Transcript Bottom line

Geriatric Pharmacology and
Clinical Syndromes
UNMC’s Division Of Geriatrics
Why Was This Session Created?
• Students requested and demonstrated
need for application of learned information
(physiology, pathology & pharmacology) to
clinical situations.
• Improve training in geriatric pharmacology
in medical school curriculum
• Address AAMC minimum geriatric
competencies for medical school
graduates
• Improve students’ ability to function in
teams
AAMC Minimum Geriatric
Competencies
• Explain impact of age-related changes on drug
selection and dose based on knowledge of agerelated changes in renal and hepatic function,
body composition, and central nervous system
sensitivity.
• Identify medications including anticholinergic,
psychoactive, anticoagulant, analgesic,
hypoglycemic, and cardiovascular drugs that
should be avoided or used with caution in older
adults and explain the potential problems
associated with each.
Objectives
On completion, the learner will be able to:
• Apply pre-existing knowledge and critical
thinking to clinical situations simulated
through multiple choice questions,
discussion, and answers.
• Demonstrate knowledge of geriatric
pharmacology and aging physiology, and
apply this to clinical situations.
• Demonstrate ability to work in teams in
clinical decision-making situations.
Process
• Divide class into teams of 2-3 students.
• Students may have and use any resources with
them.
• Students will be expected to explain why they
chose an answer and reasons they did not
choose the other answers in order to enhance
their learning.
• Each team can have only one answer.
• Students will have approximately 1 minute or
less to arrive at their answer.
• Students should raise their hands when they
have the answer.
RESOURCES
• Almost all of these are available through
UNMC’s library page on mobile resources
http://unmc.libguides.com/pda
• Clinical Pharmacology….(comprehensive, easy
to use) …………free, requires preregistration
• MICROMEDEX….(comprehensive, easy to use)
………………..free, requires preregistration
• Medscape ……(less comprehensive, easy to
use)……… no cost
• at http://www.medscape.com/public/mobileapp
• ePocrates…..(less comprehensive, easy to
use)………….no-cost, not in mobile resources
Additional Resources
• Beers list………. List of potentially
inappropriate medications for the elderly.
• Access….Google “Beers List” or go to
• http://www.americangeriatrics.org/files/doc
uments/beers/PrintableBeersPocketCard.p
df
The American Geriatrics Society 2012 Beers Criteria Update Expert Panel (2012),
American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
Journal of the American Geriatrics Society, 60: 616–631. doi: 10.1111/j.1532-5415.2012.03923.x
About the Questions
• These questions are not designed to assess
learning.
• This is not a test.
• This is an exercise to use questions to
consolidate knowledge, develop critical thinking
and acquire new knowledge through discussion
with colleagues and faculty.
• Multiple-choice format, one right answer.
• These questions are challenging.
You’re ready to start
Question #1
• A 72-year-old woman presents with complaints
of retrosternal pain and odynophagia. Three
weeks ago she began taking alendronate 10 mg
daily for the treatment of osteoporosis. She is
otherwise in good health.
• Endoscopy now shows a large, deep ulcer at the
gastroesophageal junction.
• Examination of biopsy specimens shows
necroinflammatory material and acute
esophagitis.
• The final diagnosis is alendronate-induced
esophagitis and ulceration.
Which of the following factors would
most likely increase her risk of
developing this side effect?
A. Age-related decline in esophageal
motility
B. Age-related increase in
gastroesophageal reflux
C. Ingestion of alendronate with inadequate
amounts of fluid and improper
administration
D. Ingestion of alendronate at a time other
than a true fasting state
Which of the following factors would
most likely increase her risk of
developing this side effect?
A.
B.
C.
D.
Age-related decline
in esophageal
motility
Age-related increase
in gastroesophageal
reflux
Ingestion of
alendronate with
inadequate
amounts of fluid
and improper
administration
Ingestion of
alendronate at a time
other than a true
fasting state
Answer: C
Primary points:
• Clear instructions to patients on
medication administration is critical
For oral bisphosphonate (alendronate)
• Ingest alendronate with full glass
water
• Remain upright-30 minutes
Secondary points:
• Age-related GI changes: (increased
gastric pH, decreased gastric motility,
decrease splanchnic blood flow occur,
not a factor in this case)
• Non-fasting state reduces absorption
does not increase esophagitis
Question # 2
• A 76-year-old woman has had progressive
fatigue, lack of energy, and depressed
mood for 5 weeks. She is currently taking
medication for treatment of diabetes
mellitus, hypertension, congestive heart
failure, and inflammatory osteoarthritis.
