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Fall 2020: Therapeutics 2 > Geriatrics (Introduction and Incontinence) > Flashcards

Geriatrics (Introduction and Incontinence) Flashcards

1
Q

What age bracket is the fastest growing in the US population?

A

Adults >75 years

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2
Q

Who has greater longevity: men or women?

A

Women

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3
Q

What are some advantages of being a consultant pharmacist in LTC?

A
  • Flexible schedule
  • Work independently
  • Work with multiple disciplines at a variety of facilities
  • LTC regulations clearly describe pharmacist role
  • Educational component for facility staff
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4
Q

What are some disadvantages of being a consultant pharmacist in LTC?

A
  • Travel time
  • Rely on facility staff for follow-up
  • Communication with providers often written, asynchronous
  • Frustration when recommendations are not accepted
  • Limited patient interaction
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5
Q

How do we define healthy aging?

A

“The process of developing and maintaining the functional ability that enables wellbeing in older age.”

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6
Q

What is functional ability?

A

Having the capabilties to engage in activities that patients find valuable

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7
Q

What are some activities of daily living (ADLs)?

A
  • Dressing
  • Bathing
  • Transferring
  • Feeding
  • Toileting
  • Walking/ambulation
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8
Q

What are some instrumental activities of daily living (IADLs)?

A
  • Handling finances
  • Shopping for groceries
  • Meal preparation
  • Using a telephone
  • Housekeeping/laundry
  • Handling medications
  • Using transportation
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9
Q

What are the two largest contributors to functional decline in older adults?

A

Musculoskeletal and cardiovascular

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10
Q

Functional limitations increase with age for nearly all categories except for what?

A

Lung

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11
Q

What medication classes can increase fall risk in older adults?

A
  • Sedatives/hypnotics
  • Neuroleptics/antipsychotics
  • Antidepressants
  • Opioids (especially long-acting)
  • Loop diuretics
  • Alpha-blockers
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12
Q

List the three most prevalent medication problems in older adults.

A
  1. Polypharmacy
  2. Nonadherence
  3. Altered pharmacokinetics
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13
Q

Is aging a barrier to adherence?

A

No!

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14
Q

How is total body water influenced by aging?

A

Decreased

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15
Q

How is lean body mass influenced by aging?

A

Decreased

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16
Q

How is body fat influenced by aging?

A

Increased

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17
Q

How is baroreceptor response/activity influenced by aging?

A

Decreased

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18
Q

How is heart rate variability influenced by aging?

A

Reduced

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19
Q

How is hepatic blood flow influenced by aging?

A

Decreased

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20
Q

How is renal blood flow influenced by aging?

A

Decreased

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21
Q

How is neurotransmitter volume influenced by aging?

A

Decreased

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22
Q

How are Vd and concentration of water-soluble drugs such as atenolol affected by aging?

A

↓ Vd and ↑ concentration

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23
Q

How are Vd and T1/2 of lipid-soluble drugs such as rifampin affected by aging?

A

↑ Vd and ↑ T1/2

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24
Q

How are clearance and T1/2 of most hepatically-cleared drugs like propranolol affected by aging?

