nocturia, nocturnal incontinence; micturition occurs > 8 times a day
  • stress (SUI)= urethral underactivity; leaking during physical activity, typically a small amount of leakage; risk factors: pregnancy, childbirth, menopause, cognitive impairment, obesity, aging
  • overflow= urethral underactivity and/or bladder underactivity; bladder leakage due to disease or medication, increased post void residual urine volume, straining to void, interrupted stream; associated with BPH
  • functional= difficult reaching toilet in time due to physical limitations
  • mixed= often stress and urge, but can be a combination of any
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20
Q

Urinary Incontinence

What are the common causes of urinary incontinence?

A

DRIP-DRIP
- Drugs
- Retention
- Impaction
- Polyuria
- Delirium
- Restricted mobility
- Infection
- Prostatits

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21
Q

Urinary Incontinence

What tools may be used to diagnose Urinary Incontinence?

A

international consultation on incontinence modular questionnaire- urinary incontinence or voiding diary to identify triggers and potential causes

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22
Q

Urinary Incontinence

What is the first line treatment for overactive bladder (OAB)?

A

non-pharmacological therapy (for 4-6 weeks), such as: voiding diary, bladder control exercises, kegel exercises, avoiding diet triggers- according to guidelines. other measures, such as: lifestyle modifications (weight reduction, fluid modification), scheduling regimens, pelvic floor rehabilitation, incontinence devices, supportive interventions

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23
Q

Urinary Incontinence

What is the first line pharmacological treatment for overactive bladder (OAB)?

A
  1. beta3 adrenergic receptor agonists

2. antimuscarinic agents

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24
Q

Urinary Incontinence

What is the pathophysiology of overactive bladder (OAB)?

A

involuntary contractions of the detrusor muscle

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25
# Urinary Incontinence What are the 2 receptors found on the detrusor muscle that are targeted in overactive bladder (OAB)?
- beta adrenergic receptors - muscarinic receptors (M2 and M3)
26
# Urinary Incontinence What is the mechanism of action of antimuscarinics?
supressed the involuntary bladder contractions by blocking muscarinic receptors in the bladder
27
# Urinary Incontinence What drugs are antimuscarinics?
- oxybutynin - tolterodine - fesoterodine - trospium - darifenacin (selective M3) - solifenacin (selective M3)
28
# Urinary Incontinence What dosage form of oxybutynin may be preferred?
transdermal patch | due to less SE than IR tablet, but similar efficacy
29
# Urinary Incontinence What are the patient counseling points for oxybutynin patch?
rotate sites and avoid same site within 7 days, avoid sunlight on patch
30
# Urinary Incontinence What drugs for overactive bladder (OAB) require renal adjustments?
- tolterodine - fesoterodine - trospium
31
# Urinary Incontinence What drugs for overactive bladder (OAB) require hepatic adjustments?
- tolterodine - darifenacin
32
# Urinary Incontinence What medication used for overactive bladder (OAB) may cause QT prolongation?
tolterodine
33
# Urinary Incontinence What is the important patient counseling point for trospium?
take on empty stomach
34
# Urinary Incontinence What CYP isoenzyme is used by antimuscarinics?
CYP3A4 and 2D6 | except trospium
35
# Urinary Incontinence What are the contraindications to antimuscarinic agents?
- narrow angle glaucoma - urinary retention - severely decrease GI motility
36
# Urinary Incontinence What drugs are beta3 adrenergic receptor agonists?
- mirabegron - vibegron
37
# Urinary Incontinence What are the adverse effects of beta3 agonists?
- headache - nasal congestion - mirabegron= cardiovascular effects (hypertension, tachycardia, palpitations)
38
# Urinary Incontinence What are the contraindications of mirabegron?
pregnancy or breastfeeding
39
# Urinary Incontinence What are the drug interactions of mirabegron?
CYP2D6 inhibitor
40
# BPH What are the risk factors of BPH?
- advancing age - levels of endogenous testosterone and dihydrotestosterone levels - black race - obesity - diabetes - high levels of EtOH consuption - physical inactivity - medication
41
# BPH How is BPH diagnosed?
- digital rectal exam - prostate specific antigen (PSA) - international prostate symptom score (I-PSS)
42
# BPH When should pharmacologic treatment be initiated in BPH?
I-PSS score 8+ or bothersome symptoms
43
# BPH What are the pharmacologic treatment options for BPH?
- alpha adrenergic receptor antagonists - 5alpha reductase inhibitors - phosphodiesterase type 5 (PDE5) inhibitors
44
# BPH What drugs are alpha adrenergic receptor antagonists?
- doxazosin - terazosin - alfuzosin, tamsulosin, silodosin (alpha 1 selective, uroselective)
45
# BPH What alpha adrenergic antagonists requires renal adjustment?
silodosin
46
# BPH What alpha adrenergic antagonists require titrations?
non-selective agents (doxazosin, terazosin)
47
# BPH What are the adverse effects of alpha adrenergic agents?
- dizziness, syncope - hypotension - floppy iris - headache - 1A, uroselective agents= erectile dysfunction, anejaculation, nasal congestion, flu-like symptoms
48
# BPH T/F: Alpha adrenergic antagonists decrease the size of the prostate.
false, size of prostate is not affected, but I-PSS scores can be decreased 4-7 points= effective agents
49
# BPH When should patients expect to notice improvement while on alpha adrenergic agents for BPH?
within 1 week, if no effects seen after max dose switching agents within class is not recommended | may switch between nonselective and uroselective if benefits seen
50
50
# BPH What drug used to treat BPH should be avoided in patients with true sulfa allergy?
tamsulosin
51
# BPH How is tamsulosin best taken?
30 minutes after a meal
52
# BPH What is the MOA of 5 alpha reductase inhibitors?
inhibits 5 alpha reductase which is respondsible for converting testosterone -> dihydrotestosterone= promotes prostate growth
53
# BPH When would 5 alpha reductase inhibitors be used?
prostate > 30 g or PSA 1.5ng/mL+ or palpable prostate enlargement of DRE
54
# BPH What drugs are 5 alpha reductase inhibitors?
- finasteride - dutasteride
55
# BPH What are the adverse effects of 5 alpha reductase inhibitors?
- decrease libido - erectile dysfunction (worst in the first 6 months) - ejeculation disorders - gynecomastia
56
# BPH What is the FDA Warning associated with 5 alpha reductase inhibitors?
increased risk of prostate cancer
57
# BPH T/F: 5 alpha reductase inhibitors decrease the size of the prostate?
true, 50% decrease in PSA levels within 6-12 months
58
# BPH What are the precautions associated with 5 alpha reductase inhibitors?
pregnant women should not handle broken or crushed tablets and male partners can transmit drug through sperm
59
# BPH What phosphodiesterase type 5 (PDE5) inhibitor may be used to treat BPH?
tadalafil (Cialis)
60
# BPH What is the recommended dosing of tadalfil for BPH?
5mg PO daily | renal adjustments need
61
# BPH What is phosphodiesterase type 5 (PDE5) inhibitors place in therapy?
patients with ED or SE concerns with other agents | not as effective as other agents
62
# BPH What may be used to treat patients with BPH and concomitant OAB?
alpha adrenergic antagonist + antimuscarinic OR beta3 agonist
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