Which of the following drugs is the most
likely cause of her symptoms?
A.
B.
C.
D.
E.
Lisinopril
Hydrochlorothiazide
Acetaminophen
Glargine insulin
Indomethacin
Which of the following drugs is the most
likely cause of her symptoms?
A.
B.
C.
D.
E.
Lisinopril
Hydrochlorothiazide
Acetaminophen
Glargine insulin
Indomethacin
Answer: E
Indomethacin
Primary points:
• Depression + polypharmacy always suspect drugs
• NSAIDs & CNS effects common
(dizziness, headache, cognitive,
delirium, psychiatric)
Secondary points:
• HCTZ.-could only cause symptoms
through electrolyte disturbance
• ACE inhibitors-CNS effects-rare
• Glargine would mediate symptoms
through hypoglycemia only
Question # 3
A 77-year-old woman is hospitalized for treatment
of atrial fibrillation and urosepsis. She has
bipolar disorder and a history of stress-related
peptic ulcer. She weighs 50 kg (110 lb).
Laboratory evaluation shows serum albumin
level of 4.1 g/dL and serum creatinine level of
1.0 mg/dL. There is no evidence of liver disease.
Does the patient need medication dosage
adjustment based on her renal function?
Q#1 Does the patient need medication dosage
adjustment based on her renal function?
Answer:
Yes
Primary points:
• Creatinine declines with age
(decreased muscle mass)
• Creatinine under estimates
renal dysfunction in elderly
therefore must calculate CrCl)
(Pt’s CrCl = 37 ( CKD III)
Which of the following drugs can be used
without dosage adjustment for age and renal
function in this patient?
A.
B.
C.
D.
E.
Digoxin
Gentamicin
Lithium
Metoprolol
Ranitidine
Which of the following drugs can be used
without dosage adjustment for age and
condition?
A.
B.
C.
D.
E.
Digoxin
Gentamicin
Lithium
Metoprolol
Ranitidine
Answer: D
Metoprolol
PRIMARY POINTS:
• Digoxin, ranitidine, gentamicin,
lithium-reduced excretion due to
declined renal clearance
• Low therapeutic-toxicity ratio----monitor drug levels when able
(digoxin, lithium, aminoglycosides)
Secondary Points:
• Metoprolol hepatic phase 1 metabolism,
metabolites (inactive) renal excreted
Question #4
• An 82-year-old obese woman with type 2
diabetes mellitus had been taking metformin 850
mg three times daily for 4 weeks when she
reported a 5-day history of weakness,
nonspecific abdominal pain, and myalgias.
Laboratory data included a pH of 7.1 and an
anion gap of 21 meq/L.
Which of the following age-related physiologic
factors most likely increased her risk of
developing metformin-induced lactic acidosis?
A. Decreased concentrations of albumin
and other proteins
B. Increased volume of distribution for
lipophilic drugs
C. Decreased rate of hepatic phase I
metabolic reactions
D. Decreased glomerular filtration rate
Which of the following age-related physiologic
factors had most likely increased her risk of
developing metformin-induced lactic acidosis?
A. Decreased concentrations of albumin and other
proteins
B. Increased volume of distribution for lipophilic
drugs
C. Decreased rate of hepatic phase I metabolic
reactions
D. Decreased glomerular filtration rate
Answer: D. Decreased glomerular filtration rate
Teaching points-next slide
Teaching Points
Primary points:
• Metformin excreted urine unchanged
• Avoid in renal insufficiency, hypoxia, or with
contrast dyes
• Metformin at risk age > 80
• Advantage: no hypoglycemia.
• Adverse effects: GI, rare-lactic acidosis
Secondary points:
• Not extensively bound to plasma proteins
Aging physiology metabolism
• Hepatic phase I slowed with age, hepatic phase II
preserved.
Question #5
An 83-year-old woman who lives in a
nursing home is taking warfarin for atrial
fibrillation, Trimethoprim-sulfa DS for
bronchitis, ranitidine for reflux esophagitis,
phenytoin daily for seizures, and carbidopa
plus levodopa for Parkinson's disease.
