GM

Geriatric Medicine
Shelley Kraus and Emily Siu, chapter editors Doreen Ezeife and Nigel Tan, associate editors Steven Wong, EBM editor Dr. Barry J. Golclllst. staff editor
Seniors in Canada and the U.S............. 2 Health Status Physiology and Pathology of Aging ......... 2 Differential Diagnoses of Common Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Constipation Delirium, Dementia and Depression Elder Abuse Failure to Thrive (Frailty) Falls Fecal Incontinence Gait Disorders Hazards of Hospitalization Hypertension Immobility Immunizations Malnutrition Osteoporosis Presbycusis Pressure Ulcers Urinary Incontinence Driving Compatency ..................... 9 Reporting Requirements Conditions That May Impair Driving Health Care Institutions . . . . . . . . . . . . . . . . . 11 Palliative and End of Life Care . . . . . . . . . . . . 11 Principles and Quality of Life End of Life Care Discussions Power of Attorney Instructional Advance Directives Symptom Management Geriatric Pharmacology.................. 12 Pharmacokinetics Pharmacodynamics Polypharmacy Inappropriate Prescribing in the Elderly Common Medications ................... 14 References ............................ 15

Toronto Notes 2011

Geriatric Medicine GMI

GM2 Geriatric Medicine

Seniors in Canada and the U.S./Physiology and Pathology of Aging

Toronto Notes 2011

Seniors in Canada and the U.S.

Health Status

\,
Gerillric Giant. Memory
Falls lnconlin1111C8

Table 1. Causes of Mortality end Morbidity in Canadien end American Seniors

1. Disaasas of the heart and citulatary aystam (3D.WJD.4%) 2. MaliiJI&nl neopiiiSIIII (2D.0/22.D%) 1. Hypartansion

Polypilannacy

2. Arthritis

3. Cerebrovascular disease (8.(117.4%)

4. Chronic loww respiraiDry disease (5.1/6.D%) 5. Accidents (2.9%)1
5 I of Gerillric Immobility Intellect Incontinence
latrogenesis lmpairad hameollnil

3. Heart disease
4. Diabetes 5. Ulcers

6. Alzheimer's (4.7/3.7%)2

6. S1roke 7. Asthma 8. Allergies

......

Physiology and Pathology of Aging

Table 2. Changes Occurring Frequently with Aging
Pllhologicll Chlnges Neurologic Spacill Sanes Deaeased wakefulness, decreased bran mass, carabral blood flow Daaeasad lacrimal gland sacration, lens 1111nsp111111cy, dark adapllltion, dacrB8Sad sense of smell and taste Increased insomnia, neurodegenerative disease, stroke, decraasad r&llsx rasponsa Increased glaucoma, cataraels, macular dajjenaration, pnllbycusis, presbyopia, vartigo, oral dryness

Medicltion-f'lllallld I'Mumonill
Sepsis

Malt Cornman Acat Dilanlrs lntM Ellhlrly Cardiovascular disease (CHF. r:vA, Mil Fracture (hip, vertllbree, wrist)

\,
Malt Cornman Cbranic Dilonl.,. lntM Ellhlrly Arthritis Catarscts Uld other visual problems

Canliovalcular

Increased sBP. dBP. decreased HR. CD Increased atherosclerosis, CAD. ML CHF. Decreased vassal elasticity, cardiac myocyta siza hypartansion, arrhytlmias and .-..mber, beta-achnergic responsiveness lnaeased lnlcheal cartilage calcification, mucous Pld hypertrophy Decreased elastic recoil, mucociiary claamnca, pLJmonary function reserve Increased intestinal villous atrophy Deaeased esophageal peristalsis, gastric acid secretion, liver mass, hepatic blood flow, calcium and iron absorption lnaeased proteinuria, urinary frequency Deaeased renal mass, creatinine clearance, urina acidification, hydroxylation Ill vitamin D. bladder capacity Decreased androgan, aslnlgen. sperm count, vaginal secretion Deaeased ovary, llterus, vagina, breast size lnaeased NE, PlH, insulin, vasopn!SSin Deaeased thyroid and adrenal corticosteroid secretion lnaeasad calcium loss from bona Decreased muscle mass, cartilage Atro!iJy of sabacaous and SWIIill glands Decreased epideiiTIBiand dermal thickness, dermal vascularity, melanocytes, collagen synthesis None Increased COPD, pneumonia, pulmonary embolism

