geriatric syndromes & special problemsmedia.mycrowdwisdom.com.s3.amazonaws.com/ascp/... ·...

Geriatric Syndromes & Special Problems

Scott Martin Vouri, PharmD, MSCI, BCPS, BCGP, FASCP

St. Louis College of Pharmacy

Faculty Disclosure

• Dr. Vouri is funded by the Washington University Institute of Clinical and Translational Sciences grants UL1 TR000448 and KL2 TR000450 from the National Center for Advancing Translational Sciences. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Learning Objectives

At the conclusion of this application-based activity, participants should be able to:

1. Define common geriatric syndromes seen in the elderly.

2. Develop approaches to caring for patients experiencing geriatric syndromes and special problems.

3. Discuss how drug therapy may cause or exacerbate geriatric syndromes.

4. Recommend and assess both drug and non-drug interventions for geriatric syndromes and special problems.

Geriatric SyndromesClinical, multifactorial health conditions that do not fit into specific disease categories / impact multiple domains and are associated with morbidity and mortality in older persons

Inouye et al. J Am Geriatr Soc.2007;55(5):780-791.Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).

Geriatric Syndromes

Will Cover• Bladder issues

• Bowel issues

• Pressure ulcers

• Sleep issues

• Dementia / Delirium

• Vision / Hearing issues

• Dizziness / Falls

Will Not Cover• Swallowing issues

• Malnutrition / Weight loss

• Faintness

• Gait issues

• Osteoporosis

• Depression

• Pain

• Substance abuse

Bladder Issues

Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).

Bladder Issues

Causes• D – elirium

• I – nfection (UTIs)

• A – trophic (urethritis or vaginitis)

• P – harmacology (diuretics, ACheI, alcohol)

• P – sychological (depression, dementia)

• E – xcessive urine output (CHF, diabetes, edema)

• R – estricted mobility (wheelchair bound, immobile)

• S – tool impaction

Petrou et al. Braz J Urol. 2001;27(2):165-170.Marshal et al. Consul Pharm. 2008;23(9):681-694.

Bladder IssuesNon-Pharmacological Treatment

Condition Treatment

StressWeight loss, Kegel exercises, pads, pessaries, surgery

Urge Weight loss, Kegel exercises, pads, fluid reduction

Overflow Pads, fluid reduction, TED hose, catheter

Mixed Treat predominant type

FunctionalScheduled voiding, prompted voiding, commode, grab bars

Owens NJ, Estus EL. Et als. Fundamentals of geriatric pharmacotherapy: an evidence-based approach. 1st ed. Bethesda (MD): American Society of Health-System Pharmacists; 2010. p 191-225.

Bladder Issues

Condition Treatment

Stress SNRI, alpha agonists

Urge Antimuscarinics, B3 agonist

Overflow Alpha-Blockers, 5ARI, PDE-5 inhibitors

Mixed Treat predominant type

Functional None

Owens NJ, Estus EL. Et als. Fundamentals of geriatric pharmacotherapy: an evidence-based approach. 1st ed. Bethesda (MD): American Society of Health-System Pharmacists; 2010. p 191-225.

Pharmacological Treatment

Bowel Issues


Bowel IssuesCauses• Constipation

• Medications

• Opioids, anticholinergics, CCBs, iron supplement

• Diet

• Dehydration, malnutrition

• Immobility/inactivity

• Medical conditions• Cancer, hypothyroid, neurologic

disorders

• Diarrhea• Medications

• AChEI, SSRI, antibiotics, cancer medications, constipation medications

• Medical conditions

• Short-gut, IBD, GI infections, GI bleed, HIV, Malabsorption, hyperthyroidism

Shah et al. Ann Intern Med. 2015;162(7):ITC1.Holt. Gastroenterol Clin North Am. 2001;30(2):427-444.

Bowel Issues

Condition Treatment

ConstipationDiscontinue medications, fluids, exercise, fiber, fecal impaction removal

DiarrheaDiscontinue medications, treat underlying causes, dietary fiber, pads

Non-Pharmacological Treatment

Bowel Issues

Condition Treatment

Constipation

PRN: 1st Line: Fiber, stool softeners, osmotics2nd Line: Stimulants, suppository, enema

Chronic: 1st Line: Fiber, Stool softeners, osmotics, stimulants2nd Line: Lubiprostone (US only), linaclotide, prucalopride

DiarrheaBulking agents, probiotics, loperamide, bismuth, diphenoxylate/atropine

Rogue et al. Clin Interv Aging. 2015;10:919-930.Schiller. Gastroenterol Clin North Am. 2009;38(3):481-502.