Which of her medications would
decrease the therapeutic effect of
warfarin and increase her risk of embolic
ischemic stroke?
A.
B.
C.
D.
Carbidopa/levodopa
Trimethoprim-sulfa (TMP-SMX)
Ranitidine
Phenytoin
Which of her medications increases her
risk of embolic ischemic stroke?
A.
B.
C.
D.
Carbidopa/levodopa
Trimethoprim-sulfa (TMP-SMX)
Ranitidine
Phenytoin
Answer: D. Phenytoin
Which two of the following medications
increases her risk of hemorrhagic
stroke?
A.
B.
C.
D.
Carbidopa plus levodopa
Trimethoprim-sulfa (TMP-SMX)
Ranitidine
Phenytoin
Which two of the following medications
increases her risk of hemorrhagic
stroke?
A.
B.
C.
D.
Carbidopa plus levodopa
Trimethoprim-sulfa (TMP-SMX)
Ranitidine
Phenytoin
Answers:
B. TMP-SMX
C. Ranitidine
Teaching points - next slide
Teaching Points
Explanation
• Phenytoin - decreased warfarin level, through
induction hepatic enzymes
• Ranitidine – moderate increase serum warfarin level
through (CYP450 competitive inhibition)
• TMP-SMX-significantly increases warfarin level
(CYP450 inhibition, protein displacement, vitamin K reduction in
gut)
Bottom line:
 Warfarin = most common ADE
 Phenytoin = hepatic enzyme induction, commonly
reduces Phase I metabolized drug levels
 CYP450 metabolism - common place for drug-drug
interaction
Question #6
• A 79-year-old man who has coronary artery
disease and congestive heart failure comes to
the emergency department because of nausea,
vomiting, headache, and abdominal pain.
Symptoms began 3 days ago.
• Current medications are warfarin, furosemide,
digoxin, captopril, vitamin E, and a multivitamin.
The regimen had been stable for 10 years until
the furosemide dosage was increased last week
to better control symptoms of heart failure.
Which of the following medications is the
most likely cause of this patient’s problems?
A.
B.
C.
D.
E.
Digoxin
Furosemide
Warfarin
Vitamin E
Captopril
Which of the following medications is the
most likely cause of this patient’s problems?
A.
B.
C.
D.
E.
Digoxin
Furosemide
Warfarin
Vitamin E
Captopril
Answer:
A. Digoxin
PRIMARY POINTS:
• Dig. toxicity - GI & neuro sx
• Dig. toxicity due to hypokalemia
(furosemide induced)
• Elderly most susceptible
Secondary points:
• Digoxin level always keep < 0.8
• Digoxin use - minimize in the
elderly
• Vitamin E - bleeding risks
Question #7
• An 80-year-old woman is hospitalized for
repair of a hip fracture sustained in a fall.
Which of the following medications found in
her medicine cabinet at home is least likely to
have contributed to her fall?
A.
B.
C.
D.
E.
Amitriptyline
Chlorpromazine
Flurazepam
Hydrochlorothiazide
Phenobarbital
Which of the following medications found in
her medicine cabinet at home is least likely to
have contributed to her fall?
A.
B.
C.
D.
E.
Amitriptyline
Chlorpromazine
Flurazepam
Hydrochlorothiazide
Phenobarbital
Answer: D.
Hydrochlorothiazide
PRIMARY POINT:
 Any medication that sedates or
changes neurotransmitters
increases fall risk
Secondary points:
A. Amitriptyline – anticholinergic-sedating
B. Chlorpromazine - anti-dopaminergic,
mildly anticholinergic-sedating
C. Flurazepam & Phenobarbital - sedating
D. HCTZ = nonsedating, orthostatic
hypotension risk only
Question # 8
• A 68-year-old male has a history of Parkinson’s
disease, hypertension, and osteoarthritis.
Current medications are carbidopa–levodopa
selegiline; losartan; celecoxib; and a
multivitamin.
• In the past 3 weeks, he has been taking
diphenhydramine at bedtime for insomnia.
• The patient now reports the onset of urinary
incontinence.
• Post void residual (PVR) = 300 cc
Which of the following is the most appropriate
intervention and explain why you did not
choose the other possible answers.
