Geriatrics Flashcards

Question

Mild-Moderate AD treatment

Answer 1

CI (donepezil, rivastigmine, galantamine) No agent preferred

Answer 2

NMDA receptor antagonist (memantine) CI (donepezil, rivastigmine, galantamine) Combination or monotherapy

Answer 3

GI: N/V, diarrhea (**highest w/ rivastigmine) CNS: HA, insomnia, dizziness Cardiac: bradycardia, orthostatic hypotension ,syncope (BEERS for pts w/ syncope) Long-term risks: falls, hip fracture ,pacemaker Renal dosing required for galantamine

Answer 4

rivastigmine

Answer 5

CNS: headache, dizziness, confusion, agitation, hallucinations GI: diarrhea, vomiting Usually well tolerated

Answer 6

Disease modifying immunotherapy. Anti-amyloid MAB 1mg/kg q4 week then 10mg/kg q4 week. Use ABW. Serious ADR: ARIA-H (micro-hemorrhage), ARIA-E (brain edema, HA), seizure Have MRI within 1 year of initiation and repeat with signs/symptoms of ARIA ARIA = Amyloid-Related Imaging Abnormalities

Answer 7

Disease-modifying immunotherapy. Anti-amyloid MAB 10mg/kg q2w using ABW MRI before initiation and 5th, 7th, 14th infusion. Additional if experience s/s of ARIA Serious ADR: ARIA-H, ARIA-E, anaphylaxis, decreased lymphocytes

Answer 8

Mild dementia Cognitive loss: short-term memory loss, word-finding problems Functional loss: loss of IADLs, gets lost easy

Answer 9

Moderate dementia Cognitive loss: disorientation to time/place, inability to engage in activities & conversation Functional loss: Assistance with ADLs (bathing, toileting, dressing)

Answer 10

Severe dementia Cognitive loss: loss of speech, ambulation, control of bladder & bowel Functional loss: Around the clock care

Answer 11

Scheduled preferred because they may not be able to communicate issues (pain, constipation, sleep)

Answer 12

Brexpiprazole Still has BBW of increased risk of death

Answer 13

Nonpharmacologic Figure out what need is unmet

Answer 14

Quetiapine (less dopaminergic) Pimavanserin

Answer 15

Causes of transient incontinence D= drugs, delirium R= retention, restricted mobility I= impactation, infection, inflammation P= polyuria, prostatitis

Answer 16

Decreased bladder elasticity & capacity More frequent voiding Decline in bladder outlet & urethral resistance (women) Decrease in flow rate with enlarged prostate (men)

Answer 17

Loss of moderate amount of urine Increased need to void Common w/ AD, PD, MS, stroke Induced by cholinergic agents (bethanechol, cholinesterase inhibitors) (acetylcholine mediates bladder contractions)

Answer 18

Loss of small amount of urine with increased abdominal pressure (sneezing, coughing) More common in postmenopausal women Induced by alpha-blockers (prazosin) due to decreased urethral sphincter tone (alpha stimulation tightens the sphincter)

Answer 19

Loss of urine b/c of excessive bladder volume caused by obstruction Likely incomplete emptying Induced by anticholinergics, CCBs, opioids. Decrease detrusor muscle contractions (acetylcholine mediates bladder contraction, if blocked won't be able to contract = incomplete emptying)

Answer 20

Inability to reach toilet due to mobility constraints Induced by sedating drugs (cause confusion) or diuretics (increased need to void)

Answer 21

Oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, darifenacin Use for urge incontinence BEERS Prefer LA

Answer 22

MIrabegron, vibegron For urge incontinence Less anticholinergic effects than antimuscarinics, but can be used in combo wth antimuscarinics Avoid in HTN

Answer 23

inject into Intradetrusor Use for urge incontinence Prevents simulation of detrusor muscle. Stimulation relaxes the detrusor muscle Have to self-cath

Answer 24

Alpha agonists (pseudoephedrine, phenylephrine) (efficacy limited) Topical estrogen Duloxetine (not FDA labeled for stress incontinence)

Answer 25

Alpha blockers (afluzosin, tamsulosin, silodosin preferred) 5alpha reductased inhibitors (finasteride, dutasteride) -Slows progression and reduces size of prostate Bethanecol Tadalafil 5mg daily

Answer 26

Alpha agonists Anticholinergics Diuretics Testosterone (mild prostate growth)

Answer 27

score 8-19 (moderate disease)

Answer 28

Terazosin Doxazosin Alfuzosin Tamsulosin Silodosin Tera/doxa (nonspecific alpha blockers) lower BP more than the others Lower AUASI score by 4-6 points CYP3A4 metabolism If planned cataract surgery, start after Take at bedtime

Answer 29

May be used if larger prostate size, LUTS, elevated PSA, or erectile dysfunction Finasteride + doxazosin Dutasteride + tamsulosin (FDA approved)

Answer 30

Finasteride Dutasteride Prevent conversion of testosterone to dihydrotestosterone = actually shrink prostate At least 6 months of therapy needed for benefit Need baseline PSA concentration Lower PSA, but long-term therapy puts at risk of high-grade tumors in prostate Avoid if pregnant

Answer 31

only FDA approved pde5 inhibitor Avoid with alpha blockers due to decreased BP risks

