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What is a common side effect of benzodiazepines in elderly patients?
What is a common side effect of benzodiazepines in elderly patients?
Which of the following medications is associated with a higher risk of respiratory depression in elderly patients?
Which of the following medications is associated with a higher risk of respiratory depression in elderly patients?
What is a common cause of delirium in elderly patients?
What is a common cause of delirium in elderly patients?
What is the most common type of dementia in elderly patients?
What is the most common type of dementia in elderly patients?
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What is a characteristic feature of delirium in elderly patients?
What is a characteristic feature of delirium in elderly patients?
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Why are sedative hypnotics a concern in elderly patients?
Why are sedative hypnotics a concern in elderly patients?
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What is a common medication-related issue in elderly patients?
What is a common medication-related issue in elderly patients?
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Why is it important to screen elderly patients for cognitive impairment?
Why is it important to screen elderly patients for cognitive impairment?
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What is the primary goal of cholinesterase inhibitors in the treatment of Alzheimer's disease?
What is the primary goal of cholinesterase inhibitors in the treatment of Alzheimer's disease?
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Which of the following is NOT a characteristic of Alzheimer's dementia?
Which of the following is NOT a characteristic of Alzheimer's dementia?
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Which medication is used to treat moderate to severe dementia?
Which medication is used to treat moderate to severe dementia?
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What is the most common psychiatric illness in the elderly?
What is the most common psychiatric illness in the elderly?
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Which of the following is a risk factor for depression in the elderly?
Which of the following is a risk factor for depression in the elderly?
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What is the purpose of the Geriatric Depression Scale (GDS) screening tool?
What is the purpose of the Geriatric Depression Scale (GDS) screening tool?
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Which of the following is a common characteristic of Alzheimer's disease?
Which of the following is a common characteristic of Alzheimer's disease?
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What is the primary goal of deprescribing guidelines in the elderly?
What is the primary goal of deprescribing guidelines in the elderly?
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What is the primary concern with using benzodiazepines in the elderly?
What is the primary concern with using benzodiazepines in the elderly?
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Which of the following is a characteristic of Selective Serotonin Reuptake Inhibitors (SSRIs) that makes them safer for elderly patients?
Which of the following is a characteristic of Selective Serotonin Reuptake Inhibitors (SSRIs) that makes them safer for elderly patients?
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What is the main reason for concern regarding falls in the elderly?
What is the main reason for concern regarding falls in the elderly?
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What is the definition of orthostatic hypotension?
What is the definition of orthostatic hypotension?
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What is a common consequence of falls in the elderly?
What is a common consequence of falls in the elderly?
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Which of the following is NOT a cause of orthostatic hypotension?
Which of the following is NOT a cause of orthostatic hypotension?
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What is the estimated percentage of falls that result in fractures?
What is the estimated percentage of falls that result in fractures?
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Which of the following is a characteristic of the 'E Caps' depression checklist?
Which of the following is a characteristic of the 'E Caps' depression checklist?
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What is an effective strategy to improve adherence in the elderly?
What is an effective strategy to improve adherence in the elderly?
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Why is drug prescribing in the elderly complex?
Why is drug prescribing in the elderly complex?
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What is an important consideration when prescribing medications to the elderly?
What is an important consideration when prescribing medications to the elderly?
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What is a key principle in managing polypharmacy in the elderly?
What is a key principle in managing polypharmacy in the elderly?
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What should prompt a review of a medication regimen in an elderly patient?
What should prompt a review of a medication regimen in an elderly patient?
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What is an important aspect of caring for elderly patients?
What is an important aspect of caring for elderly patients?
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What is a key concept in medication safety in the elderly?
What is a key concept in medication safety in the elderly?
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Why is follow-up important in elderly patients?
Why is follow-up important in elderly patients?
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What is an essential step in improving drug therapy in the elderly?
What is an essential step in improving drug therapy in the elderly?
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Why are clinical trials often inadequate for the elderly?
Why are clinical trials often inadequate for the elderly?
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What is the primary purpose of Beers Criteria?
What is the primary purpose of Beers Criteria?
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When considering medication therapy in the elderly, what is an important question to ask?
When considering medication therapy in the elderly, what is an important question to ask?
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What is deprescribing?
What is deprescribing?
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Why is it essential to consider drug interactions when prescribing medications in the elderly?
Why is it essential to consider drug interactions when prescribing medications in the elderly?
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What is an important component of medication safety in the elderly?
What is an important component of medication safety in the elderly?
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Why is it crucial to involve family members or caregivers in the medication management of elderly patients?
Why is it crucial to involve family members or caregivers in the medication management of elderly patients?
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What is a key challenge in managing medical conditions in the elderly?
What is a key challenge in managing medical conditions in the elderly?
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What is a recommended strategy to improve medication adherence in the elderly?
What is a recommended strategy to improve medication adherence in the elderly?
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Why is it essential to consider age, weight, and renal function when prescribing medications to the elderly?
Why is it essential to consider age, weight, and renal function when prescribing medications to the elderly?
