5.8 BEER n shit

which first gen antihistamines are considered inappropriate medication uses in older adults

chlorpheniramine

cyproheptadine

dimenhydrinate

diphenhydramine

doxylamine

hydroxyzine

meclizine

promethazine

why are first gen antihistamines in appropriate for older adults to take

this drug class has high anticholinergic side effects, reduced clearance of drug through the kidneys due to increased age, tolerance can be developed, and risk of confusion/dry mouth/constipation [bc anticholinergic]

these high anticholinergic properties can increase fall risk, delirium, and dementia

which first gen antihistamine is the only one appropriate to use in older populations when used for acute treatment of severe allergic reactions only

diphenhydramine

if the patient is experiencing allergy like symptoms, what would be alternative options for them to use instead of first generation antihistamines

irrigate nasal passages w/ purified saline solution

2nd or 3rd gen antihistamines

what are examples of 2nd or 3rd gen antihistamines that are preferred to be used in older patients over 1st gen

loratadine

cetirizine

levocetirizine

fexofenadine

what can we tell patients to do/take if they are experiencing nasal symptoms [instead of using 1st gen antihistamines]

nasal antihistamine sprays like azelastine or olopatadine

nasal corticosteroids like fluticasone, budesonide, or triamcinolone

nasal mast cell stabilizers like cromolyn

what can we tell patients to take if they are experiencing ocular symptoms instead of taking 1st gen antihistamines

eye drops like ocular antihistamines or decongestants

artificial tears

which drug are considered inappropriate to give to older adults for primary prevention of cardiovascular disease

aspirin

why is aspirin an inappropriate drug to give to older patients

increase risk for major bleeding as age increases

what is aspirin generally indicated for

secondary prevention in older adults with established CVD

what alternative is there for aspirin since we can't use for primary prevention of CVD in older adults

no prevention

avoid initiating aspiring for primary

Consider deprescribing if on aspirin for primary prevention

is it every okay for an older adult to take aspirin

yes -- for secondary prevention with a patient that already has established CVD [prob won't test on if i had to guess]

which are the nonselective peripheral alpha 1 blockers that are inappropriate to use in older adults to treat hypertension

doxasozin

prazosin

terazosin

why are non-selective peripheral alpha 1 blockers not good to treat hypertension in older adults

these drugs cause high risk of orthostatic hypotension in this patient population therefore, it is not recommended for routine use

what are the central alpha-agonists not good to treat hypertension in older adults

clonodine

why is clonodine not a good choice in treatment of hypertension in older adults

high risk of adverse CNS effects which may lead to bradycardia and orthostatic hypotension therefore it is not recommended for routine use

which agents are NOT used to treat hypertension in older adults

doxazosin

prazosin

terazosin

clonidine

what drugs should be used OVER nonselective alpha 1 and central alpha agonists in the treatment of hypertension for older adults

consider nonpharm first then drug therapy

what nonpharm treatments are preferred to help treatment of HTN in older adults

DASH diet

exercise

weight loss

what pharm treatments are preferred to help treatment of HTN in older adults

regular 1st line therapy for HTN

-thiazide diuretics

-CCB

-ACEi

-ARBs

-Beta Blockers [some cases]

thiazide diuretic examples from chat

HCTZ

chlorthalidone

indapamide

metolazone

CCB examples from chat

amlodipine [most common] nifedipine

diltiazem [non-DHP]

verapamil [non-DHP]

ACEi examples from chat

lisinopril

enalapril

ramipril

benazepril

ARB examples from chat

losartan

valsartan

olmesartan

ibesartan

BB examples from chat

metoprolol

atenolol

propranolol

carvedilol

which anitdepressants are inappropriate to use in older adults

amitriptyline

paroxetine

why are amitriptyline/paroxetine not appropriate for older adults

high anticholinergic effects, sedating, causes orthostatic hypotension

which SSRI has the highest anticholinergic SE profile

paroxetine

what should be used instead of BZDP, 1st gen antihhistamines, TCAs to help with anxiety symptoms in older adults?

first we should address the cause of that is going on with the patient. are they having anxiety because of an event that has occurred?

