Geriatrics - BCPS Part II
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In dementia, depression, behavorial and psychological symptoms tend to occur. Which comes 1st as dementia progresses?
Depression, then behavioral and psychological s(x)s
Some of the measurements of behavorial s(x)s are the neuropsychiatric inventory (NPI), behavioral pathology in AD (BEHAVE-AD), an Co-hen-Mansfield agitation inventory (CMAI). For all three, higher scores indicate...?
For all three, higher scores indicate more behavioral problems
Which AP is FDA-approved for the tx of dementia-related psychosis or agitation?
Which 2 AP's have the most evidence for psychosis and aggression in dementia?
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
What are 4 common adverse efx of AP's, if used in dementia patients (or anyone)?
- Dose-dep movement disorders
- Inc'd risk of stroke and mortality
In patients w/AD, if they have comorbid PD or lewy body dementia, which AP is preferred for psychosis and aggression?
When are antidepressants useful in dementia pt's? SSRI's are 1st line except for ________ b/c of....?
Useful hen they have psychosis/aggression and underlying anxiety or depression.
SSRIs 1st line except for paroxetine d/t anticholinergic efx
Which SSRI is useful in dementia patients either for sleep or sundowning?
Which 2 drugs, although with conflicting evidence, may be useful for target s(x)s of irritable mood, impulsivity, or combativeness?
VPA and CBZ
FYI use lower doses and drug levels do not correlate w/efficacy in dementia
Dementia and urinary incontinence are/are not a normal part of aging.
Dementia and urinary incontinence ARE NOT a normal part of aging.
What are the 4 aging efx on the genitourinary system?
- 1. Dec in bladder elastacity
- 2. Dec in bladder capacity
- 3. Inc'd frequent voiding
- 4. GU changes related to sex -
- --Women have loss of estrogen, weakening pelvic musculature
- --Men have prostate enlargement, causing dec in urine flow rate and instable detrusor muscle
Wut does the acronym DIAPERS stand for, which stands for causes/risk factors for urinary incontinence?
- Atrophic vaginitis/urethritis
- Psychological disorders
- Excessive urinary output
- Restricted mobility
- Stool impaction
What r the 5 types of urinary incontinence? Which type is mostly found in severe stages of AD (void of other causes...)?
- 1. Urge or overactive bladder
- 2. Stress incontinence
- 3. Overflow incontinence
- 4. Functional incontinence - mostly found in severe AD
- 5. Mixed incontinence
Urge or overactive bladder is when one has a loss of mod amt of urine w/inc'd need to void. Detrusor instability can be caused by....?
CNS damage from stroke
Urge or overactive bladder may be induced by what pharmacological drug class? What 2 drug classes are preferred for treatment?
May be induced by cholinergics (ie bethanechol and cholinesterase inhibitors)
Tx: Anticholinergic (anti-muscarinic) agents (tolterodine, trospium, etc) or mirabegron (Myrbetriq, a B3-agonist, most pricy)
What are the 6 antimuscarinic agents available for urge or overactive bladder? (brand n generic) Which one has the highest antichol efx? Which 2 have the lowest CNS penetration?
- Oxybutynin (Ditropan) - highest antichol efx
- Tolterodine (Detrol)
- Fesoterodine (Toviaz)
- Trospium (Santura) - low CNS penetration
- Darifenacin (Enablex) - low CNS penetration
- Solifenacin (Vesicare)
Stress incontinence is loss of urine w/inc'd abdominal P (i.e. sneezing/coughing). This condition is more common in WHICH women? Which men?
More common in postmenopausal women, and men w/post-prostatectomy
Stress incontinence may be caused by which types of drug class? What drug is effective for women? What other tx is effective?
Caused by alpha-blockers which dec uretheral sphincter tone (i.e. prazosin)
Tx: Conj. estrogen vaginal cream, or estradiol vaginal insert/ring
Tx: Surgery to support bladder and bladder neck
Overflow incontinence is loss of urine b/c of excessive bladder volume caused by outlet obstruction or acontractile detrusor. PVR value of >______ indicates incomplete emptying.
Overflow incontinence may be induced by what 3 drug classes? Which 4 drug classes/drugs are effective tx options?
Induced by anticholinergics, CCBs, and opioids which dec detrusor muscle contractions
- Tx: Alpha blockers (i.e. tamsulosin, etc)
- Tadalafil 5mg once daily
- Add-on w/tadalafil: Finasteride or dutasteride
- Bethanechol (Urecholine, stimulates detrusor)
What are the 6 available alpha blockers (brand n generic)? Which 3 are more specific for prostate?