RaiPilltory

COPD

Cardiovascular disease Dillbatn Mallitul (Type 2) Hearing impainnent Hypertension Mllllal disordtlrs Orthapaedil: di&ordars Sinusitis

Glltnlilleltiall

Increased Clllcer, diverticulitis, constipation. fecal ilcontinence, hemorrhoids, intestinal obstruction Increased urinary incontinence, nocturia, BPH, prostate cancer, pyelonepilritis, naphrolithiasis, lJTI Increased breast and endomal!ial cancer, cystDcele, rectocele. atrophic vaginitis Increased DM, hypcrlhyroidism, stress response

Ranlland urologi:

Reproductive

Endocrina

Musculoskelalll lntegumenlllry

Increased arthritis, bursitis, osteoporosis, polymyalgia rheumatics Increased lantigo, cherry hamangiolllil$, pruritus, seborrheic keratosis, herpes zoster, decubitus ulcers, skin cancer Increased depression. dementia, delirium, suicidality, substance abuse, anxiety, insomnia

Psychiatry

Toronto Notes 2011

Differential Diagnosea of Common Presentations

Geriatric Medicine GM3

Differential Diagnoses of Common Presentations

Constipation
see Gastroenterology, G25
Definition

less than 3 bowel movements in one week and/or hard stools, straining, sense of blockade, manual maneuvers or incomplete evacuation on more than 25% of occasions
Epidemiology

chronic constipation increases with age (up to 1/3 of patients >65 years experience constipation)
Pathophysiology

impaired rectal sensation colorectal dysmotility

Risk Factors

immobility dehydration polypharmacy drugs - narcotics, calcium channel blockers low fibre/ calorie diet obstructive lesions - bowel obstruction, cancer, diverticular disease, mD, strictures altered colonic motility - ms, colonic inertia neurological- sacral cord dysfunction, Parkinson's disease, stroke metabolic - diabetes, hypokalemia, hypercalcemia psychiatric - depression, dementia

Treatment

non-pharmacological increase fibre intake adequate fluid intake discourage chronic laxative use regular exercise review medication regime, reduce dosages or substitute pharmacologic see Common Medications, GM14

Delirium, Dementia and Depression

see Ps:ychiati:y. PS17, PS18, PS8 and Neurology. NlO
Delirium Prevention in Elderly

----------------

ensure optimal vision and hearing to support orientation (e.g. clean, appropriate eyewear and hearing aids) provide adequate nutrition and hydration encourage regular mobilization to build and maintain strength, balance and endurance avoid unnecessary medications and monitor for drug interactions avoid bladder catheterization if possible

Elder Abuse
Definition

includes physical abuse, sexual abuse, emotional or psychological abuse, financial abuse, abandonment and neglect elder abuse is a criminal offence under the Criminal Code of Canada in the U.S., most states have criminal penalties for elder abuse, laws vary from state to state
Epidemiology in Canada, approximately 4% of elderly persons living in private homes have suffered abuse

in the U.S., estimates of the frequency of elder abuse range from 3-8% physician reporting is mandatory only in Newfoundland, Nova Scotia and PEl; in Ontario, only abuse occurring in nursing homes is mandatory to report insufficient evidence to include/exclude screening in the Periodic Health Exam

GM4 Geriatric Medicine

Differential Diagnose5 of Common Presentations

Toronto Notes 2011

Riskfacton
bd F ..p fw El-* AIIUII 1. Delay in ueking 1118dicllllltbntion 2. llispriy in histories 3. Implausible or vague axplanetions 4. FrecJjent emergency room visil$ for Ullcerbations of chronic diullse despite plan lor medical Cllre and edaquat& I'8SOUI"C81 5. Presentlll:ion of functionally impaired patient without dasignllllld caregivll" 6. Lab findings iK:onsistsnt history

situational factors isolation, lack of money, lack of community resources for additional care, unsatisfactory arrangements inadequate access to appropriate beds, low staff-to-patient ratio, low pay rates for staff, low educational level of staff, staff burnout characteristics ofthe victim physical or emotional dependence on caregiver, lack of close family ties, history of family violence, age over 75 years, recent deterioration in health, dementia characteristics ofthe perpetrator stress caused by financial, marital or occupational factors, deterioration in health, bereavement, substance abuse, mental illness, related to victim, living with victim, long duration of care for victim (mean 9.5 years) Management assess safety and determine capacity to make decisions about living arrangements establish need for hospitalization or alternate accommodation (e.g. immediate risk of physical harm by self or caregiver) involve multidisciplinary team (e.g. nurse, social worker, family members and physicians including geriatrician, psychiatrist or family physician) contact local resources (e.g. legal aid, elderly advocacy centre, crisis centre) educate and assist caregiver, link up with community resources (e.g. personal support worker, homemaking services, caregiver support groups)