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What is the primary goal of a team approach to caring for the elderly?
What is the primary goal of a team approach to caring for the elderly?
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What is a recommended approach to medication initiation in the elderly?
What is a recommended approach to medication initiation in the elderly?
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Why is it important to review medication regimens regularly in the elderly?
Why is it important to review medication regimens regularly in the elderly?
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What is a key concept in medication safety in the elderly?
What is a key concept in medication safety in the elderly?
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What is the importance of follow-up in elderly patients?
What is the importance of follow-up in elderly patients?
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What is the main reason why caring for the elderly is considered a team sport?
What is the main reason why caring for the elderly is considered a team sport?
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What is the importance of education in avoiding adverse drug reactions in the elderly?
What is the importance of education in avoiding adverse drug reactions in the elderly?
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Study Notes
CNS Depressants
- Benzodiazepines: 2-3x sensitivity, leading to more falls and fractures
- Barbiturates: CNS depressant
- Antipsychotics: sedation, anticholinergic effects, orthostatic hypotension, and arrhythmias; decrease dopamine receptors/neurons, levels, and increase risk of EPS effects
- Opioids: 2-8x higher risk of respiratory depression, but decreased N/V; hallucinations and cognitive impairment may increase risk of falls and fractures
- Antidepressants: increase risk of falls and fractures
Pharmacodynamics in the Elderly
- Increased sensitivity to:
- Sedative hypnotics
- Anticholinergics
- Analgesics
- Warfarin
Geriatric Giants
Geriatric Giant 1: Cognitive Impairment
- Delirium:
- Acute disturbance in attention and disorganized thinking
- Disorientation, perceptual disturbances, memory impairment
- 60% of elderly hospitalized for surgery
- Medical emergency; can cause death
- Causes: drugs (e.g. sedatives, anticholinergics, narcotics), infection, pain, metabolic disturbances
- Treatment: quiet, dim room, 1:1 care, hydration, reorientation, discontinuation of causative drugs
- Dementia:
- Newly acquired cognitive impairments that interfere with social or occupational functioning
- Prevalence increases with advancing age
- Types: Alzheimer's Dementia (AD), Vascular Dementia, Mixed Vascular + AD, Dementia Lewy Body (DLB), and Frontotemporal Dementia (FTD)
- Progressive and irreversible
- Alzheimer's Dementia:
- Memory problems (e.g. losing items, missing appointments)
- Difficulty performing complex tasks
- Word finding difficulties, difficulty with names
- Geographic disorientation (e.g. getting lost driving, familiar places)
- Apathy and disinterest in surroundings
- Sleep disturbances (e.g. increased daytime sleeping)
- Disinhibiting behavior (e.g. impulsivity, socially inappropriate)
- Alzheimer's Disease Treatment:
- Cholinesterase inhibitors (e.g. Donepezil, Rivastigmine, Galantamine) to slow progression
- NMDA receptor activator (e.g. Memantine) for moderate/severe dementia
Depression
- Most common psychiatric illness in the elderly
- Often under-recognized and under-treated
- Geriatric Depression Scale (GDS) screening tool
- Common in Long Term Care patients, those with dementia, bereavement, disabilities, stroke, Parkinson's Disease, chronic illness, social isolation, poor education, poverty, alcoholism, and chronic pain
- Mnemonic for Depression: "Sig.E Caps" - depression checklist:
- Suicidal Ideation
- Interest, lack of G uilt E nergy, none C oncentration, poor A ppetite(s), altered P sychomotor changes (slowed or revved up) S leep
- Depression Treatment:
- Non-pharmacologic: psychotherapy
- Pharmacologic: Selective serotonin reuptake inhibitors (SSRIs) - safest in elderly, less concern for overdose and interaction with other meds
Geriatric Giant 2: Falls in the Elderly
- Falls are serious!
- More than 1/3 of patients > 65 fall each year in the community
- ½ of people who fall do so repeatedly
- ~5% of falls result in fractures
- ~5-10% result in other serious injuries
- 10% of visits to the ER
- Reason for 40% of nursing home admissions
- Orthostatic Hypotension:
- Excessive drop in BP when changing from lying/sitting to standing
- Symptoms: dizziness, faints, near falls/falls
- Causes: diarrhea/vomiting, anemia, salt-losing kidney disease, alcohol, adrenal insufficiency, stroke, Parkinson's disease, deconditioning, and prolonged bed rest, autonomic problems associated with diabetes, drugs
Take Home Messages
- Changes due to aging (physiological, PK, and PD), co-morbidities, and many other drugs make drug prescribing in the elderly complex
- Caring for the elderly is a team sport! - Teamwork with the health professional team, patient, family, and caregiver
- Education is important to avoid ADRs and IDP
- "Start Low, Go Slow" (but keep going!)
- Review regimen regularly
- Non-specific complaints should prompt review to avoid prescribing cascades
General Approach to Caring for the Elderly and the Role of the Pharmacist
- Take a thorough history
- Collateral history - family member, caregiver
- Patient needs to bring in all pill bottles, blister packs, OTC meds, etc. to EVERY VISIT; complete and regular MedsChek
- Improving prescribing:
- "I medicate first and ask questions later."