- Alfuzosin (Uroxatral)
- Silodosin (Rapaflo)
- Tamsulosin (Flomax)
- Terazosin (Hytrin)
- Doxazosin (Cardura)
- Prazosin (Minipress)
F(x)al incontinence is inability to reach toilet d/t mobility constraints. What 2 drug classes may induce this? What is tx options?
Causes: Sedative-hypnotics (and other sedatives) causing confusion, diuretics inc voiding
Tx: Remove barriers and obstacles, provide scheduled toileting, assistance
What are the 2 common disorders predominant in mixed incontinence?
Usually stress incontinence and overactive bladder
Kegel exercises are recommended as 1st line therapy for __ months for what 3 types of incontinence in women?
Stress, urged (overactive bladder), or mixed
Bladder training is used to inc time b/w voiding, especially useful in wut type of incontinence?
Urge incontinence (overactive bladder)
What are 4 foods/drinks rec'd to avoid to help with incontinence?
- Spicy/citrus foods
- Carbonated beverages
Lower urinary tract s(x)s (LUTS) generally consists of voiding (obstructive) s(x)s and storage (irritative) s(x)s. What are the 7 voiding s(x)s?
- Voiding (obstructive):
- 1. Dec'd stream force
- 2. Hesitancy
- 3. Straining
- 4. Dribbling
- 5. Prolonged voiding
- 6. Incomplete voiding
- 7. Retention
Lower urinary tract s(x)s (LUTS) generally consists of voiding (obstructive) s(x)s and storage (irritative) s(x)s. What are the 6
- Storage (irritative):
- 1. Urinary urgency
- 2. Frequency
- 3. Nocturia
- 4. Small voided volume
- 5. Urge incontinence
- 6. Dysuria
The American Urological Association Symptom Index (AUASI) helps determine severity of LUTS n appropriate tx for BPH on a 0-5 scale. Lower/Higher # indicates more severe s(x)s.
AUASI: Higher # indicates more severe s(x)s.
What are the tx suggestions for:
Mild AUASI (0-7)
MOD AUASI (8-19)
Severe AUASI (>20)
- Mild AUASI (0-7): Watchful waiting
- MOD AUASI (8-19): Consider medical therapy
- Severe AUASI (>20): Assess 4 surgery
What 4 drug classes may exacerbate BPH s(x)s?
- 1. Alpha-agonists (decongestants)
- 2. Anticholinergics
- 3. Diuretics
- 4. Testosterone replacement - stim prostate growth
Which 3 alpha blockers are nonselective and are ineffective for BPH at lower doses?
- Doxazosin (Cardura)
- Terazosin (Hytrin)
- Prazosin (Minipress)
Compared w/placebo, a reduction in how many points of AUASI can be seen with use of alpha-blockers in improving LUTS in pts w/BPH?
Reduction of 4-6 points in AUASI
What is metabolic pathway of alpha blockers that RPh should be wary of?
What syndrome is a concern in use with alpha blockers (esp tamsulosin), where d/cing isnt rec'd but delaying initiation until afterwards is?
All are CYP3A4 metabolites
Intraoperative floppy iris syndrome may occur during cataract surgery (do not d/c alpha blockers, but if abt to start use, delay til after surgery)
Prostatic DHT (dihydrotestosterone) is suppressed with which 2 drugs? (brand n generic)
- Finasteride (Proscar, Propecia)
- Dutasteride (Avodart)
FYI both reduce prostate size
Alpha-reductase inhibitors dont immediately reduce LUTS n should b reserved for men with large prostate volume >_____. At least __ months of therapy is needed 4 clinical benefit.
What test is recommended b4 using these drugs?
Should b reserved for men with large prostate volume >40g
At least 6 months of therapy is needed 4 clinical benefit.
Test baseline PSA level b4 initiation as it lowers PSA (PSA monitored for prostate cancer)
Wut is the dose of tadalafil approved for BPH? Wuts the dose for E.D.?
Tadalafil 5mg once daily for BPH
Tadalafil (Cialis) 10-20mg before activity for ED
In wut circumstances can alpha blockers and tadalafil be used concurrently? (FYI blood pressure lowering efx...)
To treat both BPH and ED separated by 4 hours
What 3 circumstances warrant use of combination of alpha blocker AND alpha reductase inhibitor (finasteride + doxazosin or dutasteride + tamsulosin (FDA approved for this one))?
- 1. LUTS
- 2. Large prostate sz
- 3. Elevated PSA
Wut is the bottom line of efficacy of saw palmetto for BPH?