A.
B.
C.
D.
E.
Discontinue celecoxib
Discontinue diphenhydramine.
Discontinue losartan.
Substitute fosinopril for losartan.
Begin tolterodine.
Which of the following is the most appropriate intervention and
explain why you did not choose the other possible answers..
A.
B.
C.
D.
E.
Discontinue celecoxib
Discontinue
diphenhydramine.
Discontinue losartan.
Substitute fosinopril
for losartan.
Begin tolterodine
.
Answer: B.
Discontinue
diphenhydramine.
Explanation of answers
• Patient has overflow incontinence due to
diphenhydramine
• Diphenhydramine – anticholinergic inhibits detrusor muscle contraction
• Celecoxib and losartan – no effect on
bladder function
• Tolterodine – bladder antispasmadic –
would add to overflow incontinence.
Bottom-line:
 Anticholinergic medications = avoid
in the elderly
 Avoid “negative cascade prescribing”
Question # 9
JT is a 72 year old woman who presents to the
geriatrics clinic. Her past medical history is
significant for depression, insomnia,
gastroesophageal reflux, benign positional
vertigo and edema.
Her family reports a rather sudden onset of
problems with remembering appointments,
misplacing her house keys, and paying bills on
time.
Her medication list includes sertraline 50mg/d,
meclizine 25mg q. 6 hours for dizziness,
omeprazole 20mg/d, and furosemide 20mg/d.
Which of JT’s medications is
MOST LIKELY to contribute to
her cognitive complaints?
A.
B.
C.
D.
Furosemide
Meclizine
Sertraline
Omeprazole
Explanation
Explanation of answers
ANSWER
• Furosemide - possible dehydration or
electrolyte/RF problems, not as high risk
A. Furosemide
delirium as meclizine
B. Meclizine
• Meclizine - Anticholinergic – significant
C. Sertraline
association with delirium, cognitive
impairment.
D. Omeprazole
• Antidepressants – SSRIs without
anticholinergic - low risk delirium/cognitive
Answer: B.
impairment
Meclizine
• Proton pump inhibitors – low risk confusion
Bottom line:
 Anticholinergics = high risk CNS sxs.
 Manage BPV with canalith repositioning
Question# 10
A 75 year old man has been experiencing
insomnia due to the recent death of his
son and due to the stress of caring for his
wife who is in poor health. You are
considering pharmacologic treatment for
insomnia.
Which of the following drugs is
most appropriate ?
A.
B.
C.
D.
Temazepam
Amitriptyline
Diphenhydramine
Mirtazapine
Which of the following drugs is
most appropriate ?
ANSWER
A.
Temazepam
B.
Amitriptyline
C.
Diphenhydramine
D.
Mirtazapine
Correct: D.
Mirtazapine
A. Temazepam - accumulation, fall risk,
tolerance
B. Amitriptyline & diphenhydramine highly anticholinergic
D. Mirtazapine – sleep, treats possible
depression
Bottom line:
 First choice - manage sleep
disorders without medication
 Insomnia - choose
medications with least side
effects and additional
benefits
Question #11
• An 85 year old white male has a history of heart
failure (EF ~35%), hypertension, mild
Alzheimer’s disease and renal insufficiency.
This “pleasantly confused” man complains of
pain in his hips and knees.
• He is allergic to sulfa.
• He takes valsartan 80mg/d, furosemide 20mg/d,
metoprolol 25mg BID, and EC ASA 81mg/d.
• His pain is present upon awakening in the
morning, but resolves after he begins his daily
activities.
• X-ray shows joint space narrowing of the hips
and the presence of osteophytes on the knees.
Which one of the following is the best
choice for pharmacologic pain
management in this patient?
A.
B.
C.
D.
Acetaminophen
Ibuprofen
Celecoxib
Tramadol
Which one of the following is the best choice
for pain management in this patient?
Teaching points
ANSWER
A.
Acetaminophen
B.
Ibuprofen
C.
Celecoxib
D.
Tramadol
A. Acetaminophen - well-tolerated < 4
gm/d, dose adjustments needed in
liver disease
B. Ibuprofen - ”G.I. toxicity, renal, HTN, edema,
CNS
Correct: A.
