BCPS 2013: Geriatrics

Geriatric pharmacy is a field that will continue to grow due to the aging population.  Not only do you need to remember the physical changes that geriatrics experience, but the current guidelines.

Know your guidelines!

PK/PD

Organ System	Physiologic Change with Aging	Resulting Effect on PK
GI	↑ stomach pH ↓ GI blood flow Slowed gastric emptying & GI transit	↓ absorption of basic drugs and nutrients ↓ in 1st-pass metabolism Rate of absorption may be prolonged
Skin	Thinning of dermis Loss of SQ fat	↓/↔ to drug reservoir formation with transdermal formation
Body Composition	↓total body water ↓ lean body mass, ↑body fat ↑ α1-acid glycoprotein ↓/↔ serum albumin	↑ VD and accumulation of lipid soluble drugs (i.e. BZDs) ↑ free fraction of highly bound acidic drugs and ↓ free fraction of basic drugs
Liver	↓ liver mass ↓ blood flow to the liver	↔ in phase II drug metabolism ↓/↔ phase I metabolism ↓/↔ CYP450 enzymes ↑ half-life and ↓ CL of drugs with high 1st-pass metabolism
Renal	↓ GFR and renal blood flow ↓ tubular secretion ↓ renal mass	↓ renal elimination of many meds ↑ half-life of renally eliminated drugs and metabolites

Salts of acid drugs: sodium (sodium naproxyn), calcium (atorvastatin calcium), potassium (penicillin G potassium)

Salts of basic drugs: HCl (tetracycline HCl), sulfate (atropine sulfate)

Medications to AVOID in the elderly

• Beer’s List: includes consensus drugs only
• Anticholinergic medications (anti-SLUDGE)

DEMENTIA

Delirium	Dementia	Depression
SUDDEN, RECENT ONSET Lasts hrs to weeks Look for changes in meds, setting, and infection; often reversible	Slow, progressive onset Irreversible, memory impairment In the present, with you in the moment (good attention)	Slow or recent onset Withdrawn and/or sad Flat affect but emotional Answers with “I don’t know”

Medication causes of mental status change (reversible):

• Anticholinergics
• Opioids
• Glucocorticosteroids
• BZDs and other sedative/hypnotics
• Antiparkinsonian med

MMSE (mini-mental status exam) Scores:

• Normal cognitive function= > 24 (out of 30)
• Mild Alzheimer’s Disease= 21-24
• Moderate AD= 10-20
• Severe AD= <10
• Expected point decline in untreated pt= 2-5 points/year

Also assess a patient’s function (IADLs) and global assessment (CIBIC-Plus)

AD Pharmacological Treatment:

1^st line: cholinesterase inhibitors (CIs); all equal efficacy; risk of bradycardia and syncope increased for all CIs

• Donepezil (Aricept): 5mg/d (10mg-23mg/d); also ODT tabs; mild-mod AND severe AD
• Rivastigmine (Exelon): 1.5-6mg tabs BID [also 9mg (delivers 4.6 mg/d) and 18mg (delivers 9.5 mg/d) patches]; ADRs of  N/V/D more intense than w/ other CIs; mild-mod AD & mild-mod dementia with PD
• Galantamine (Razadyne): 4-12mg BID or 8-24mg/d (ER formulation); administer with food; syncope at high doses

2^nd line/adjunct: glutamatergic therapy (NMDA antagonist; blocks glutamate)

• Memantine (Namenda): 5mg/d up to 10mg BID; mod-severe AD, may be used in combo w/ Aricept; well tolerated but sometimes confusion seen

**NOTE: CIs and memantine show stat sig improvement in cognition, global assessment, and ADL in high-quality studies but NOT clinically significant!

> 50% of pts with dementia have psychosis and agitation

1. Determine cause

2. Non-pharmacological interventions (i.e. educate caregivers, have routine, improve environment)

3. Pharmacologic

A. CIs: ? efficacy; can increase agitation; 1^st line for psychosis in Lewy body dementia

B. Atypical Antipsychotics (APs): NO FDA-APPROVED AP for tx of dementia-related psychosis

• No clear standard on when to use, use for shortest time possible
• Cochrane review suggests olanzapine and risperidone have most evidence for use in psychosis and aggression; however, use quetiapine if pt has comorbid PD or Lewy body dementia
• High rate of ADRs: sedation, orthostasis, ↑ risk of stroke/death (OR 1.54 (CI 1.06-2.23), p=0.02)

URINARY INCONTINENCE

Type	Description	Drug-induced causes	Drug Tx	Comments
Urge or Overactive Bladder	Loss of mod amts of urine w/ an ↑ in need to void; can result from CNS damage from stroke	Cholinergic agents (stimulate bladder; i.e. CIs)	Anticholinergic agents (i.e. darifenacin, oxybutynin, solifenacin, tolterodine)	-1st line agents -Oxybutynin has highest CNS effects
Stress incontinence	Loss of urine w/ ↑ ab pressure (i.e. sneezing, coughing)	α-blockers	α-agonists (i.e. PSE and phenylephrine) Topical estrogens and Duloxetine	-All variable efficacy -SURGERY normally 1st line
Overflow incontinence	Loss of urine b/c of excessive bladder volume caused by outlet obstruction or an acontractile detrusor	Anticholinergics, CCB, opioids ↓ detrusor contractions	α-blockers (outlet obstruction) Add-on 5-α reductase inhibitors or bladder antispasmodics (i.e. oxybutynin, tolterodine) à advanced BPH or refractory sxs Cholinomimetic (bethanechol)
Functional incontinence	Inability to reach toilet due to mobility constraints	Sedating meds cause confusion; diuretics	Remove barriers and obstacles, provide toilet scheduling; assist pt on/off toilet
Mixed incontinence	UI w/ >1 cause; usually stress and overactive bladder		Focus on dominating symptoms

Reversible causes of UI: DIAPERS (Delirium, Infection, Atrophic vaginitis and urethritis, Psychiatric disorders, Excessive urine output, Restricted mobility, and Stool impaction)

BPH Treatment:

1^st line: α-blockers (↓ smooth muscle contraction in urethra); all can cause hypotension!