nonpharm is first line

if pharm therapy is indicated, consider agents with safer aDE profile for older adults

which antipsychotics are considered inappropriate for older adults

aripiprazole

haloperidol

olanzapine

quetiapine

risperidone

why are these antipsychotics inappropriate for older adults

these can cause increase risk of stroke or greater rate of cognitive decline/mortality, especially in patients with dementia [dont want to make their dementia worse]

what conditions would be allowable for these antipsychotics to be given to older adults

schizophrenia

bipolar disorder

parkinson's disease psychosis

when would we consider using antipsychotics [not talking about dz allowed in]

may be appropriate if nonpharm options have failed and the patient is threatening substantial harm to self or others

what is the alternative option for antipsychotics

none :(

which BZDP are inappropriate to use in older adults

alprazolam

chlordiazepoxide

clonazepam

clorazepate

diazepam

estazolam

lorazepam

midazolam

oxazepam

temazepam

triazolam

which nonBZDP BZDP receptor agonist hypnotics are inappropriate for older adults

eszipiclone

zaleplon

zolpidem

why are BZDP inappropriate for older adults

this patient population has an increased sensitivity to BZDP and has a decreased metabolism of long acting agents

continued use can lead to dependence

all BZDP lead to increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes

when may BZDP be appropriate for older adults

for seizure disorders, rapid eye movement sleep behavior disorders, BZDP/ethanol withdrawal, severe GAD, periprocedural anesthesia

why are nonBZDP inappropriate in older adults

similar to BZDP as they cause delirium, falls, fractures, and increased ER visits/ hospitalizations

these have minimal improvement in sleep latency and duration

should we be taking BZDP for insomnia

bro no

what would be an alternative option for treatment of insomnia INSTEAD OF BZDP, Z drugs, 1st gen antihistamines, TCAs? what would we do first?

1st look for health conditions or anything that would cause sleep disruption [is patient anxious, have bills to pay so can sleep, unsafe neighborhood, medical conditions keeping them from sleep]

what kind of nonpharm therapy is considered 1st line for treatment of insomnia instead of inappropriate drug therapy

cognitive behavioral therapy for insomnia including sleep restrictions, stimulus control therapy, cognitive therapy, relaxation, sleep hygiene

T/F: good sleep hygiene alone is most effective for treating chronic insomnia

FALSE--alone is not effective

what medications may be used and are considered safe to give older adults to treat insomnia

low dose doxepin

ramelteon [short term use]

which medications have insufficient evidence and are not recommended to use for the treatment of insomnia in older adults

trazodone

meltaonin

what kind of diabetic medication is inappropriate for older adults

insulin sliding scale and SU

why is sliding scale insulin inappropriate for older adults

causes higher risk of hypoglycemia without improvement in hyperglycemia management

avoid short or rapid acting insulin if used without basal or long acting

what could be an alternative to sliding scale insulin for this patient population

adding basal insuline allows for safe d/c of sliding scale

what are the SUs that are inappropriate to give to older adults

glimepiride

glipizide

glyburide

why are SUs inappropriate for this patient population

these have higher risk of CV events, all cause mortality, and can cause hypoglycemia

this drug class can increase the risk of CV death and ischemic stroke

do long or short acting SUs have a higher risk of prolonged hypoglycemia -- aka making these even more of a reason not to use in older adults

long-acting agents like glyburide and glimepiride

which SU is considering short acting

glipizide

when would be the only option it is "okay" to use SUs in this patient population to treat DM

when there are substantial barriers to the use of safer and more effective agents

what are some alternative agents to SUs

metofrmin

SGLT2 inhibitors

GLP1

DPP4 inhibitors

SGLT2 examples from chat

dapagliflozin

empagliflozin

canagliflozin

DPP4 inhibitor examples from chat

sitigliptin

saxagliptin

which PPIs are inappropriate to use in older patients

all of them:

dexlansoprazole

esomeprazole

lansoprazole

omeprazole

pantoprazole

rabeprazole

why are PPIs inappropriate to use in this patient population

there is a risk of c. diff infections, pneumonia, FI malignancies, bone loss, and fractures if these patients take this medication

[due to even more decreased acid in the body bc of the PPI and also at the body ages it naturally has decreased acid]

what would be the only "okay" time to use PPIs in older adults

if the patient is at high risk for erosive esophagitis, Barrett's esophagitis, pathologic hypersecretory conditions, etc.

what would be nonpharm alternatives for PPIs for older adults to try

lifestyle

dietary

weight management

not eating within 2-3 hours of bedtime

elevate head of bed

what would be pharm alternatives for PPIs for older adults to try in the event nonpharm isn't good enougth

for nocturnal symptoms, patients can try nighttime H2 receptor antagonists

if they are on BID PPI, it is suggested to reduce to QD if they can't completely d/c

what are Non-COX 2 selective NSAIDs that are inappropriate to use in older adults

aspirin >325

diclofenac

etodolac

ibuprofen

indomethacin

ketorolac

meloxicam

naproxen

piroxicam

why are Non-COX 2 selective NSAIDs inappropriate

they have an increased risk of GI bleeding or PUD [especially in high risk groups like those taking steroids, anticoags, or antiplatelets]

using PPIs or misoprostol may reduce this risk

what happens with longer use of NSAIDs

upper GI ulcer, gross bleeding, or perforation may occur if treated with this drug class for an extended period of time

longer use = more likely to cause problems

when would it be "okay" to use NSAIDs in this patient population

if alternatives are not effective and patients can take the PPI

what is significant about indomethacin and ketorolac

oldest drug in class

have an increased risk of GI bleeding/PUD/AKI

of all NSAIDs, which one has the most ADE including higher risk of CNS effects

indomethacin

which skeletal muscle relaxants are inappropriate for older adults to have

carisoprdol

cyclobenzaprine

methocarbamol

why are skeletal muscle relaxants inappropriate in this patient population

high risk of anticholinergic ADE like sedation. can also have increased fracture risk