Acetaminophen
C. Celecoxib – “ditto” plus avoid in sulfa allergic
D. Tramadol - limited maximum daily dose, drug
interaction SSRI’s
Bottom line:
 Always include nonpharmacologic
modalities to reduce medication need
 Choose safest medications & use
scheduled doses
Question # 12
(two-part question)
Part One
Which of the following changes normally
occurs in the elderly?
A. Increase in lean body mass
B. Significant decline in serum albumin
C. Increase in percent body fat
D. Increase in plasma volume
Which of the following changes
normally occurs in the elderly?
A.
B.
Increase in
lean body
mass
Significant
decline in
serum albumin
C.
Increase in
percent
body fat
D.
Increase in
plasma
volume
Correct: C.
Increase in
percent body fat
Primary points:
• Aging leads to increase % body fat
(decreased lean body mass)
Leads to:
• Decreased vol. of distribution (Vd)
of hydrophilic drugs
• Increased Vd of lipophilic drugs.
Additional points:
- albumin changes minimally if at all with
age, but significantly with disease.
- plasma volume moderate decrease
with age (~ 8%)
Question # 12
part two
Due to Vd changes in the elderly, which two
of the following drugs will take longer to
reach steady concentration and longer to
be eliminated from the body?
A.
B.
C.
D.
E.
Digoxin
Ethanol
Diazepam
Trazodone
Lithium
Due to Vd in the elderly, which two of the following
drugs will take longer to reach steady concentration
and longer to be eliminated from the body?
A.
B.
C.
D.
E.
Digoxin
Ethanol
Diazepam
Trazodone
Lithium
Correct:
C. Diazepam
D. Trazodone
Teaching points:
RE: digoxin, ethanol, lithium - all
hydrophilic, require less loading
dose, lower dosages & reach earlier
steady-state.
RE: diazepam, trazodone - all
lipophilic - longer time to steadystate, longer elimination & increased
total body drug.
Bottom line:
Hydrophilics = need less drug, easily
toxic
Lipophilics = longer side effects
Prescribing rule: “Start Low, Titrate
Slow”
Question # 13
87-year-old Master Gardener presents with low
back muscle pain from planting his spring
garden. He is taking scheduled acetaminophen
650 mg TID as you suggested, but he needs
something stronger to treat his sore muscles
so he can finish his garden.
Which of the following medications is the best
choice to relieve his back pain? Why?
A.
B.
C.
D.
Ketorolac ( Toradol)
Cyclobenzaprine (Flexeril)
Tramadol (Ultram)
Hydrocodone with acetaminophen
(Vicodin)
Which of the following medications is the best
choice to relieve his pain? Why?
Explanation of answers
ANSWER
A.
B.
C.
D.
Ketorolac
(Toradol)
Cyclobenzaprine
(Flexeril)
Tramadol
Hydrocodone with
acetaminophen
(Vicodin)
Correct: C.
Tramadol
•
•
Ketorolac - risks outweigh benefits
Cyclobenzaprine (Flexeril) - anticholinergic,
does not treat underlying problem
•
Tramadol - safest of the medications
listed
•
Hydrocodone with acetaminophen
(Vicodin) – excess acetaminophen risk
Bottom-line:
 Muscle relaxers = anticholinergic, do
not treat source (OA)
 Avoid narcotic/acetaminophen combos
when using scheduled acetaminophen
Question # 14
75-year-old male diabetic receiving cisplatin
for prostate cancer. After his first infusion
he had problems with nausea and
vomiting. He is very concerned about side
effects of medications.
Which of the following would be your first
choice as an anti-emetic? Why?
A.
B.
C.
D.
E.
Promethazine (Phenergan)
Ondansetron (Zofran)
Metoclopramide (Reglan)
Hydroxyzine (Vistaril)
Lorazepam (Ativan)
Which of the following would be your first
choice as an anti-emetic? Why?
A. Promethazine (Phenergan)A.
B.
C.
D.
E.
Promethazine
(Phenergan)
Ondansetron
(Zofran)
Metoclopramide
(Reglan)
Hydroxyzine (Vistaril)
Lorazepam (Ativan)
Correct: B.
Ondansetron (Zofran)
anticholinergic, not CTZ effective
B. Ondansetron (Zofran) - safest, 5HT,
expensive.
