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Year 4 OPIC > Drugs used in old age/ Polypharmacy > Flashcards

Drugs used in old age/ Polypharmacy Flashcards

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1
Q

What are the aims of alzheimers dementia treatment?

A

Promote independence, maintain function, manage symptoms, there is no cure

3 acetylcholinesterase inhibitors are recommended as first line for managing mild to moderate AD

Donepezil
Rivastigmine
Galantamine

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2
Q

How do acetylcholinesterase inhibitors work?

A

The cholinergic hypothesis suggests that a dysfunction of neurones in the brain, containing the neurotransmitter acetylcholine significantly contributes to the cognitive decline seen in those with advanced age and alzheimers disease

Acetylcholinesterase inhibitors inhibit the enzyme acetylcholinesterase from breaking down acetylcholine into choline and acetate thereby increasing both the level and duration of action of the acetylcholine

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3
Q

How does memantine work? When is it used?

A

NMDA receptor agonist (glutamate receptor antagonist)
Recommended for patients with moderate AD who are intolerant or have a contraindication to acetylcholinesterase inhibitors or severe AD

Patients can now be started on memantine on top of their Acetylcholinesterase inhibitors

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4
Q

How do you treat lewy body dementia/parkinsons?

A

AChEi can be given, rivastigmine

VD optimise vascular risk factors- BP, DM, cholesterol etc

AChEi and memantine are not recommended in patients with frontotemporal dementia or cognitive impairment by MS

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5
Q

What are the cautions of anti choleresterases?

A 
Gastric/duodenal ulcers
Bladder obstruction 
Asthma
COPD
Heart block
Syncope 
Seizures
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6
Q

What should you be cautious of when giving memantine?

A

Epilepsy/ seizures

Max 10mg OD if eGFr <30

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7
Q

What are the side effects of anti cholinesterases?

A

GI disturbance- reduced appetite, arrythmias, dizziness, drowsiness, falls, headache, GI bleed

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8
Q

What are the side effects of memantine??

A

ConstipationDizziness
Drowsiness
Headache
Seizures

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9
Q

What is BPSD?

A

Behavioural and psychological symptoms of dementia
Very common- point prevelance is 60-80%
Cumulative risk >90% over the course of the illness
The number, type, severity of BPSD varies between patient

Symptoms- agitation, agression, wandering, sexual disinhibition, shouting out, sleep disturbance, depression, anxiety, hallcuinations and delusions, sundowning

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10
Q

What are the non pharmacological managements of BPSD?

A

ABC charts (date and time of behaviours, where, description of behaviour)
Nutrition
Hearing aids/glasses to compensate for sensory impairements
Reminscence therapy ie: life story books
Complimentary therapies (hand massage, aromatherapy, beauty therapies)
Risk assesment, reduction and intervention- are the patients needs being met
Psychological
Know about their life
Structure of days are important

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11
Q

What are the general principles of pharmacological management of dementia?

A

Benefits must outweigh the any anticipated risks for the individual

If meds started, review in 6 weeks

Start low and go slow

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12
Q

What meds are used in BPSD?

A

Antidepressants- SSRIs, mirtazapine
For low mood and anxiety

AcheI / memantine for agitation in AD

Benzos- lorazepam

Analgesia- regular paracetamol or buprenorphine patch if indicated

Mood stabilisers/ anticonvulsants (depakote)

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13
Q

Are antipsychotics used in BPSD?

A

Not routinely, only if severe agitation

Risperidone is usually used

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14
Q

Where do you find patients drugs?

A

MAR chart

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15
Q

What are important parts of prescribing

A 
Tell nurses about once only dose
Write renal function on front
Allergies
Write micrograms or units in full 
Write insulin brand
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16
Q

How to measure elderly patients clearance?

