Geriatrics Flashcards
(30 cards)
3 main mechanism of STOPPFALL drugs in causing falls?
OH, Anticholinergic effect and Sedation
Common causes of Delirium? (IWATCHDEATH)
o Infectious (encephalitis, meningitis, urinary tract infection, pneumonia)
o Withdrawal (alcohol, barbituates, benzodiazepines)
E.g abrupt stopping of anticholinergics
E.g high dose benzhexol when stopped abruptly cause tachycardia possibly due to anxiety; benzhexol used to treat bradycardia
o Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure)
o Trauma (head injury, postoperative)
o CNS pathology (stroke, hemorrhage, tumour, seizure disorders, Parkinson’s)
o Hypoxia (anemia, cardiac failure, pulmonary embolus)
o Deficiencies (vitamin B12, folic acid, thiamine)
Replacing b12 might not improve delirium but still replace it anyway
o Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
o Acute vascular (shock, vasculitis, hypertensive encepahalopathy)
o Toxins, substance use, medication (alcohol, anesthetics, anticholinergics, narcotics)
o Heavy metals (arsenic, lead, mercury) (less common cause)
Risk factor for developing delirium according to NICE guidelines? (4)
1) Age > 65
2) Hip fracture
3) Past hist of/ Current cognitive impairment (incl delirium)
4) Severe illness
What are some drugs classes that may cause delirium? (11)
1) Anticholinergics
2) Opioids
3) Benzo
4) Z-drug
5) H2RA
6) Antidepressant
7) Dopamine agonist
8) Antibiotics (FQ, Cefepime)
9) Steroid
10) Anticonvulsant
11) Hypoglycemic agents
List some non-pharm ways to manage delirium (11)
Sensory functions optimisations
* If got hearing aid wear it, if got glasses wear it etc
Hydration/nutrition
Bowel movement/urination
Early mobility
Pain control
Medication review
Social interaction with loved ones
Reorientation with clock/calendar/proper lighting
Conducive environment (not too stimulating but also Not too quiet)
Promote good sleep
Address infection/hypoxia
What is the general management of hypoactive delirium? (3)
- Withdraw CNS drugs that may cause delirium,
- Address any underlying infections
- Do NOT give any medications used for hyperactive delirium
State the role of medications in the treatment of hyperactive delirium and list the medications (4) used.
Used to treat agitation, usually as last resort if behaviours are a danger to safety of patient or carers.
Medications used:
Lorazepam, Quetiapine, Haloperidol, Olanzapine
State the which medication in the treatment of hyperactive delirium is the most PD friendly. State usual dose and max dose.
Quetiapine: 6.25-12.5mg
Max 100mg/day
State the which medication in the treatment of hyperactive delirium is the best if concomitant psychotic disorder needs to be treated. State usual dose and max dose.
Olanzapine 1.25-2.5mg
Max: 10mg/day
List the medication classes that are FRIDs in STOPPFALL (think of mechanisms)
- OH Induction: Alpha-blockers, Central antihypertensives, Vasodilators, diuretics
- Opioids
- Psychotropics: Antidepressants, Antipsychotics, Benzodiazepine/Z-Drugs
- Psychotropics change thoughts, behaviour, mood. Different risk of causing falls via the various mechanisms (sedation, anticholinergic effects)
- Anticonvulsants
- Ataxia is ADR of anticonvulsant that may increase risk of falls
- Anticholinergics: First gen antihistamines, muscle relaxants
What are 3 key questions used for fall risk screening?
1) Any falls in past year?
2) Any fear of falling?
3) Any unsteadiness in standing or walking?
State the stepwise approach in management of delirium or psychosis in DLB/PDD patients (5)
o Start by treating precipitating factors such as sepsis, then eliminating medications with anticholinergic burden and considering the total anticholinergic burden.
Examples of medication classes with Anticholinergic effects (E.g, antispasmodics, antiallergy medications, tricyclic antidepressants)
o Benzodiazepine and opiates should also be eliminated
These classes may worsen hallucinations and confusion
o Consider attempt to wean off dopamine agonists such as pramipexole, ropinirole, and rotigotine, as well as amantadine
These medications (class effect?) can contribute to worsening hallucinations and cognition
o Interventions could include a trial of donepezil or rivastigmine.
o Only after all these interventions have been tried that providers may consider antipsychotic medications, including quetiapine, clozapine, and pimavanserin for psychosis control
State what TiTrATE approach to evaluating dizziness comprises.
Timing of the symptom (i.e. Continuous or Episodic (Onset, Frequency, Duration))
Triggers that provoke the symptom (i.e. head movement, posture change, etc), And a
Targeted Examination.
Describe the pathogenesis of Benign paroxysmal positional vertigo and it’s management (3)
- Pathogenesis
- Occurs when loose otoconia, known as canaliths, become dislodged and enter the semicircular canals, usually the posterior canal.
- Management
- Surgery – canalith repositioning procedure such as the Epley maneuver, which repositions the canalith from the semicircular canal into the vestibule
- Pharmacologic treatment has no role in the treatment of BPPV.