- Teamwork with MD: Before prescribing, think about:
- What are we treating (Disease? Symptom? Prevention? Could it be an ADR caused by a drug?)
- Can we use a non-drug approach?
- Can we treat locally rather than systemically?
- Can we remove something before adding something?
- What interactions will there be?
- Do we know this drug's pharmacology (e.g. renal clearance vs hepatic, P450 interactions, etc)
- Deprescribing:
- Apply tools/methods for patients and clinicians - help make decisions about reducing or stopping medications
- Beers Criteria:
- List of drugs NOT recommended for use in adults older than 65 in all settings.
- First version in 1991, last update 2023.
Pharmacokinetic Changes with Age
- The action of drugs in the body over time includes processes of absorption, distribution, metabolism, and elimination
- Age-related changes in absorption:
- Gastric pH increases
- Splanchnic blood flow decreases
- Delayed gastric emptying
- Intestinal transit slows down
- GI absorptive surface decreases
- However, the extent of drug absorption is generally unchanged, but may be slower in the elderly
Pharmacokinetic Changes with Age: Distribution
- Three key areas that change with age and affect drug distribution:
- Protein Binding
- Albumin binds to acidic drugs (e.g., Naproxen, Phenytoin, Warfarin)
- Alpha-1-acid glycoprotein binds to basic drugs (e.g., Lidocaine, Propranolol, Quinidine, Imipramine)
- Volume of Distribution
- Blood Flow
- Protein Binding
- Changes in body composition with age:
- Decrease in total body water (from 61% at age 25 to 53% at age 70)
- Increase in fat percentage (from 14% at age 25 to 30% at age 70)
- Decrease in cell solids and bone mineral
Predisposing Risk Factors for Falls
- Previous falls
- Depression
- Balance impairment
- Decreased muscle strength
- Medications
- Gait impairment and walking difficulty
- Visual impairment
- Arthritis
- Cognitive impairment
- Pain
- Age >80
- Female
- Low BMI
- Urinary incontinence
- Diabetes
Geriatric Giant: Urinary Incontinence
- Definition: Involuntary loss of urine in sufficient amount or frequency to constitute a social or health problem
- Types:
- Urge incontinence: leakage due to urgency
- Stress incontinence: leakage due to cough, laugh, or sneeze
- Mixed incontinence: combination of urge and stress incontinence
- Overflow incontinence: leakage due to overextended bladder
- Functional incontinence: leakage due to inability to toilet
Acute, Reversible Causes of Urinary Incontinence (DRIP)
- D: Delirium
- R: Restricted mobility, retention
- I: Infection, inflammation, impaction (fecal)
- P: Polyuria, pharmaceuticals
Drugs Associated with Urinary Incontinence
- Alpha blockers (e.g., terazosin)
- Anticholinergics (e.g., amitriptyline)
- Antipsychotics/neuroleptics (e.g., methotrimeprazine, chlorpromazine)
- Calcium-channel blockers (e.g., diltiazem)
- Antihistamines (e.g., diphenhydramine)
- Diuretics (e.g., furosemide)
- Drugs for Alzheimer's disease (e.g., donepezil)
- Ethanol
- Lithium
- Metoclopramide
- Narcotics
- Phenytoin
- Sedatives/hypnotics (e.g., lorazepam)
- Skeletal muscle relaxants (e.g., Can)
Beers Criteria and STOPP/START Criteria
- Purpose: Improve medication safety in older adults by increasing awareness of inappropriate medication use
- Encourage healthcare providers to stop and consider carefully the risks, consider non-drug alternatives
- Guide clinicians in making decisions about safe medication use in older adults
- Broad application to electronic health records
Medication Appropriateness Index (MAI) – Toolkit Online
- Measures the appropriateness of prescribing for elderly patients using 10 criteria for each medication prescribed
- Criteria include:
- Indication
- Is drug effective?
- Is dose correct?
- Are directions correct?
- Are directions practical?
- Drug-drug interactions
- Drug-disease interactions
- Is there duplication with other drugs?
- Is duration of therapy acceptable?
- Economics
Strategies to Improve Adherence
- Provide education to patients, family, and caregivers
- Link medication doses with daily routines, such as meals
- Use memory aids and administration aids
- Team approach with MD: recommendations to assist in reducing the number of meds taken and/or frequency of doses
Take Home Messages
- Changes due to aging, co-morbidities, and multiple drugs make drug prescribing in the elderly complex
- Adjustments for age, weight, renal function, hepatic metabolism, and low serum albumin are necessary
- Education is important to avoid ADRs and IDP
- "Start Low, Go Slow" (but keep going!)
- Review regimen regularly
- Non-specific complaints should prompt review to avoid prescribing cascades
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Description
This quiz covers the effects and risks of CNS depressants, including benzodiazepines, barbiturates, antipsychotics, opioids, and antidepressants. Learn about the potential risks of falls, fractures, respiratory depression, and cognitive impairment.