A

EGFR
(Age, gender, ethnicity, creatinine level)
Creatinine clearance

However this doesn’t take into account the patient’s size

MHRA recommend oral anticoags, nephrotoxic, extremes of muscle mass, and if they have nephrotoxic meds then use the calculated creatinine clearance (system one tool) affects Enoxaparin, apixaban

Cockcroft-Gault formula should be used to calculate creatinine clearance (CrCl).

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17
Q

What is the prescribing cascade?

A

The treatment of side effects of drugs as a new disease

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18
Q

What are the side effects of anticholinergics?

A

Constipation
Blurred vision
Affect on heart
Increase cognitive impairement

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19
Q

What problems do elderly patients have taking tablets?

A
  • memory
  • not knowing when to take them
  • shaky
  • swallowing problems
  • don’t know why they are on them
  • reading labels
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20
Q

What can be done to aid the elderly taking lots of drugs?

A

Blister packs
MAR chart- a chart that old people can tick off
Phone apps
Pharmacy Carousel
Give information Leaflets
Pharmacy’s can print larger labels for medications
Can try and switch them to less frequent tablets by giving them slow release ones

For big tablets- some can be crushed (some have protective gastro lining you can’t crush these ones)

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21
Q

How can you help old people use eye drops?

A

Opticare devices

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22
Q

What class is Haloperidol?

A

1st generation antipsychotic

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23
Q

What is the indication for Haloperidol?

A

Delirium not treated by pharmalogical treatment
Post operative nausea and vomiting
Restlessness and confusion in palliative care

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24
Q

What side effects of haloperidol is there?

A

Parkinsonism (bradykinesia, resting pinrolling tremor 4-6Hz, rigidity)