- Vestibular suppressant medications should be avoided because they interfere with central compensation and may increase the risk of falls
Describe the pathogenesis of Meniere Disease and it’s management (4 non-pharm, 3 pharm)
- Pathogenesis
- The underlying pathology is excess endolymphatic fluid pressure leading to inner ear dysfunction; however, the exact cause is unknown
- Management
1) Lifestyle changes (1st line)
o Limit dietary salt intake to less than 2,000 mg per day,
o Reducing caffeine intake
o Limiting alcohol to one drink per day.
2) Daily thiazide diuretic therapy can be added if vertigo is not controlled with lifestyle changes
3) Transtympanic injections of glucocorticoids and gentamicin can improve vertigo.
o Although transtympanic glucocorticoids may improve hearing, transtympanic gentamicin is associated with hearing loss and should be reserved for patients who already have significant hearing loss.
4) Vestibular suppressant medications may be used for acute attacks.
o Prochlorperazine, promethazine, and diazepam (Valium) have been effective.
5) Other non-pharmacological management:
o Surgery is an option for patients with refractory symptoms.
o Vestibular exercises may be helpful for patients with unilateral peripheral vestibular dysfunction. Vestibular rehabilitation may be needed for persistent tinnitus or hearing loss.
Describe the pathogenesis of Vestibular Neuritis and it’s management (4)
(medicines to use, duration)
Pathogenesis: Thought to be of viral origin
- Management
- Vestibular neuritis is treated with medications and vestibular rehabilitation
- Vertigo and associated nausea or vomiting can be treated with a combination of antihistamine, antiemetic, or benzodiazepine.
- Antiemetics and antinausea medications should be used for no more than three days because of their effects in blocking central compensation. Avoid if possible
- Antiviral medications are ineffective
List the 3 classes of medication used as Vestibular suppressants
Benzodiazepine, Antiemetic (Scopolamine, Metoclopramide, Ondansetron), Antihistamine (incl Phenothiazine), Cinnarizine (Ca Channel Antagonist), Histamine analogue (Betahistine)
Describe the pathogenesis of Vestibular Migraine and it’s management (pharm, non-pharm)
- Pathogenesis
- Abnormalities in the central vestibular system
- Management
- Initial management focuses on identifying and avoiding migraine triggers. Stress relief is recommended, and adequate sleep and exercise are encouraged.
- Vestibular suppressant medications are helpful.
- Preventive medications include anticonvulsants, beta adrenergic blockers, calcium channel blockers, tricyclic antidepressants, butterbur extract, and magnesium.
List a central cause of dizziness.
Vestibular migraine
List Symptoms of OH (8)
- Postural lightheadedness or dizziness
- Sensation of blacking out
- Falls with or without syncope
- Less common symptoms:
- Orthostatic cognitive dysfunction
- Executive function worsens significantly during the orthostatic challenge in patients with autonomic dysfunction
- Mental dulling
- Generalized weakness
- Neck pain or discomfort in the suboccipital and paracervical region
* (‘coat hanger’ configuration—a manifestation of hypotension-induced ischemia of the strap muscles of the neck) - Platypnea
* (Dyspnea while standing due to OH causing inadequate perfusion of ventilated lung apices or ventilation perfusion mismatch)
State when Vestibular suppressant use is warranted
o For symptomatic relief
Only if vestibular symptoms are prolonged (>30 mins) -> doesn’t make sense to give suppressant if only last a few minutes as most drugs increase risk of falls (Beers List)
Almost all are Beers List drugs. Requires timely review of things such as ADRs affecting functional status and review of efficacy.
List the Differential Diagnosis of Transient UI (DIAPPERS)
o Delirium
o Infection (acute urinary tract infection)
o Atrophic vaginitis
o Pharmaceuticals
o Psychological disorder, especially depression
o Excessive urine output (e.g., hyperglycemia)
- May also occur with use of diuretics or SGLT2i
o Reduced mobility (i.e., functional incontinence) or reversible (e.g., drug-induced) urinary retention
o Stool impaction
- Causes compression of urethra and lead to urine retention
List the non-pharm management for UI (10)
1) Lifestyle changes
*a) Smoking cessation (considered bladder irritant too)
*b) Caffeine and alcohol reduction
*c) Weight loss
*d) Modify fluid intake.
2) Kegel exercise (both SUI and UUI)
3) Self-monitoring (bladder diary)
* Patient writes down the times they void and the time and circumstances of any leakage, may help identify a pattern that can be treated with a behavioral strategy
* Also helpful for identifying times when a strategy might have prevented leakage, planning for the next time, and monitoring progress of behavioral interventions
4) Scheduled or prompted voiding, delayed voiding
5) Normal bowel habit
6) Continence products
7) Bladder control strategies/ Retraining (UUI)
* Hold bladder for as long as possible then increase the interval
* Also need patient to be motivated and have the cognitive ability to follow instructions
State management of Stress UI (1 pharm female specific, 1 general, 2 non-pharm) (think male and female)
- Kegel’s exercise
- Topical estrogen [may take up to 3 months for action onset, need counseling, FEMALE]
- Usually 2-3 weeks
- Duloxetine, esp if depression present but not for patients with crcl <30 ml/min [Both gender]
- Not rly used in SG
- Surgery/Devices
- Surgery not advisable for elderly especially if frail
