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704 Geriatrics > Deprescribing > Flashcards

Deprescribing Flashcards

1
Q

T/F: All medications on the Beer’s list should be discontinued at age 65

A

FALSE
Just use as a “warning light” for clinical decision-making

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2
Q

What is clinical inertia?

A

Keeping a patient’s therapy consistent when it is working instead of making changes for optimization that may not be necessary

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3
Q

What classes of drugs are potentially inappropriate medications for older adults (PIMs)?

A
  • Anticholinergics
  • Benzodiazepines
  • Antidepressants
  • NSAIDs
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4
Q

What are anticholinergic side effects?

A
  • Impaired vision (falls/accidents)
  • Dry mouth (infection/malnutrition)
  • GI problems (malnutrition/pain)
  • CV problems (anxiety/disease worsening)
  • Urinary issues (incontinence/infection)
  • CNS problems (dysfunction/impaired ADL)
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5
Q

What classes of drugs are anticholinergic?

A
  • Muscle relaxants
  • Antispasmodics
  • TCAs
  • Antihistamines
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6
Q

What is the anticholinergic activity level of amitriptyline?

A

25mg/17.6

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7
Q

What is the anticholinergic activity level of paroxetine?

A

20mg/5.4

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8
Q

What is the anticholinergic activity level of atropine?

A

0.4mg/20.25

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9
Q

What is the anticholinergic activity level of oxybutinin?

A

10mg/5.5

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10
Q

What is the anticholinergic activity level of tolterodine?

A

2mg/9.75

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11
Q

What indications make benzodiazepines appropriate for older adults?

A
  • Seizures
  • REM sleep behaviors
  • Benzodiazepine withdrawal
  • Ethanol withdrawal
  • Severe anxiety
  • Anesthesia for procedure
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12
Q

What is associated with a dose of >3mg of diazepam equivalents in older adults?

A

> 50% increase in hip fracture risk

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13
Q

T/F: SSRIs should be used instead of benzos for anxiety since they do not carry the same fall risk

A

FALSE: data shows us a similar increase in fall risk

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14
Q

What are some NSAID toxicities in older adults?

A
  • GI effects (ulcers, PUD)
  • CV disease
  • Renal issues
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15
Q

NSAID GI toxicity is dose (dependent/independent)

A

Dependent

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16
Q

What can we use to prevent NSAID GI toxicity?

A
  • Misoprostol (needs high dose)
  • H2RA (doubled dose needed)
  • PPIs (gold standard)

COX-2 selective agents should be used for high-risk patients

17
Q

T/F: All NSAIDs increase risk of acute MI, INCLUDING celecoxib and naproxen

A

TRUE

18
Q

When should you especially avoid NSAIDs in older adults?

A

History of MI/stroke

19
Q

What do NSAIDs do to the kidneys?

A
  • Reduction in renal blood flow
  • Sodium/water retention

(Fluid overload, acute renal failure)

20
Q

What are the domains of of deprescribing barriers?

A
  • Individual/patient factors
  • Sociocultural factors
  • Personal and relational factors
  • Organizational factors
21
Q

What are the steps of deprescribing?

A
  1. Comprehensive med history
  2. Identify inappropriate meds
  3. Determine if it/they can be deprescribed
  4. Plan and initiate deprescribing
  5. Monitor, support, document
22
Q

What would make a med discontinuable?

A
  • No valid indication
  • Part of a prescribing cascade
  • Harm clearly outweighs potential benefit
  • Preventative med unlikely to confer benefit (older patients)
  • Impose unacceptable treatment burden
23
Q

Patient wishes + Clinician opinion = ?

A

Shared healthcare decisions

24
Q

What are drug-related risk factors of drug induced harm?

A
  • Number of medications prescribed
  • Use of potentially inappropriate or “high risk” drugs
  • Past or current toxicity
25
Q

What are patient-specific risk factors of drug induced harm?

A
  • Age >80 years
  • Cognitive impairment
  • Multiple comorbidities
  • Multiple prescribers
26
Q

How should you prioritize medications to be deprescribed?

A
  1. Most harm and least benefit
  2. Easiest to stop
  3. Those that the patient is willing to stop first (can lead to further deprescribing)
27
Q

What is the time to benefit (TTB)?

A

Time it takes for medication effects to become evident in a population

28
Q

What is the time to harm (TTH)?

A

Time until a significantly significant adverse effect is seen in a trial for the treatment group compared to control

29
Q

What is the TTB estimated for bisphosphonates?

A

8-19 months

30
Q

What is the TTB estimated for primary prevention statins?

A

2-5 years

31
Q

What is the TTB estimated for primary prevention antihypertensives?

A

1-2 years

32
Q

What is the TTB estimated for primary prevention aspirin?

A

10 years

33
Q

What is the TTB estimated for intensive glucose control in diabetes?

A

10 years

34
Q

What are some general rules for deprescribing?

A
  • Make sure patient is on-board
  • Discontinue one drug at a time
  • Taper when withdrawal is a concern
  • Communicate with caregivers and doctors

704 Geriatrics (8 decks)

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