Failure to Thrive (Frailty)

-----------------------------------

Four Syndromes in fllilure to lbrive

My ... C...l Dril'l

Definition declining independence and functional capacity with loss ofvigor and/or weight in older adults not an inevitable consequence of aging Etiology four syndromes are prevalent in older patients with failure to thrive: malnutrition, functional impairment, cognitive impairment and depression
Hx: Environment

Ph'f'ical impairment

CognitiVI impainnant
Depression

FunctiDul AM-mm

(ADLImiiADLI} ADLI: AIICDE-TT

Ambulating Bathing

Social Somatic Ducreasud Energy lncreasad Catabolism Drugs

f---+

l!H!!m

PIE: Gl-i:onslipation

Malnutrition Cllgnitive inpairment Functional impairmant (decnasud mobility!

+---

Cardiac Respiratory Skin Changes S&nsory

ContiniiiCI
Dressing

Eating
Transferring Toileting

I Failura to Tlniva I
May include laboratory and/or radiologic teal$, MMSE, ADL/IADL assiiSIIIlant. "Up and Go Till!." Geriatric Dupr811ion Scala, nutritionalan1111munt. mudication ruviuw, chronic disease evaluation, anvironmantalessassmant

... ...

llll!llllilll1iiiDI

IADLI: SHAFT-IT
Shoppi"lg

lllllli& liltal
Treat general mudiclll condition

Housework
Accountinw'Managing linlllCus Food preparation Transporllltion T1l1phona Taking mudications

...
l'$ychothen;py Antidep1811111nts Modily environment

...
Mln!dritian SLP evaluation Treat oral pathology lncraasa fnlquancy of feedings Nutritional suppl&mants

...
Optimim livi1g conditions Treat undanying depi"IIISion, infection Administer dementia-delaying medications

...
lilllldiiDIIImllliaalld
Phy$ical1hurapy Occupational therapy Modily environment

lillloilillllmaiaallll

Dnarwiao

...
If positive response,
continua traatm&nt

I Ifwith minimal or no response, conduct conference I patient, patienfs family and carugiven;

...

...
I
Repeat evaluations, if appropriate Considlr discussion of and-oflifl options

Figure 1. Evaluation of the Geriatric Patient who is Failing in the Community

Adaip11d fnlm: smililn CA. lachs MS. 1tilura1o1tri'll" in oldlrldi.Aml biarm Med 1996; 24:10721078.

Toronto Notes 2011

Differential Diagnosea of Common Presentations

Geriatric Medicine GM5

Table 3. Common Medical Conditions Associated witiJ Failure to Thrive

Medical Conlilian
Cancer Clnnic lung disease Clnnic 1111al ilsufficiency Clnnic steruid use Cin11osis, hepatitis Depression, other psychiatric disorder Diabetes Gastrointestillll surgery Hip, long bone fracture Inflammatory bowel disease Myocardial infarction, congestive heart failure Recummt Ull, pnaJII'IOIIia Rheumatologic disease (GCA, RA. SLE)

CluH of flilureiD 11wivll

Metastases, malnutrition, cachexia Respiratory failure Renal failura Steroid myopathy, diabetes, osteoporosis. vision loss Hepatic failure Major depression, psychosis. poor functional status, cognitive loss Malabsorption, poor glucose homeostasis, end-organ damage Malabsorption, malnutrition Functional impairment Malabsorption, malnutrition Cardiac failure Chronic infection, functional impairment Chronic inllanmrtion Dysphagia, depression, cognitive loss, functional impairment Chronic infection

lt'

lly l'llvU:III Filldingl in the Elderly 1'81ient Wba Fells or Nurly Falls

Stroke Tlberculosis. other sys18mic infection

Verdlry RB. "CiinicaiiMIDIIiln al flliknlltotlliw in lilll'paapla." Cil GlllilllrMrld 11117; 13:761-78.