C. Metoclopramide (Reglan) - antidopaminergic
D. Hydroxyzine (Vistaril) - anticholinergic,
not CTZ effective
E. Lorazepam (Ativan) - confusion, falls,
best for anxiety/anticipatory N/V.
Bottom line:
 Medication induced nausea = CTZ
 Choose anti-emetics based on
etiology nausea, mediating
neurotransmitter, side effects &
routes of administration
Question # 15
78-year-old male with URI symptoms; cough,
runny nose, sore throat.
PmHx: Alz Dz-mild, HTN, Depression, BPH.
Medications; sertraline
VS: 36.6-18-80-120/70
Orpharynx; mild erythema, clear nasal discharge
Lungs clear
Please choose 2 acceptable treatments for his
symptoms.
Why? Why not the others?
A. Chlorpheniramine
B. Saline nasal spray and irrigation four
times a day and prn congestion
C. Guafenesin
D. Pseudoephedrine
E. Dextromethorphan
Please choose 2 acceptable treatments for his
symptoms.
Explain the reasons for your choices.
A.
B.
C.
D.
E.
Chlorpheniramine
Saline nasal spray and
irrigation four times a
day and prn congestion
Guafenesin
Pseudoephedrine
Dextromethorphan
Correct:
B. Saline nasal
spray and
irrigation
C. Guafenisin
A. Chlorphenarmine - anticholinergic
B. Saline nasal spray and irrigation – safe,
effective
C. Guafenisin – side effects at higher doses only
D. Pseudoephedrine - urinary retention, HTN
E. Dextromethorphan - sedation, fatigue, DDI
->serotonin syndrome with SSRI
Bottom line:
 Manage symptoms with safest
modalities
 OTC often have significant side
effects & drug-drug interactions
Question # 16
82 year old frail male; 3 days diarrhea, no
recent antibiotics, no vomiting, no blood or
melena, no abdominal pain. 3-5 stools per
day. Difficulty keeping up with hydration
and getting to the bathroom. Wants
something to slow it down
What do you want to do on physical
exam?
Here are your findings:
0; 36.6-18-80-lying120/80; standing 118/80
Wt : 150# (152# two months prior)
Adequately hydrated, alert, normal attention
Abdomen-benign
DRE-negative, with fecal occult blood
negative
What would be your laboratory
evaluation?
(you may choose more than one)
A.
B.
C.
D.
E.
Stool cultures
Stools for C. Dif.
BMP (basic metabolic profile)
CBC
Stool sample for Cysts, Ova and
Parasites
What would be your evaluation?
(you may choose more than one)
A.
B.
C.
D.
E.
Stool cultures
Stools for C. Dif.
BMP (basic
metabolic profile)
CBC
Stool sample for
Cysts, Ova and
Parasites
Answer:
C and D. BMP
+/- CBC
TEACHING POINTS:
A. Stool cultures - too early, sx do
not indicate bacterial dz.
B. Stools for C. Dif. - sx pattern
does not fit
C. BMP (basic metabolic profile) screen for metabolic/renal prob.
D. CBC - marginal indication
E. Stool sample for Cysts, Ova and
Parasites - no exposures, shortterm diarrhea
Laboratory Evaluation
RESULTS
BMP (basic metabolic profile)
Electrolytes-normal
Blood sugar-110
BUN- 30
Cr- 1.1
CBC ( marginally indicated but if requested)
WBC-6000
Hgb-14
Remainder of the profile normal
Besides increasing fluids, what would be your
initial dietary therapy?
Choose one answer
A.
B.
C.
D.
E.
Clear liquid diet
Bananas, rice, apples and tea
Regular diet
High fiber diet
Gatorade
Besides increasing fluid intake, what would be
your initial dietary therapy?
Choose one answer
A.
B.
C.
D.
E.
Clear liquid diet
Bananas, rice,
apples and tea
Regular diet
High fiber diet
Gatorade
Answer: C.
Regular diet
A.
B.
C.
D.
E.
Clear liquid diet - no impact
diarrhea, reduces calorie intake
Bananas, rice, apples and tea - not
necessary to change diet in the
elderly
Regular diet - maintains
calories, protein
High fiber diet - for constipation,
occasional IBS
Gatorade - for perspiration induced
fluid loss, not G.I.
Would you add pharmacologic
therapies? If so, what would they be?