A

↓ Clearance and ↑ T1/2

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25
How are the clearance and T1/2 of most renally-cleared drugs like atenolol affected by aging?
↓ clearance and ↑ T1/2
26
What are the Beers Criteria?
Criteria for ***potentially*** inappropriate medication use in older adults (65+)
27
What medication classes should be avoided/used with caution according to Beers Criteria?
* Anticholinergics (cognitive impairment) * Sedatives and other medications with CNS effects (falls) * Diabetic agents (sliding scale insulin, long-acting SUs) * Medications that may exacerbate chronic conditions (heart failure)
28
What factors should be considered when choosing medications for older adults?
* Life expectancy * Goals of care * Treatment targets * Time required to benefi (i.e. DCCT trials for tight FBG control, bisphosphonates in osteoporosis)
29
What is palliative care?
After diagnosis of terminal illness, disease is not responsive to curative treatment or treatment doesn't exist; holistic care for patient and family with the goal to optimize QOL
30
What is hospice care?
Care provided at home, in LTC, or in an independent facility where most patients have a life expectancy of 6 months or less (certified by an MD); diagnostic tests, hospitalizations, and labs are no longer covered
31
Advanced Care Directives are supported by which act?
Patient Self-Determination Act
32
What are Advanced Care Directives (ACDs)?
* Verbal/written instructions about future medical care and treatment * Elective and do not take away a patient's right to make current care decisions * Include Health Care Representative, Psychiatric Advance Directive, and Power of Attorney
33
What does it mean to designate a Health Care Representative?
Naming someone to make decisions if you are unable (or prevents someone from making decisions for you)
34
What is a Psychiatric Advance Directive?
Sets preferences regarding mental illness during periods of incapacity
35
What is a Power of Attorney?
Can be financial or healthcare-based; grants power to others you choose
36
Physician Orders for Scope of Treatment (POST) is a legal document declaring what four things?
1. Preferences for resuscitation 2. Medical interventions (intubations, dialysis, hospitalization) 3. Antibiotics 4. Artificial nutrition
37
What must occur for a Physician Orders for Scope of Treatment (POST) document to be valid?
Must be signed and dated
38
What is the preferred alternative to the term "geriatric"?
"Older adult"
39
What sex is urinary incontinence more common in?
Females
40
Rank the types of UI by the frquency that they occur in women.
1. Urge 2. Stress 3. Overflow 4. Mixed
41
Rank the types of UI by the frquency that they occur in men.
1. Urge 2. Overflow 3. Mixed 4. Stress (0%)
42
Explain the process of urine release in a normally-functioning bladder.
1. Stretch receptors notify the brain that the bladder is full (B3 receptors in the dome support detrusor relaxation/filling) 2. Neurologic stimulation initiates contraction (ACh receptors in the dome and alpha-adrenergic receptors in base and proximal urethra) 3. Sphincter relaxes to allow urine release
43
List the three age-related changes to the bladder and urethra.
* Decreased bladder capacity/elasticity * Increased spontaneous detrusor contractions * Decreased sphincter compliance
44
What is Urge UI (AKA overactive bladder)?
Hyperactivity of destrusor muscle = sudden, frequent, and unpredictable urination
45
What are the two possible causes of Urge UI?
* Neurologic * Medications (i.e. ACh inhibitors for Alzheimer's)
46
What is Stress UI?
Outlet incompetence (external urethral sphincter) + abdominal pressure
47
Describe the volume of Urge UI accidents.
Can be large or small
48
Describe the volume of Stress UI accidents.
Usually small volume
49
What are the two risk factors for Stress UI?
* Multiple childbirths * Estrogen deficiency
50
What medication class can exacerbate or cause Stress UI?
Alpha-antagonists
51
What is Overflow UI?
Abdominal discomfort/pain paired with increased freqency and need to void shortly following last urination, resulting from outlet obstruction or inability to/uncoordinated detrusor constriction.
52
Overflow UI is most commonly caused by what condition?
BPH or prostatic blockage of the urethra
53
True or false: in Overflow UI, urine builds up in the bladder.
True
54
What is Neurogenic (Atonic) Bladder?
Disruption in neurologic innervation of the bladder, usually characterized by inability/uncoordinated detrusor constriction.
55