Hypersalivation

Angiooedema

Hypertension

Eye disorders

Headaches

Neuromuscular dysfunction

Nausea

Psychotic disorders

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25
What are the interactions of haloperidol?
Alcohol Hypertensive meds- acebutolol/amlodipine/candesartan Amitriptyline
26
Does haloperidol have an impact on falls?
Yes research indicates that antipsychotics are associated with increased fall risk
27
What class is macrogol and what is it used for?
Osmotic laxative | It is used for chronic constipation
28
What are the SEs of Macrogol?
``` Flatulence GI Discomfort Nausea Vomiting ```
29
What is alendronate, how does it work?
It is a bisphosphonate | It works by being adsorbed onto hydroxyapatite crystals in bone which slows their rate of growth and dissolution
30
What are the side effects of alendroate?
``` Alopecia Anaemia Arthralgia Constipation Diarrhoea Dizziness Electrolyte imbalance Peripheral oedema RENAL IMPAIREMENT (shouldn’t use if the eGFR is <35mmol/l) GI disorders Joint swelling Vertigo ```
31
What is the indication of alendroate?
Treatment of postmenopausal osteoporosis Prevention and treatment of corticosteroid induced osteoporosis in both men and women Treatment of osteoporosis in men
32
How should you advise someone to take bisphosphonates ie: alendronate…
Take whole with plenty of water Can take either sitting or standing but must be sat upright or standing half an hour after Take on an empty stomach, at least 30 mins before breakfast or another oral medicine
33
What warning should you give a patient taking alendroate?
Atypical femoral fractures- patients should be advised to report any thigh, hip or groin pain during the treatment Osteonecrosis of the jaw Osteonecrosis of the external auditory canal Also warn about symptoms of oesophageal irritation such as- dysphagia, new or worsening heartburn, pain on swallowing or retrosternal pain
34
What medications does Alendroate interact with?
Antacids- these decrease the absorption of alendroate, alendroate should be taken 30 mins before antacids Aspirin- increases gastrointestinal irritation Calcium carbonnate/acetate- again should be taken 30 mins before NSAIDS- increase GI irritation
35
What is Adcal D3?
Chewable tablets | This is a combination of Vit D3 and Calcium carbonate
36
What are the indications for Adcal D3?
Osteoporosis | Where body’s calcium and vit D levels need to be increased
37
What are the side effects of Adcal D3?
``` Constipation Nausea Abdominal pain Diarrhoea Hypercalcaemia ```
38
What drugs should not be taken at the same time as Adcal D3?
Antacids- this might damage the enteric coatings which are designed to prevent dissolution in the stomach
39
What is the class of strontium ranelate?
Strontium salt of ranelic acid
40
What is the indication of strontium ranelate?
Used in the management of severe osteoporosis in high risk postmenopausal women and adult men
41
What are the side effects of strontium ranelate?
``` Hyperactivity Consciousness impaired Angioedema Arthralgia Bronchial hyperactivity Constipation Diarrhoea Dizziness ```
42
What interacts with strontium ranelate?
Calcium! Avoid taking the same time as calcium rich foods or calcium supplements as this decreases the absorption
43
What is colchicine and what is it used for?
An alkaloid which is used in the symptomatic relief of pain in attacks of gout Short term prophylaxis during initial therapy with allopurinol
44
What are the side effects of colchicine?
Common- abdo pain, diarrhoea, nausea, vomiting Frequency not known- agranulocytosis, alopecia, bone marrow disorders, GI haemorrhage, Kidney injury, Liver injury
45
What class is Allopurinol and what are the indications for it’s use?
Xanthine Oxidase inhibitor 1) management of patients with signs and symptoms of primary or secondary gout 2) the management of patients with leukaemia, lymphoma and malignancies who are receiving cancer therapy which causes elevations of serum and urinary uric acid levels
46
What are the side effects of allopurinol?
Rash- common Hypersensitivity, N and V- uncommon Rare/very rare- agranulocytosis, alopecia, aplastic anaemia
47
What cautions should you take with allopurinol?
Ensure adequate fluid intake (2-3L/day) For hyperuricaemia associated with cancer therapy then allopurinol treatment should be started before cancer therapy Thyroid disorders
48
What class is prednisolone and what is it used for?
``` Corticosteroid Acute exacerbations of COPD Severe croup for kids Mild to mod asthma UC/Crohn’s ```
49
What are the side effects of prednisolone?
``` Side effects- Anxiety Behaviour abnormal Cataract subscapular Cognitive impairment Cushing’s syndrome Electrolyte imbalance Fatigue Fluid retention GI discomfort Headache Heeling impaired Hirsutism HYPERTENSION Increased risk of infection Menstrual cycle irregularities Mood altered Nausea Osteoporosis Peptic ulcer Psychotic disorder Skin reactions Sleep disorders Weight increased ```