Pressure Ulcers


Pressure Ulcers

Causes• Immobility

• Poor tissue viability• Loss of muscle, poor nutrition, poor sensation

• Urinary, fecal incontinence

• Poor overall physical and mental health

Health Quality Ontario. Ont Health Technol Assess Ser. 2009;9(3):1-203.

Pressure Ulcers

Condition Treatment

PressureUlcers

Repositioning/turning, promote good wound healing (dressings, nutrition, frequent pad changes), psychosocial support

Health Quality Ontario. Ont Health Technol Assess Ser. 2009;9(3):1-203.Gorecki et al. J Am Geriatr Soc. 2009;57(7):1175-1183.


Pressure Ulcers

Condition Treatment

PressureUlcers

Local treatment: Wound cleansing (saline), debridement, Topical treatment (barrier cream), dressings (hydrocolloid)

Biologic treatment: platelet-derive growth factors (becaplermin) – only available in U.S.

Nutrition treatment: protein supplement, vitamin/nutrient supplement

Other treatment: Pain relief, infection control

Health Quality Ontario. Ont Health Technol Assess Ser. 2009;9(3):1-203.


Sleep Issues


Sleep Issues

Causes• Medications

• Stimulants, caffeine, bupropion, HS diuretics, nicotine

• Medical conditions• Depression

• Bladder issues (nocturia)

• Heart Failure

• Neurological conditions (tremor, parkinsonism, RLS)

• Sleep Apnea

• Insomnia

Rodriguez et al. Med Clin North Am. 2015;99(2):431-439.Wennberg e tal. Maturitas. 2013;76(3):247-252.

Sleep Issues

Condition Treatment

Medical Conditions

Treat the underlying medical condition

Sleep ApneaContinuous Positive airway pressure (CPAP), nasal surgery, weight loss

Insomnia

Sleep hygiene – stimuluscontrol/environmental changes, avoid daytime naps, daytime activities, relaxation techniques, “Old remedies”



Sleep Issues

Condition Treatment

Medical Conditions

Treat the underlying medical conditions

Sleep ApneaAvoid treating with sleep medications or stimulants

Insomnia

1st Line: Melatonin2nd Line: Mirtazapine, trazodone3rd Line: Non-BZD and BZDsAvoid: Diphenhydramine, TCAs, antipsychotics



Active Learning

The use of methylphenidate is most likely to precipitate ________ issues.

a) Bladder

b) Bowel

c) Sleep

d) Vision

Active Learning

A patient with BMI of 35 is experiencing issues with sleep. He is currently treated with lisinopril, pravastatin, and aspirin. What is the best treatment option for this patient?

a) Non-pharmacological treatment

b) Pharmacological treatment

c) Discontinuation of current therapy

d) Initiate a new medication

Dementia / Delirium


Dementia / Delirium

Causes

• Dementia• Genetics

• Reduced O2 to brain

• Substance abuse

• Medical conditions

• TBI, HIV, PD

• Delirium• Substance intoxication• Substance withdrawal• Medications (next slide)• Medical conditions

• Infections, dementia, visual/hearing impairment, terminal illness, pain, seizures, malnutrition, urine/stool retention, low B12/folate, syphilis, electrolyte issues (low Na, BG)

Alves et al. World J Clin Cases. 2013;1(8):233-241.Inouye et al. Lancet. 2014;383(9920):911-922.

Dementia/Delirium

Medication-Induced Delirium

A – ntiparkinson’s

C – orticosteroids

U – rinary meds

T – heophylline

E – mptying drugs

C – V (rhythm) meds

H – 2 blockers

A – nticholinergics

N – SAIDS

G – eropsych Meds

E – NT drugs (EtOH)

I – nsomnia meds

N – arcotics

M – uscle relaxants

S – eizure meds

http://www.unmc.edu/media/intmed/geriatrics/reynolds/pearlcards/delirium/deliriums_mnemonic.htm

Dementia/Delirium

Condition Treatment

DementiaBehavioral interventions, assistance with ADLs/IADLS, caregiver support

Delirium Treat underlying condition, sleep, glasses/hearing aides, exercise, orientation, taper/discontinue unnecessary medications



Dementia/Delirium

Condition Treatment

Dementia

AD – AChEI, NMDA antagonists, caprylidene (US only)AD Behavior – Non-Pharm (avoid antipsychotics) Vascular – Optimal treatment of vascular issuesLewy Body – AChEIPseudodementia – SSRIs

DeliriumNon-Pharm – (antipsychotics or BZD – last resort –smallest dose/shortest duration)