Conflicting evidence of benefit
....and may reduce efficacy of reductase inhibitors
When are anticholinergic agents (i.e. tolterodine, trospium) appropriate for use in BPH pts? (2)
- 1. LUTS is predominantly storage (irritative s(x)s)
- 2. WITHOUT elevated PVR
Wut is the tx of choice for osteoarthritis (OA) pain and dose? Wuts the max dose in liver dz?
APAP 650mg QID
Max: APAP 2600mg/day (same as above)
NSAIDs should seldom be used in elderly with OA, but if must be used, with other drug class is recommended in moderate-severe risk patients?
PPI's (preferred over H2RAs) to prevent ulcers and bleeding risk
ASA should be taken at least 30 minutes before 1st daily dose of _______ to avoid reduction in ASA efficacy. Which 1 if these drugs have least cardiac risk? Which 2 drugs have most cardiac risk?
ASA should be taken at least 30 minutes before 1st daily dose of NSAID to avoid reduction in ASA efficacy.
Least cardiac risk: Naproxen
Most cardiac risk: Celecoxib, diclofenac
For pt w/mod-severe OA, AGS recommends tx with what drug class if elderly who dont respond to initial APAP therapy?
Which drug in that particular class is preferred?
Tramadol with or w/o APAP, when NSAIDS r ineffective or CI. Use this b4 stronger opioids are tried.
In older pts w/muscle spasms related to OA, what drug is recommended?
Baclofen can be considered over cyclobenzaprine, carisoprodolol (antichol efx)
Wuts the bottom line for glucosamine 500mg TID w/or w/o chondroiton for OA?
Contradictory evidence, but can be used to prevent joint degradation and relieve pain for chronic therapy
What are the 5 clinical presentation points representative of rheumatoid arthritis (RA)?
- 1. Joint pn
- 2. Morning stiffness
- 3. Warmth and redness
- 4. Fatigue
- 5. Swelling of joints
What are the 5 lab tests that are diagnostic for RA?
- 1. Positive rheumatoid factor (RF)*
- 2. Elevated erythrocyte sedimentation rate (ESR)
- 3. C-reactive protein (CRP)
- 4. Anti-cyclic citrullinated peptide Ab*
- 5. Normochromic normocytic anemia (normal MCV, normal Hgb, low RBC, nl B12 and Fe)
*FYI signs of poor prognosis of RA
What are the 4 1st-line DMARD (disease-modifying antirheumatic drug) agents for RA, which should be initiated w/in the 1st few months of dx?
- 1. MTX
- 2. Hydroxychloroquine
- 3. Sulfasalazine
- 4. Leflunomide
How long must a DMARD be used for RA b4 seeing effect?
What is next in line, after 1st-line agents for RA? (2 drug classes)
Tumor necrosis factor (TNF blockers) or interleukin antagonists
What are 5 signs (hint: 2 lab tests) that indicate poor prognosis for RA?
In these types of pts, what are 2 recommendations for initial therapy in general?
- Poor prognosis:
- 1. Positive RF
- 2. Anti-cyclic citrullinated peptide Ab
- 3. F(x)al limitation
- 4. Extraarticular dz
- 5. Bony erosions on radiography
Rec tx: Combo DMARD therapy OR anti-TNF therapy at med initiation
When are NSAIDs and/or glucocorticoids recommended for RA?
NSAIDs: Immediate tx of pain and inflammation
Glucocorticoids: Above but not rec for long-term use. Often used as bridge therapy for anti-inflammation til DMARDs take effect
FYI NSAIDs dont affect dz progression in RA. Anti-inflamm efx takes 1-2 wks of daily dosing, and analgesic efx occurs after several hrs
MTX use for RA can lead to folate deficiency (n/v, mouth sores, liver tox). What dose of folic acid is recommended to prevent this?
Folic acid 1mg daily (FYI no need to skip dose on day of MTX dose... no proof that MTX efficacy is reduced)
What are the 5 TNF blockers for RA? (brand n generic)
Which is the least antigenic?
What lab must be checked in all of these agents prior to use?
- 1. Adalimumab (Humira) - least antigenic
- 2. Certolizumab (Cimzia)
- 3. Etanercept (Enbrel)
- 4. Golimumab (Simponi)
- 5. Infliximab (Remicade)
Check baseline PPD - risk of TB
What are 2 possible agents preferred for combo therapy with MTX if 3 months of monotherapy as alternative to combo of MTX with TNF blockers? (brand n generic)
- Abatacept (Orencia)
- Rituximab (Rituxan)
FYI both are infusions but Orencia can be used as subc (initiated w/or w/o IV LD)
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