50
In terms of prednisolone, what do you need to make the patient aware of in terms of adrenal suppression?
During prolonged therapy with corticosteroids, particularly with systemic use, adrenal atrophy can develop and persist for years after stopping Abrupt withdrawal after a long period can lead to acute adrenal insufficiency, hypotension or death To compensate for a diminished adrencortical response caused by prolonged corticosteroid treatment then any significant illness, trauma or surgical procedure requires a temporary increase in corticosteroid dose, or if already stopped, a temporary reintroduction of corticosteroid treatment
51
What advice should you give in regards to infections and steroids?
Prolonged courses of corticosteroids increase susceptibility to infections and severity of infections Clinical presentation of infections may also be atypical Unless they have had chickenpox, patients are at risk of severe chickenpox (DIX/pneumonia/hepatitis, rash in not a prominent feature) Confirmed chickenpox warrants specialist care and urgent treatment Corticosteroids shouldn’t be stopped, doses may need to be increased Measles- should take extra care to avoid exposure and IM normal immunoglobulin prophylaxis may be needed
52
What should you advise in terms of psychiatric reactions when giving prednisolone?
Systemic corticosteroids- particularly in high doses are linked to psychiatric reactions including euphoria, insomnia, irritability, mood lability, suicidal thought, psychotic reactions and behavioural disturbances.
53
What is pizotifen and what are some side effects?
It is a drug which is used in the prevention of vascular headache, prevention of classical migraine, prevention of common migraine, prevention of cluster headache Side effects= appetite increased, dizziness, drowsiness, dry mouth, fatigue, nausea, weight increased
54
What is zopiclone used for? What are the side effects? Why is zopiclone relevant in the elderly?
This is used for insomnia (short term use) Side effects- dry mouth, taste bitter For hypnotic z- drugs, prescription is potentially inappropriate (STOPP criteria) in elderly as may cause protracted daytime sedation and/or ataxia.
55
What is Entacapone, how does it work, when is it given?
Entacapone prevents the peripheral breakdown of levodopa, by inhibiting catechol- O- methyltransferase, allowing more levodopa to reach the brain. It is used as an addjunct to co-beneldopa or co-careldopa in Parkinsons disease with ‘end of dose’ motor fluctuations
56
What are the side effects of entacapone?
Abdo pain CONFUSION Constipation Diarrhoea Dizziness FALL IHD Etc
57
What is ropinirole, what are the side effects? Why is it relevant in terms of prescribing in old people?
This can be used alone or as an adjunct to co-beneldopa or co-careldopa Can also be used in moderate to severe restless legs syndrome The MOA is unkown, thought to be related to activated D2 receptors Side effects…. Common- confusion, dizziness, drowsiness, fatigue, GI discomfort, hallucination, movement disorders, nausea, nervousness, peripheral oedema, sleep disorders, syncioe, vertigo, vomiting In the elderly it can cause hypotension and severe cardiovascular disease- need to monitor the blood pressure
58
What are the indications for Amitriptyline, should it be used in the elderly?
Used for multiple things; - Major depressive disorder - Neuropathic pain - Migraine prophylaxis - Chronic tension-type headache prophylaxis - Emotional lability in MS Although it is a great drug for young people, it shouldn’t be used for the elderly as it can cause them to fall, they are also particularly susceptible to many of the side effects of TCAS… - Anticholinergic syndrome - Drowsiness - QT INTERVAL PROLONGATION (shouldn’t be used in severe hepatic impairment)
59
What are the symptoms/signs of anticholinergic syndrome?
``` Fever Mydriasis Tachycardia Hypertension Delirium Warm, dry skin Coma Ileus Urinary and gastric retention ```
60
What are the symptoms/signs of serotonin syndrome?
``` Fever Mydriasis Tachycardia Hyperkinesia Tremor Irritability Diaphoresis Diarrhoea Hyperreflexia ```
61
What is co-beneldopa/co-careldopa?
They are the brand names for LEVODOPA used in parkinsons disease They work by being converted to dopamine in the brain, by taking it as a drug treatment it boosts the supply, meaning the nerve cells can make more dopamine.
62
What are the benefits of taking Levodopa?
Helps with bradykinesia and rigidity! However they don’t prevent the disease progressing- dopamine producing cells are still being lost.
63
What are the side effects of levodopa?
Involuntary movements- with long term use, the patient may experience involuntary movements (dyskinesia), these are muscle movements which the patient can’t control- twitches, jerks, writhing movements. Impulsive and compulsive behaviours- gambling, shopaholic, binge eating, etc Withdrawal syndrome- neruoleptic malignant syndrome, rhabdomyolysis Anxiety, appetite decreased, arrythmia, depression, diarrhoea, hallucination, movement disorders, nausea, parkinsonism, postural hypotension, taste altered, vomiting Can cause postural hypotension and therefore fall risk