Answer 32

NSAIDS - prefer topical If chronic, change to COX2 inhibitor or Add PPI Preferred with cardiac disease = naproxen *if on aspirin for cardiac disease, take aspirin 30 min before any NSAID

Answer 33

Diclofenac gel Capsaicin

Answer 34

Methylprednisolone or triamcinolone IA inj APAP (if NSAID contraindicated) Duloxetine Glucosamine Tramadol

Answer 35

OA affects larger joints like hip, knee RA affects smaller joints of hands, wrists, feet

Answer 36

Nonbiologic DMARDs DOC: methotrexate (weekly) Alterative DOC: leflunomide (daily) Second line: hydroxychloroquine (BID) or sulfasalazine (BID)

Answer 37

Nonbiologic DMARDs DOC: Hydroxychloroquine (low adverse effect profile) Alt: Sulfasalazine > methotrexate or leflunomide Pregnancy DOC = sulfasalazine

Answer 38

MTX, leflunomide: myelosuppression, liver dysfunction, pulmonary fibrosis, teratogenic Hydroxychloroquine: Ocular toxicity Sulfasalazine: GI adverse effects limit use

Answer 39

within 3 months of diagnosis of RA

Answer 40

Use for severe RA **in combination with methotrexate** TNF blockers, non-TNF blockers, biologic kinase inhibitors Most common: etanercept, infliximab, abatacept, rituximab

Answer 41

Etanercept (SC weekly) Infliximab (IV @ 0, 2, 6 wk then q8w) Adalimumab (SC q2w) Certolizumab (SC every other week) Golimumab (SC monthly) Monitor infection Check baseline PPD (purified protein derivative) Avoid in heart failure

Answer 42

Abatacept (monthly) Anakinra (SC daily) Rituximab (IV given 2 weeks apart) Sarilumab (SC every other week) Tocilizumab (q4w IV) Monitor infection

Answer 43

Baricitinib (PO daily) Tofacitinib (PO BID) Upadacitinib (PO daily) Class BBW: increased risk of serious cardiac-related events (MI, stroke, cancer, blood clot, death) Avoid in those who smoke or have smoked, with CV risk factors, and known malignancy

Answer 44

No longer recommended If have to use, short term (<3 months) preferred

Answer 45

Does not inhibit disease progression

Answer 46

Prior to therapy: -Screen for tuberculosis and viral hepatitis -Give all immunizations, especially live. Wait 2 weeks before starting therapy During therapy: -avoid live vaccines If hx of hep B or C and treated, consider as pt has never had hepatitis If untreated hep B or C, prefer DMARD to TNF blocker

Answer 47

Ideal = aspiration of joint to visualize birefringement of urate crystals Unlikely to occur, so use clinical judgment Get serum uric acid level 2 weeks after flare, if >6.8 then gout likely (uric acid low during flare)

Answer 48

Thiazide and loops Niacin Calcineurin inhibitors (cyclosporine, tacrolimus) low dose aspirin Xanthine oxidase inhibitors (during induction)

Answer 49

Start within 36 hours of gouty attack 1.2mg x1 ,then 0.6mg 1 hour later; then 0.6mg BID until flare resolves ***Use with Pgp inhibitors or strong CYP3A4 inhibitors is CONTRAINDICATED in RENAL or HEPATIC impairment! Fatal toxicity has occurred**** Reduce dose if normal renal/hepatic function but strong 3A4, Pgp inhibitors No dose adjustments necessary until on dialysis (0.6mg x1)

Answer 50

Naproxen 750mg then 250mg q8h Indomethacin 50mg TID Sulindac 200mg BID If NSAIDs contraindicated or not tolerated, can consider celecoxib (day 1: 800mg, then 400mg, day 2 on: 400mg BID)

Answer 51

Prednisone 0.5mg/kg/day x5-10 days (taper option available) Medrol dose pack Intra-articular injection if two large joints Can use PO steroids, NSAIDs, or colchicine in combination with intra-articular injection

Answer 52

First line for urate-lowering therapy, even if CKD stage 3 or higher **Allopurinol** Initial dose: 100mg/day Initial dose if CKD4: 50mg/day Titrate to target serum uric acid level (<6) *Max doses can be as high as 800mg (normal renal fxn) or >300mg (even in CKD) If unable to tolerate or refractory, change to febuxostat 40mg daily *Febuxostat has BBW for increased risk of CV deathu **ALWAYS INITIATE CONCOMITANT PROPHYLACTIC THERAPY**

Answer 53

SJS, TEN Eosinophilia, rash, vasculitis, major end-organ disease Highest risk during first few months Risk factors: thiazide diuretics or renal impairment HLA-B*5801 testing recommended for African Americans or Southeast Asian populations

Answer 54

Probenecid 500mg 1-2x daily with dose titration Pegloticase (NOT first line in any case. D/C other agents and start if SU not reached and continual gout flares)

Answer 55

Increased risk of gout attacks during ULT initiation -Rapid decrease in urate concentration = remodeling of articular urate crystal deposits Add on colchicine, NSAIDs, or prednisone and continue as prophylaxis for 3-6 months, continuing beyond if evidence of gout disease activity (tophi, flare, chronic gouty arthritis) Colchicine: 0.6mg 1-2x daily Naproxen: 250mg BID Indomethacin: 25mg BID Prednisone: <10mg/day