IIIATl: FAlliNG Inflammation of joints Hypotension (orthostatic changes} Auditoly and visual abnonnalities Tremor Equilibrium (bai111Ce) problem Foot Problems Arrhythmia, heart block orVIIIv..... disease di.crepancy Lack of conditioning (gllllnllizad
weaknessI

Falls
Epidemiology 30-40% of people >65 years old and -50% of people >80 years old fall each year approximately 20% of falls require medical attention 5% of falls lead to hospitalization 5-10% with serious injuries (e.g. hip fracture, head injury, laceration) 1-2% of falls associated with hip fracture 15% die in hospital, 33% 1-year mortality between 25-75% do not recover to previous level of ADL function mortality increases with age (171/100,000 in men >85 years old) and type of injury (25% with hip fracture die within 6 months)
Complllbl History & Physical ExBm
SptcificiM11 Gut Up & Go lelt ChlirStand Romberg test. P...l test 20 foot walt with 360 turns

Dln.s Nutrition Gait disturbanca

Fullar.G.Itlll illillaldaJtr. Am lim Plrp 2001; 61[7): 215&-2171

.....

.>-------------------,

Drugslhlt May In- thl Risk ofF.Uina Sadatiw-hypnotic and anxiolytic druga (especially long-llcting benmdilllepines} Tricyclic antidapra&lilllllli Major 1ranquHizers (phenothiazines and butyrophanones) drugs Cardiac madicstio111 Corticoiiii'Oids Nonsteroidal anti-inftammatory drugs Anticholinergic diUQI Hypoglycemic agents Alcohol
Fuller, G. Filii iltheekle!ty. Am lim Plrp 2001; 61(7): 215t-Z17l

Identification of Pracipitating Al:livity

...
W.lmllfLIII
Impaired chair sta'ld Slow gait Poor &lair climbing

...
1!111[ IIIIIID Positive Romberg test Positive P...ltiiSt Poor vision

...
l!llllli,lliiD IGii'ib:
Alcohol Anticholinargics Anticonvulsllnts Antihypertensives Digoxin Nitrates Sadstivas

...
!lypgtansign Orthostatic Poslprandial

Will My Pltilllt Flll1 .lAMA 2001; 297:77-86 l'll'flall: To ilanliylill pmgnDIIic wkll Gf risk flldDn farfuun fills lllllrlg older l)llilllll. S1udy Wlclian: ltlRs al rill f1CIIn far fall the! IJ8I(ormld I nU1imia1J

Ellwiu

llaultl: Cinically idlldlilbll risk fllcfml

lf!bmnljpo Rasistanceb'aining Quadriceps strengthening

lf!bmgljpn Balance1n.ining Widen SL41JlOrl bue (i.s. ihoes, cane, walksr) Corral:! vision

hdl!!!lgljgn Madicstion miaw Reduce or eliminlllll nitrates, banzodiazapinas.

lnllmntjgn Medication raviaw Behaviour changas (separata meals and medicstions, exercise)

antihypertensives (if possible)

(compression stockings, lilllt inlllks)

lflhnranllool AoamaEIIII fll[ All rdilllll!lllb E1ll1 EvaiUBtion and correction of loose rugs, cords, poor lighting, movable furniture, bathtubs, 1hmholds, clutter

wn idinlilied ICIOI5 6dimins: orlllostl1i: hypablnlion, wiul algM or biiMce, mediclb use,limilllions il basic or illllrummDIIICtivilils rl dlily ivillQ and cogriiM implirnnt. EigiDinltldll11111 incUiion cri1lril lid proo.oided IIDJIIiwrilta nltlil includillQII llut 1aiU. risk factor dornlinl. The tltirnl1ld pral85t fl"llllbilily of filing llill5t CIIIC8 i11ny gilllln YIUfar ildMdlllll65 oklor Wll 27UHconiderailllml. who I'M lillian in 1he pill ye1r1ra mora iklfy1D flllaallil [iklllood lllio 2.3-2.81. The mo11 Clllliltllltpllldictln alfutunlfllls ll'llcR:IIr detlcl!d 1baarmai1ies al gait 01 bllllnce Pilllllood ratio llngl, 1.7-2.4). Viul ilfilirmanl, 1111dic:atill wriabls, decnued ac1Mties al dalv lvilg 11111
i . . cognition did -lluliii.Ortlilllllllich'/flllllllliantidnat

Tneai ME. Baker IJ. McAwy G, etal A11111tif1ctorial illerwrdion 1D reib:e 1he risk Gf elderly people lilring in the CGIII'Tiunity. NEJM 19!14; 331(13):821-821.