A. Loperamide
B. Bismuth subsalicylate;
C. Diphenoxylate/atropine
D. Dicyclomine
Would you add pharmacologic
therapies? If so, what would they be?
A.
B.
C.
D.
Loperamide
Bismuth
subsalicylate;
Diphenoxylate/atropine
Dicyclomine
Answer: B.
Bismuth subsalicylate;
15-after each diarrhea
stool. max.240 ml/day
A. Loperamide - dizziness, mild CNS side
effects, bladder dysfunction
B. Bismuth subsalicylate - low risk side
effects
C. Diphenoxylate/atropine - anticholinergichigh risk CNS SE
D. Dicyclomine - anticholinergic
Bottom line:
- treat diarrhea with hydration
- if adding pharmacologic treatment,
choose low side effect ( Bismuth
Salicylate)
Options
• Stop and call it a day
• Go to the Bonus round
Summary
• Thank you for your efforts
• Continue to develop astute prescribing skills
• Additional geriatric resources:
- Geriatrics at Your Fingertips (GAYF)
- M3 ambulatory medicine rotation
- M4 sub internship
- M4 Hospice And Palliative Medicine Rotation
- M4 basic science selective
- website; geriatrics.unmc.edu
- GERI pearls
- geriatric resources
THE END
Bonus Question # 1
• RF is an 83 year old man with a history of
Type II diabetes, GERD, osteoarthritis,
and hypothyroidism.
• He is currently taking a multivitamin daily,
glyburide, acetaminophen, omeprazole,
and levothyroxine
Question: Which medication places RF
at the greatest risk for an adverse drug
event?
Which medication places RF at the
greatest risk for an adverse drug event?
A.
B.
C.
D.
Acetaminophen
Omeprazole
Glyburide
Levothyroxine
Which medication places RF at the greatest
risk for an adverse drug event?
ANSWER
A.
Acetaminophen
B.
Omeprazole
C.
Glyburide
D.
Levothyroxine
Correct: C. Glyburide
Return to last slide
(summary)
• All drugs have potential side
effects
• Hypoglycemia in the elderly less aware
• Most common drug class with
adverse events;
cardiovascular agents,
sedative/hypnotics, and
anticoagulants
Bonus Question # 2
84-year-old female highly functional diabetic who
wishes good control of her diabetes.
PHx: heart failure. Follows her diet well.
Medications: Metformin. Lisinopril, ASA,
Simvastatin
VS 134#, 126/68, Creatinine 1.7, Hgb A1c 9.5%.
Which of her medications is the highest risk of
side effects for her?
What is your next step in management?
Which of her medications is the highest risk of side
effects for her? Why?
A.
B.
C.
D.
Metformin
Lisinopril
ASA
Simvastatin
Which of her medications is the highest
risk of side effects for her? Why?
ANSWER
•
Metformin
•
Lisinopril
•
ASA
•
Simvastatin
Correct: A. Metformin
A. Metformin – risk; age >
80, chronic kidney disease.
B. Lisinopril – indicated in
DM, renal protective, HTN
C. ASA – indicated prevention
ASCVD
D. Simvastatin - lipid control
What is your next step in
management of her diabetes?
Besides stopping metformin, which of the
following would you add? Why?
A.
B.
C.
D.
Glyburide
Glargine Insulin
Rosiglitazone
Acarbose
Besides stopping metformin, which of
the following would you add? Why?
ANSWER
A. Glyburide
B. Glargine Insulin
C. Rosiglitazone
D. Acarbose
Correct: B.
Glargine
Insulin at HS
Return to last slide
(summary)
A. Glyburide - contra indicated in CKD
B. Glargine Insulin at HS - most effective,
but pt high functioning, motivated
C. Rosiglitazone - contra indicated, heart failure
D. Acarbose - complicated, costly, limited
reduction A1c
Bottom-line:
• Sulfonyreas - avoid in CKD III-V
• Rosiglitazone – avoid in heart failure
• Insulin (although requires subcutaneous
administration, may be best choice
Bonus Question # 3
• BH is a 70 year old female diagnosed with depression.
• Her medical history includes hypertension, insomnia,
constipation, and a seizure disorder.
