Safe Medication Use

Question 1

Any symptom in an elderly patient should be considered as what until proven otherwise?

Answer 1

A drug side effect

Question 2

High-risk elderly: polypharmacy

Answer 2

Use of multiple drugs by a single patient for one or more conditions

≥9 meds, ≥12 doses

Question 3

High-risk elderly: high-risk drugs

Answer 3

BZDs, hypnotics, APs, anticholinergics, narcotics, long-acting sulfonylureas, insulins, anticoagulants

Question 4

High-risk elderly: patient characteristics

Answer 4

decreased weight, ≥85 years old, decreased renal function

Question 5

High-risk elderly: drugs with a narrow TI

Answer 5

warfarin, digoxin, phenytoin, CBZ, VPA, Li

Question 6

Other characteristics of high-risk elderly patients

Answer 6

History of prior ADRs
≥6 comorbidities

Question 7

Effect of anticholinergics in the elderly

Answer 7

Confusion, which may lead to delirium +/- dementia

Question 8

Anticholinergic effects on vision and potential outcome

Answer 8

Impaired ADL, falls and accidents

Question 9

ACh effects on oral cavity and potential outcome

Answer 9

Decline in nutritional status, increased risk of infection

Question 10

ACh effects on GI tract and potential outcome

Answer 10

Decline in nutritional status, worsening of disease, anxiety, pain

Question 11

ACh effects on CV system and potential outcome

Answer 11

Worsening disease, anxiety

Question 12

ACh effects on UT and potential outcome

Answer 12

Incontinence, infection, loss of independence

Question 13

ACh effects on CNS and potential outcome

Answer 13

Cognitive dysfunction, impaired ADLs

Question 14

ACh muscle relaxant examples

Answer 14

cyclobenzaprine, methocarbamol, carisoprodol, oxybutynin

Question 15

ACh TCA example

Answer 15

amitriptyline

Question 16

ACh antispasmodic examples

Answer 16

dicyclomine, hyoscyamine, propantheline

Question 17

ACh antihistamine examples

Answer 17

diphenhydramine, chlorpheniramine, cyproheptadine, hydroxyzine, promethazine

Question 18

Most anticholinergic medications

Answer 18

Amitriptyline, paroxetine, atropine, oxybutynin, tolterodine

Question 19

How to reduce ACh risk from meds

Answer 19

D/C them

Question 20

Effects of BZDs in the elderly

Answer 20

Increased risk of cognitive impairment, delirium, falls/fractures, motor vehicle crashes

Question 21

Uses for BZDs in the elderly

Answer 21

May be appropriate for seizure disorders, rapid eye movement sleep behavior disorder, BZD withdrawal, severe generalized anxiety disorder, periprocedural anesthesia

Question 22

How to reduce BZD risk in the elderly

Answer 22

Use a short-acting BZD at the lowest dose
If you have to treat anxiety, use an SSRI

Question 23

ADs risk in the elderly

Answer 23

falls, anticholinergic ADRs (paroxetine, amitriptyline). Increased risk of hip fractures

Question 24

How to reduce AD risk in the elderly

Answer 24

Start the patient on lower doses, start low and go slow

Question 25

NSAID risks of the elderly

Answer 25

GI toxicity, CV risks, renal considerations

Question 26

GI toxicity with NSAIDs

Answer 26

Ulcer risk is 4-5x higher than nonusers
~4-fold increased mortality related to PUD
Highest risk early
Risks increase ~4%/year of age >65
Study on NSAID-induced GI toxicity: ALL NSAIDs increase risk of GI complications compared to ibuprofen as a control

Question 27

CV risks with NSAIDs

Answer 27

All NSAIDs increase risk of AMI
Worsening HF

Question 28

Renal effects with NSAIDs

Answer 28

Reductions in renal blood flow
Sodium and water retention
Concern for combinations with ACEIs or diuretics commonly used in elders

Question 29

How to reduce NSAID risk in the elderly

Answer 29

Misoprostol: 800mcg/day needed; lower doses decrease diarrhea, but less effective

H2RA: standard doses shouldn’t be used for prophy, but double doses are effective

PPI: standard doses effective

High-risk GI patients: COX-2 alone or NSAID + PPI offer similar but potentially insufficient protection, so consider COX-2 + PPI