Vision / Hearing Issues


Vision/Hearing Issues

Causes• Vision

• Presbyopia• Cataracts• Glaucoma• Macular degeneration • Chronic dry eyes• Medications

• Anticholinergics, PDE-5 inhibitors, tamsulosin, anti-cancer drugs, eye drops, amiodarone

• Hearing• Cerumen impaction• Aged-related changes• Inattention • Medications

• AMGs

Kane RL, Ouslander, Abrass IB. Essentials of clinical geriatrics. 5th ed. New York: McGraw-Hill. 2004.Williams ME et al. Case-based geriatrics: a global approach. 1st ed. New York:McGraw-Hill;2011. p 59-68.Li et al. Drug Saf. 2008;31(2):127-141.


Condition Treatment

Vision

Appropriate glasses, routine examinations, controlling of diabetes/hypertension, surgery, avoid anticholinergics, warm compressCommunication: Large font/magnifiers, avoid glare, contrasting colors

Hearing

Remove wax, routine examinations, encourage use of hearing aidsCommunication: Enunciation, eliminate background noise, ask if needing to speak louder

Akpek et al. Am J Manag Care. 2013;19(5 Suppl):S76-84.Wagner J. Advance for nurses. 2001;3(20):15.



Condition Treatment

Vision

Glaucoma – beta-blockers, prostaglandins, a2agonists, carbonic anhydrase inhibitorsMacular degeneration – anti-VEGF (aflibercept, ranibizumab, bevacizumab)Chronic dry eyes – OTC eye drops, cyclosporine ophthalmic, D/C anticholinergics

Hearing Ear irrigation – glycerin, mineral oil, hydrogen peroxide

Akpek et al. Am J Manag Care. 2013;19(5 Suppl):S76-84.Wagner J. Advance for nurses. 2001;3(20):15.


Dizziness/Falls


Dizziness/Falls

Causes• Dizziness

• Medical conditions• Positional vertigo, Meniere’s

disease, vestibular migraines, vestibular paroxysmia, orthostasis, arrhythmia, panic attacks

• Medications • TCAs, anticholinergics, BZDs,

AMG (ototoxicity), antiepileptics, diuretics, beta-blockers, vasodilators, antidiabetics, EtOH

• Falls• Gait, balance, dizziness, poor

muscle strength, weakness• Medical conditions

• Stroke, PD, cancer, low BP, dementia, arthritis

• Medications• Miscellaneous

• Tripping hazards, poor vision

Lempert. Continuum (Minneap Minn). 2012;18(5):1086-1101.Swartz et al. Am Fam Physician. 2005;71(6):1115-1122.Rubenstein. Age Ageing. 2006;35(S2):37-41.

Dizziness/Falls

Condition Treatment

Dizziness Treatment of cause, reposition maneuver, rest

Falls

Exercise, remove tripping hazards, correct vision (glasses, cataract surgery), use of assistive devices, appropriate footwear, utilize interdisciplinary team

Lempert. Continuum (Minneap Minn). 2012;18(5):1086-1101.Swartz et al. Am Fam Physician. 2005;71(6):1115-1122.Health Quality Ontario. Ont Health Techol Assess Ser. 2008;8(2):1-178.


Dizziness/Falls

Condition Treatment

DizzinessSymptomatic treatment – Nausea (short-term use of meclizine, BZD, promethazine, betahistine (Canada only); D/C medications

FallsVitamin D supplementation, discontinue medications

Lempert. Continuum (Minneap Minn). 2012;18(5):1086-1101.Swartz et al. Am Fam Physician. 2005;71(6):1115-1122.Health Quality Ontario. Ont Health Techol Assess Ser. 2008;8(2):1-178.


Active Learning

A elderly patient is having recurrent falls due to dizziness. What is the BEST recommendation for this patient?

a) Scheduled meclizine

b) Evaluate current medication list

c) Perform repositioning maneuvers

d) Refer to physical therapist

Active Learning

Which medication is most associated with delirium in older adults?

a) Aspirin

b) Diazepam

c) Omeprazole

d) Metformin

Conclusion

• There are several Geriatric Syndromes that impact morbidity and mortality of older adults

• Many manifest due to comorbid conditions and/or medications

• Withdrawal of medication, non-pharmacological treatment, and pharmacological treatment can improve these signs/symptoms

• Geriatric syndromes should be managed using an interdisciplinary approach

geriatric syndromes & special problemsmedia.mycrowdwisdom.com.s3.amazonaws.com/ascp/... ·...

Documents