• Her medications are amlodipine, senna, phenytoin
• Laboratories: Na = 128 , K = 3.7, Cl = 98, CO2 = 23,
anion gap + 5, BUN = 19, SCr = 1.0 mg/dL.
Which of the following is the most appropriate
intervention for treating BH’s depression?
Which of her present medications adds to her
constipation?
Which of the following is the
most appropriate intervention for
treating BH’s depression?
A.
B.
C.
D.
Amitriptyline
Citalopram
Mirtazapine
Bupropion
Which of the following is the most appropriate
intervention for treating BH’s depression?
ANSWER
•
Amitriptyline
•
Citalopram
•
Mirtazapine
•
Bupropion XL
Correct: C.
Mirtazapine
A. Amitriptyline – anticholinergic constipation
C. Citalopram – SIADH hyponatremia
D. Bupropion - lowers seizure
threshold
Bottom-line:
Choose antidepressants
based on additional benefits,
lowest side effects & least
risk drug-drug interaction
Which of her present
medications adds to her
constipation?
A. Amlodipine
B. Senna
C. Phenytoin
Which of her present medications adds to her
constipation?
Answer
A. Amlodipine
B. Senna
C. Phenytoin
Correct: A.
Amlodipine constipation
A. Amlodipine - all calcium
blockers - constipation,
peripheral edema
B. Senna - if you chose this
drug, you must repeat M1
C. Phenytoin - many drug-drug
interactions, not
constipation
Return to last slide
(summary)
Bonus Question # 4
• 75-year-old female sees you as a new patient,
Pmhx; HTN
Troubled by daytime sedation, mild problems
concentrating, urinary incontinence &
constipation.
Medications: Clonidine 0.1 mg BID, prazosin 5
mg/day, HCTZ 12.5 mg/day, nifedipine 30
mg/day
Which one of her medications does not
contribute to her side effects?
Which one of her medications does not
potentially cause some of her current
symptoms?
A.
B.
C.
D.
Clonidine
Prazosin
HCTZ
Nifedipine
Also must explain other medications side
effects and mechanisms.
Which one of her medications does not
potentially cause some of her current
symptoms? Also must explain other
medications side effects and mechanisms.
ANSWER
• Clonidine
• Prazosin
• HCTZ
• Nifedipine
Correct: C. HCTZ
Return to last slide
(summary)
A. Clonidine - central alpha blocker sedation, confusion
B. Prazosin - alpha blocker - internal
sphincter sympathetic inhibition.
C. HCTZ
D. Nifedipine - constipation, potentially
inappropriate medication elderly
Bottom-line:
- HCTZ most effective, best tolerated,
first choice antihypertensive
Question # 5
82-year-old female has fallen, has a Colles
fracture right arm. Needs pain control.
Pain significant 8/10.
Please choose the most effective and safest
for the patient. You may choose 2 items
from the following list.
Please choose the most effective and safest for
the patient. You may choose 2 items from the
following list. Why and why not the others?
A.
B.
C.
D.
E.
F.
Tramadol 50 mg QID
Codeine 30 mg every six hours prn pain
Acetaminophen 650 milligrams TID
Ibuprofen 600 mg TID
Oxycodone 2.5 mg every four hours prn pain
Acetaminophen/oxycodone 5/500 1 every six
hours prn pain
Please choose the most effective and safest for the patient.
You may choose 2 items from the following list.
A.
B.
C.
D.
E.
F.
Tramadol 50 mg QID
Codeine 30 mg every
six hours prn pain
Acetaminophen 650
milligrams TID
Ibuprofen 600 mg TID
Oxycodone 2.5 mg
every four hours prn
pain
Acetaminophen/oxyco
done 5/500 1 every six
hours prn pain
Answer
A. Acetaminophen 650
milligrams TID
B. Oxycodone 2.5 mg
every four hours prn
pain
Return to last slide
(summary)
Tramadol - dose too high for this patient
- Codeine too constipating
Ibuprofen - side effects too extensive (HTN, CKD,
UGI )
Acetaminophen/oxycodone - potential
acetaminophen toxicity, unable to use
scheduled, oxycodone dose too high
Acetaminophen schedule dose - better than
PRN, least risk toxicity
Oxycodone 2.5 milligram - starting dose,
every four hours best interval
Bottom line: best pain management
elderly:
- acetaminophen scheduled dose plus
- low dose PRN narcotic