Beyond inability/uncoordinated detrusor constriction, how else may Neurogenic (Atonic) Bladder occur?
Atony of bladder muscle from stroke, neuropathy, or spinal cord injury
56
Describe the volume of accidents from Neurogenic (Atonic) Bladder.
Small volume
57
Neurogenic (Atonic) Bladder increases the risks of what two conditions?
UTI and kidney stones
58
What is Functional Incontinence?
The inability to get to the bathroom in a timely fashion.
59
What are the four most common causes of Functional Incontinence?
* Impaired mobility * Change in mental status (dementia) * UTI * Medications (sedating)
60
What are the five non-pharmacological treatment options for urinary incontinence?
1. Scheduled voiding 2. Kegels 30-60x a day 3. Avoiding irritants (coffee, alcohol, caffeine, water at bedtime) 4. Absorbent products 5. Catheters
61
What is the main goal when treating Urge UI?
Reducing detrusor contraction frequency
62
What are the three medication classes that may be used to treat Urge UI?
* Anticholingeric/antimuscarinic * B3-antagonists * Combination
63
What is the single UI type that cannot be managed with injections or surgery?
Functional UI
64
List the six anticholinergic/antimuscarinic medications.
1. **Oxybutynin** (Ditropan, Oxytrol OTC patch, Gelnique) 2. **Tolterodine** (Detrol) 3. **Solifenacin** (Vesicare) 4. **Darifenacin** (Enablex) 5. **Trospium** (Sanctura) 6. **Fesoterodine** (Toviaz)
65
What is the only B3-agonist option to treat Urge UI?
Mirabegron (Myrbetriq)
66
What are the most common adverse effects of anticholineric/antimuscarinic medications?
* Dry mouth * Constipation * Fatigue * Confusion (acute or chronic) * Tachycardia
67
What are the most common adverse effects of mirabegron?
* Minor increase in BP * UTI
68
When treating Urge UI pharmacologically, how long does it usually take to receive max benefit?
4 weeks
69
When talking to patients taking medications for Urge UI, why would you advise against stopping a medication too quickly?
May cause recurrence of symptoms that is worse than baseline
70
How often should oxybutynin patches be applied?
Every 3-4 days
71
What medication is most clinically similar to oxybutynin?
Tolterodine
72
What anticholinergic/antimuscarinic medication is selective to the M3 receptor?
Solifenacin
73
What anticholinergic/antimuscarinic medication is a CYP2D6 inhibitor, CYP3A4 sub?
Darifenacin
74
What anticholinergic/antimuscarinic medication's absorption is decreased by food and should be taken on an empty stomach?
Trospium
75
What anticholinergic/antimuscarinic medication is a prodrug and CYP3A4 sub?
Fesoterodine
76
What is the most important counseling point for patients taking mirabegron?
Do not crush
77
What pharmacologic treatment options are available for Stress UI management?
* Duloxetine 40 mg BID * Topical estrogen 21 days on, 7 days off * Alpha-agonists like pseudoephedrine (rare) * Vaginal pessaries
78
In what order do you address Overflow UI treatment?
1. Address obstruction 2. Alpha-adrenergic blockers (if BPH) 3. Catheterization
79
What two alpha-adrenergic blockers can be used in Overflow UI management?
* Doxazosin 1-4 mg daily * Tamsulosin 0.4 mg daily
80
Which alpha-adrenergic blocker is slightly more selective for bladder neck subtypes of alpha receptors, and also has less of a hypotensive effect?
Tamsulosin 0.4 mg once daily
81
Since pharmacologic management is not routinely effective for Neurogenic UI, what other treatment options are?
* Non-pharmacologic like scheduled voiding * Intermittent catheterization * Botox injections in the bladder or urinary sphincter * Augmentation cystoplasty
82
What is augmentation cystoplasty?
Bladder walls and intestinal walls are connected to improve storage capacity
83
What catheter type is this?
Intermittent straight
84
What can intermittent straight catheters be made from?
* Rubber latex * Silicone * PVC
85
What catheter type is this?
Foley (indwelling) catheter
86
Are Foley catheters used chronically or acutely?
Chronically
87
What catheter type is this?
Condom catheter
88
What catheter type is this?
Suprapubic catheter
89
What is an appropriate follow-up time for UI treatment efficacy?
4-8 weeks
90
What is the mechanism of anticholinergic adverse cognitive effects?
1. Central muscarinic antagonism 2. Increased central amyloid 3. Loss of total cortical and temporal lobe thickness 4. Lower performance in processing/memory/executive function 5. Cognitive impairment

Fall 2020: Therapeutics 2 (11 decks)

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