64
What are the indications for trimethoprim, is it appropriate in elderly?
Respiratory tract infections Prophylaxis of recurrent UTI Treatment of mild to moderate pneumocystis jirovecii Acne resistant to other antibacterials SE’s include: diarrhoea, electrolyte imbalance, fungal overgrowth, headache, nausea, skin reactions, vomiting Should be used with caution in elderly
65
What is tamsulosin used for, how does it work, what are the side effects, is it risky to use in the elderly?
It is an alpha1- selective adrenoceptor blocker It is used for benign prostatic hyperplasia Causes dizziness, sexual dysfunction As it causes dizziness Causes postural hypotension STOPP criteria= - This is potentially inappropriate in the elderly - it is inappropriate with symptomatic orthostatic hypotension or micturition syncope (risk of precipitating recurrent syncope) - In those with persistent postural hypotension ie: recurrent drop in systolic blood pressure > or equal to 20mmhG (There is a risk of syncope and falls)
66
What is oxybutynin hydrochloride used for? What are the side effects?
It is a antimuscarinic Urinary frequency Urinary urgency Urinary incontinence Neurogenic bladder instability Side effects= Constipation, dizziness, drowsiness, dry mouth, dyspepsia, flushing, headache, nausea, palpitations, skin reactions, tachycardia, urinary disorders, vision disorders, vomiting Can cause confusion in elderly
67
When is oxybutynin hydrochloride potentially inappropriate in elderly?
STOPP criteria: To treat extrapyramidal side effects- there is a risk of antimuscarinic toxicity With delirium or dementia (risk of exacerbation of cognitive impairement) Narrow angle glaucoma Chronic prostatism (urinary retention) If two or more antimuscarinic are prescribed concomitantly (risk of antimuscarinic toxicity)
68
What is cinnarizine, what is it used for?
Cinnarizine is a calcium channel blocker and a antihistamine It is used for relief of symptoms of vestibular disorders- vertigo, tinnitus,nausea and vomiting in menieres disease. It can also be used in motion sickness in kids
69
What are the side effects of cinnarizine and should it be used in the elderly?
Drowsiness GI discomfort Nausea Weight increased
70
What is baclofen, when is it used, what are the side effects, should it be used in the elderly?
It is a skeletal muscle relaxant It it used for pain of muscle spasm in palliative care, hiccups due to gastric distension in palliative care, chronic severe spasticity from disorders like MS or traumatic partial section of the spinal cord Can cause confusion, constipation, depression, diarrhoea, hYPOTENSION, dizziness, drowsiness, hallucination, vision disoders etc… Should be used with caution in the elderly
71
What is Digoxin, when it is used, what are the side effects, should it be used in the elderly?
It is a cardiac glycoside, that increases the force of myocardial contraction and reduces conductivity within the AV node Used in AF/flutter Heart failure for patients in sinus rythm Used as a loading dose for AF or flutter Side effects= Arrythmias, cardiac conduction disorder, cerebral impairement, diarrhoea, dizziness, eosinophilia, nausea, skin reactions, vision disorders, vomiting Prescription is potentially inappropriate in elderly… Stopp CRITERIA Where it is being used for heart failure with normal systolic function there is no evidence of benefit Where it is used at high dose in renal impairement eGFR <30mL/minute, this can lead to digoxin toxicity
72
What is Doxasozin, when is it used, what are the side effects, should it be used in the elderly?
Doxasozin is an alpha blocker It is used in hypertension/ BPH/ Can cause arrythmias, chest pain, cough, cystitis, drowsiness, dizziness, dry mouth Needs to be used with caution in elderly due to the risk of postural hypotension and falls
73
What is simvastatin, how does it work, what is it used for, side effects and should it be used in elderly?
Statin is a HMG-CoA reductase inhibitor, which is an enzyme involved in cholesterol synthesis, especially in the liver Lipid lowering medication Indications- Primary hypercholesterolaemia or combined hyperlipidaemia in patients who have not responded adequately to diet and other appropriate measures Prevention of cardiovascular events in patients with atherosclerotic cardiovascular disease or diabetes mellitus Need to be careful in renal impairement/hypothyroidism- increases risk of muscular toxicity Side effects- asthenia, constipation, diarrhoea, dizziness, GI discomfort, headache, myalgia, nausea, sleep disorders, THROMBOCYTOPENIA

Year 4 OPIC (15 decks)

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