• Nonspecific α-blockers: doxazosin (Cardura), prazosin (Minipress, not FDA-approved for BPH), and terazosin (Hytrin)
• Selective α1-blocker: tamsulosin (Flomax)- less hypotension but ↑rate of ejaculatory dysfunction
• Selective post-synaptic  α1-blocker: alfuzosin (Uroxatral)

2^nd line: α-reductase inhibitors (prevent conversion of testosterone to DHT, DHT stimulates prostate growth)

• Finasteride (Proscar) and dutasteride (Avodart); decreased libido
• DO NOT IMMEDIATELY REDUCE SXS! At least 6 mo’s needed for benefit
• Need baseline PSA to monitor for prostate cancer

Combo therapy for men w/ lower urinary tract symptoms, larger prostate size (>40g) and elevated PSA

• Dutasteride w/ tamsulosin FDA-approved

Saw palmetto- conflicting efficacy data; may decrease efficacy of reductase inhibitors if used together

Surgery- for severe sxs and those with mod sxs not responding to meds

OA

Weight-bearing joints, unilateral, increased with age

Treatment

1^st line: APAP up to 4 g/d (< 2.6 g/d if EtOH abuse); 2^nd line: opioids, NSAIDs should seldom be used

Other options with ?efficacy: gabapentin (if neuropathic pain), baclofen if muscle spasms, topical agents (i.e. capsaicin, licocaine 5% patch), glucosamine +/- chondroitin

RA

Autoimmune disease, common in women (3:1 vs men) and younger people; bilateral inflammation in small joints of hands, wrists, and feet; (+) RF, ESR, C-reactive protein, and normochromic normocytic anemia

Treatment: goal = control inflammation à disease remission

• 1^st line tx: methotrexate (7.5-15mg/week) or potentially other DMARD; 3 months of use before effects seen!
  • For IMMEDIATE tx of pain and inflammation: NSAIDs (analgesic effects w/in hrs, antiinflammation 1-2 weeks) and glucocorticosteroids…both used SHORT-TERM
  • 2^nd line if methotrexate does not work: TNF (etanercept, infliximab, adalimumab, etc) or IL inhibitor

Canada Pharmacy Reviews from Best Price RX Pharmacy

Dick Cheney and the Polarizing Heart Transplant

I suppose my first thought at the news that former Vice President Dick Cheney had received a heart transplant paid for by the taxpayers was, "wait… he’s 71? Isn’t that too old for a heart transplant when I am sure there are younger people on the list that could benefit much more in terms of longevity than Cheney would. Then I read that he was on the transplant list for 20 months. That means he was in his sixties when on the list and also on the list longer than average 6-12 months. The most disturbing thing about the whole thing is the comments that have poured in online, online articles and twitter.

Chimed in Tim Viselli of La Canada Flintridge: After many transplants, the body will reject an incompatible heart. This may be the first time where the heart rejects an incompatible body.

Andrew Rubin of Malibu added: Seeing the headline that Cheney had received a heart transplant, I could not help but think, "Better ten years late than never."

Patricia Coelho of South Pasadena echoed several others when she wondered: Does this mean that Dick Cheney will finally have a heart?

Clearly not a fan, Steve Wollenberg of Los Angeles asked: Dick Cheney had a heart transplant? Really? Did anyone toss in a brain? They usually, but not always, come as a set.

And finally, from Phoenix, Ernie Haas emailed a wish: Just heard that ex-Vice President Dick Cheney had a change of heart. Maybe now he'll become a Democrat.

Or Twitter:

I heard a nurse’s hand slipped and touched Cheney’s original heart and she transformed into a spidergoat and ate 2 babies in the maternity ward. -@robdelaney (who is hilarious, by the way)

MUST READ: Cheney Receives Heart Transplant; Bush Still on Waiting List for Brain. @BorowitzReport

@GerryDuggan said “They’re throwing Cheney’s old heart into a volcano, right?

I suppose for me the biggest issue I have with the operation is the age limit of heart transplants. Is there one?

The indication and contraindications for heart transplantation. Indication for heart transplantation - End-stage heart disease not remediable by more conservative measures Contraindications - Irreversible pulmonary hypertension /elevated pulmonary vascular resistance - Active systemic infection - Active malignancy or history of malignancy with probability of recurrence - Inability to comply with complex medical regimen - Severe peripheral or cerebrovascular disease - Irreversible dysfunction of another organ, including diseases that may limit prognosis after heart transplantation

I don’t believe it’s time to place a value on human life based on politics, decisions in the past, age, etc… I’m not surprised that so many negative thoughts are out there regarding Cheney. We have sort of lost the human filter of sympathy for our fellow man.

And, hey, it's easy when you are behind a keyboard ;)

I Want to Die

Patient is 93 year old female with an order, "Consult psychiatry. Paranoid. States that she wants to die. Eval." Are you serious? 93 year old and wanting to die. I think that would be a part of her normal course of life.