[does not apply to management of spasticity]

what is the key goal in treating pain

improving function

what are nonpharm alternatives to pain management instead of TCAs, NSAIDs, or skeletal muscle relaxants

good alone or in combo with meds

-education

-exercise therapy

-physical therapy

-psychological interventions

what are pharm alternatives to nociceptive pain management instead of TCAs, NSAIDs, or skeletal muscle relaxants

short term use of NSAIDs

topical NSAIDs

COX-2 selective inhibitors

topical capsaicin, menthol, lidocaine

APAP

intra-articular steroids

what are nonpharm alternatives to neuropathic pain management instead of TCAs, NSAIDs, or skeletal muscle relaxants

SNRIs [Duloxetine (chat)]

Gabapentinoids [gabapentin]

topical capsaicin, menthol, lidocaine

which drugs may lead to an exacerbation in heart failure

non-DHP CCB like Diltiazem and Verapamil

NSAIDS/COX2 inhibitors

Thiazolidinediones like Pioglitazone

why are these medications not goot to give heart failure patients

promote fluid retention and exacerbate heart failur

which drugs to avoid if patient has HF with reduced EF

diltiazem

verapamil

which drugs to avoid if the patient has asymptomatic or symptomatic HF

NSAIDs

COX-2 inhibitors

Thiazolidinediones [pioglitazone]

which drugs cause syncope

antipsych: olanzapine

AChEIs: donepezil,galantamine, rivastigmine

non-select alpha 1 block: doxazosin, prazosin, terazosin

TCAs: amitriptyline

how do antipsychotics and TCAs increase syncope risk

lead to increased risk of orthostatic hypotension

how to AChEIs increase syncope risk

cause bradycardia and should be avoided in those that have syncope due to bradycardia

how do non-selective peripheral alpha 1 blockers increase syncope risk

cause othostatic blood pressure changes

which drugs worsen dementia or cause cognitive impairment

anticholinergics

antipsychotics

BZDP

non-BZDPs: eszopiclone, zaleplon, zolpidem

what is the main reason dementia is worsened with these drugs

because of CNS adverse effects

why don't we use antipsychotics to help with dementia

they cause increase risk stroke/greater rate of cognitive decline

which drugs cause more falls or fractures and should not be used in older adults

anticholinergics

antidepressants" SSRIs, SNRIs, TCAs

antipsychotics

BZDP

non BZDP: eszopiclone, zaleplon, zolpidem

opioids

why are do these drugs cause increase in falls/fractures

may cause ataxia, impaired psychomotor function, syncope, and more falls

how do antidepressants increase risk of falls/fractures

risk of falls/fractures are mixed

SNRIs cause increase fall risk

how do BZDP increase risk of falls/fractures

shorter acting are NOT safer than long acting

which drugs worsen gastric or duodenal ulcers

aspirin

non-COX 2 selective NSAIDs

what happens if patient continues to take aspirin or non-COX 2 selective NSAIDs

may exacerbate existing ulcers or cause new/additional ulcers

which drugs should be used with caution in older adults

antidepressants: SNRIs, SSRIs, TCAs

diuretics

tramadol

SGLT2 inhibitors

why should we caution the use to antidepressants, diuretics, and tramadol in older adults

may exacerbate or cause SIADH or hyponatremia

monitor sodium levels closely

which SGLT2 inhibitors should be used with caution in older adults

caniglifozin

dapaglifozin

empaglifozin

ertuglifozin

why should we caution the use of SGLT2 inhibitors in older adults

may increase risk of urogenital infections especially in women

may increase risk of euglycemic diabetic ketoacidosis

what should be done and monitored in patients on SGLT2 inhibitors

monitor patient for urogenital infections and ketoacidosis

DRINK LOTS OF WATER

which antidepressants have strong anticholinergic properties

amitriptyline

paroxetine

which antiemetic has strong anticholinergic properties

promethazine

which antihistamines have strong anticholinergic properties

clorpheniramine

cyproheptadine

dimenhydrinate

diphenhydramine

doxylamine

hydroxyzine

meclizine

promethazine

which antimuscarinics have strong anticholinergic properties

darigenacin

fesoterodine

oxybutynin

solifenacin

tolterodine

which antipsychotics have strong anticholinergic properties

olanzapine