What makes older adults unique

< 130/80

What is the BP goal for healthy adults over 65?

frail or multimorbid older adults

Who may have higher BP targets?

< 7-7.5%

What is the A1c goal for healthy (few coexisting chronic illnesses, intact cognitive and functional status: longer remaining life expectancy)?

individualized

There is also _________ A1c goals (< 7%, <7.5%, <8%) depending on function/cognition.

avoidance of hypoglycemia

What is the priority in diabetes?

sulfonylureas, meglitinides, sliding scale insulin

What are the hypoglycemic-prone drugs that should be avoided in geriatrics?

< 8%

What is the A1c goal for complex/intermediate (multiple coexisting chronic illnesses or 2 or more ADL impairments or mild to moderate cognitive impairment)?

avoid reliance on A1c

What is the A1c goal for very complex/poor health (LTC or end stage chronic illnesses or moderate to severe cognitive impairment or 2 or more ADL impairments)?

80-130

What is the goal preprandial BG in healthy ppl?

90-150

What is the goal preprandial BG in complex/intermediate ppl?

100-180

What is the goal preprandial BG in very complex/poor health ppl?

< 140/90

What is the goal BP for a very complex/poor health person?

simplify

You should also try to __________ insulin regimens in the elderly.

-change timing from bedtime to morning

-titrate dose of basal insulin

-add non insulin agents

What are some ways to simplify the insulin regimens in the elderly?

-Mentation

-Medications

-Mobility

-What matters most

What are the 4 Ms framework of age-friendly health systems to address person-specific issues that can affect diabetes managment?

mentation

-self admin of meds

-ability to use diabetes tech

-anxiety, depression, and diabetes distress

-mild cognitive impairment or dementia

-coping skills and self care

medicaitons

-tx burden

-affordability or insurance coverage

-end organ disease or complications affecting med choice

-polypharmacy

-hx of adverse med effects

-social and fam support

-risk of hypoglycemia, hypoglycemia unawareness, and fear of hypoglycemia

mobility

-foot complications

-funcional ability

-frailty and sarcopenia

-leg weakness

-neuropathy

-vision and hearing impairment

what matters most

-discussing goals and expectations

-symptom and disease burden

-meal and tx preferences (injections and glucose monitoring)

-risks, burdens, and benefits of tx

-loneliness, social isolation, and overall QoL

-life expectancy

protective

Being slightly overweight in the elderly is ________

exercise

You must prioritize _________ along with weight loss

sarcopenia

the loss of muscle mass, strength, and function that comes with aging

sarcopenia

What is the concern with weight loss in the elderly?

1.6 mcg/kg/day

What is the dosing of levothyroxine in younger adults?

12.5-50 mcg/day

What is the dosing of levothyroxine in older adults?

12.5-25 mcg/day

What is the dosing of levothyroxine in older adults with CAD?

increased risk of Afib, angina, osteoporosis, falls and delirium

What is the risk with too much thyroid hormone in the elderly?

0.5-4.5

subclinical hypothyroidism normal TSH:

usually do NOT treat (just monitor)

subclinical hypothyroidism TSH 4.5-10 and asymptomatic:

treat

subclinical hypothyroidism TSH > 10:

initiation of mod or high intensity statin is reasonable

OR

continuation of high intensity statin is reasonable

If a pt is > 75 yo with ASCVD not at very high risk:

high intensity or max statin

If very high risk ASCVD:

moderate

In adults older than 75 yo with an LDL 70-189, initiating a _______ intensity statin may be resonable.

160

You should not use Aspirin in dose > _____

primary

You should NOT use aspirin for ________ prevention of ASCVD.

NO

Should you use aspirin in combo with anticoagulants for A fib?

antiplatelet

should be used with hx of coronary, cerebral, or peripheral vascular disease

2

Anticoagulation for A fib if CHADSVASc Score ≥ _____

benzos and TCAs (amitriptyline, nortriptyline)

What should be avoided for depression/anxiety?

SSRI/SNRIs

What should be used in depression/anxiety?

6-8 weeks; full response may take 12 weeks

What is the time to effect for SSRI/SNRIs?

half

You should start SSRI/SNRIs at ________ the usual dose

sertraline (clean renal/hepatic profile, low interactions), escitalopram (well-tolerated, low anticholinergic)

What are the best SSRIs?

20 mg

What is the max dose of citalopram in the elderly due to QTc prolongation?

paroxetine

most anticholinergic SSRI

SNRI

good for depression and neuropathic/chronic pain

hyponatremia

What should we monitor for in SSRI/SNRIs?

Bupropion

can worsen anxiety; avoid in seizure/fall risk and low weight

Mirtazepine

helpful for poor appetite + insomnia, but can cause sedation and weight gain

Buspirone

can help with anxiety, less sedation and safer option

Hydroxyzine

very anticholinergic; increases risk of sedation and falls

Z

You should avoid _____ drugs for sleep.

Melatonin

is best - max dose of 3 mg (higher doses can worsen REM cycle)

Mirtazepine

used in low doses for sleep if poor appetite or weight loss co-exists

Doxepine

3-6 mg (lowest dose, least anticholinergic - for sleep onset and maintenance)

OTC

Avoid ______ sleep aids (anything with PM = anticholinergic)

GI/renal/CV risk

What are the risks with NSAIDs used long term for chronic pain?

multimodal, nonpharm strategies

What should be used for chronic pain?

overdosing

A creatinine-based eGFR will over estimate GFR in older adults

with sarcopenia leading to drug _________

dizziness, falls, and fracture

What are the risks that cause us to have strict BP lowering in CKD pts?

low

You should start ______ doses with SGLT2i and RAAS inhibitors.

dexerity/cognition

What should inhaler device selection be based on?

soft mist inhalers

What might be the best inhalers?

Nebulizers

may be the best option for COPD/asthma for both maintenance and rescue therapy

higher

Elderly pts have a _________ sensitivity to systemic steroids.

Immunizations

• High dose flu vaccines

• RSV vaccine options

• Shingrix

• Pneumonia vaccine pathways

pre-op anesthesia

avoid benzos, anticholinergics, and NSAIDs

intra-op anesthesia

avoid long-acting sedative and over sedation

start low dose anesthetics, consider regional anesthesia

post-op anesthesia

avoid meperidine, tramadol, zolpidem, unmanaged pain

delirium prevention and multimodal pain control