Figura 2. Approach to Falla in tha Elderly Adaplld from: llaiV, DA. Baa 't Shablll PE, Rubansllin lL Wilmr l)llirntlal! .l4AM 2007; 291: 17-811.

prudict fills aJar far DlhtrfiCIIn. tnMiall: SCIIIIIillQ for risk of flllillQ dLWillQ1hl lilical eunilation begins with d!Aennili'G w 1fle pllilrlllu 111111 in 1hl pill Ylll' Ftr pllilllll who 1-. nat prMIIISt;' filen, ll:l!lllilg consis11 alan IR8IIII1III1I Gf gait 11111 bllne.l'llienllwho bne filial or who 11m 1 !Ilk or blllnce f)!Oblem are at hpriaGftwafll..

GM6 Geriatric Medicine

Differential Diagnose5 of Common Presentations

Toronto Notes 2011

.....

', ..

Etiology
commonly multifactorial extrinsic environmental (e.g. home layout, lighting, stairs, footwear), accidental, abuse medications/substances (e.g. alcohol) month after hospital discharge, acute illness, exacerbation of chronic illness intrinsic orthostasis/syncope age-related changes and diseases associated with aging: musculoskeletal (arthritis, muscle weakness), sensory (visual, proprioceptive, vestibular}, cognitive (depression, dementia, delirium, anxiety), cardiovascular (CAD, arrhythmia, MI, low BP), neurologic (stroke, decreased LOC, gait disturbances/ataxia), metabolic (glucose, electrolytes)

hll Prenntion TIPI

1. Improve lighting. especially on stairs 2. Caution whill adjUiting 1D niW bifllcal prescription (paar depth

3. Sidenils in bathtubs
an Slaps 5. CaMact pati8nt 1D IWalina button signalingsystlms

panceptionl

4.

6. Remove loose mats ar carpiiiJ,

telephone cards and other tripping
hiiZIIIlls

7. Ruc011111end liUppart hose for varicose veins and swelling of ankles Galdlst B, Turpic l Borins M. (1 1971-f.an.t

Investigations
directed by history and physical CBC, electrolytes, BUN, creatinine, glucose, Ca, TSH, B12, urinalysis, cardiac enzymes, ECG, CThead

FtctDr far Fils: Cdlicll ....... lllllilw J 6efMIDIA/ia SdltfedSriDIJ; 62(1Dj:I11Z-411 To review II Olijnlllllicles n.k fKtDr flr Ills ..hlfelllld hll:bres il peaple llgld more lban &0 ywm.

Hilt

Prevention
multidisciplinary, multifactorial, health and environment risk factor screening and intervention programs in the community program of muscle strengthening, balance retraining and group exercise programs (e.g. tai chi) home ha2ard assessment and modification (e.g. remove rugs, add shower bars, etc.) withdrawal of psychotropic medication cardiac pacing for those with cardio-inhibitory carotid sinus hypersensitivity optimize eyesight and footwear

crilaria. TIIIOUiron_ra_afalinZ2 IUiies and a1r1ctre in 7 SUii8t. Th1 main groop af dqs BSIDCillld with an incrllllll risk Dfflllinu- prfChDtmpics: benmdilil(lines. llllicll!mwlls.llld ll1lipayl:boli:L Anti8(iaptics IIIII drugs 1lilt lclwer bbld prmue were westly BSIOCillld will IIIII. ClncUin: Central neMJUS $VSI2m drugs, aspecillly paycholropics. saemtD be IIIOCilflld wMh n inaaued n.kolfllll. Thl obsaMdioniiiiUdies 11111111111 be impnMid. u many IPPB 111 let Mill ar dllinilian alalal llrget medicines, or paspedM drugs c.-nmonly uasd bv older pnans 1r1 IIIII IS risk flclln flr fils.

Sl.dy ..... "ICCidsntll 1111( IIIII "phlrmlciiUiil:ll includld. nat lllllrin; the aae crit11D11, nal canl!olled will I10IUIII allllgal medicinll at nonllln, or wMh no cllr dl.finitian of11rget mediclb were llnldbi: Twenly-eiglt obsefvltiaual sWes 1111 ana rndolrimd CIIOO"o..d1rill 11"1111111 inelllion

Fecal Incontinence
Epidemiology
second leading cause of nursing home placement

Etiology
commonly multifactorial peMc floor intact neurologic conditions- age-related. neuropathy, multiple sclerosis, stroke, dementia tumour/trauma (e.g. brain, spinal cord. cauda equina} overflow (e.g. encopresis, impaction) diarrheal conditions peMc floor affected trauma/surgery nerve/sphincter damage malformation, anorectal

lnllmlllianl far I'IMIIilg Fill illldlr lilillinlber-Er CIJdrwle DlltJbae S)'lt 1/ev2IJ09; 2:CCIIK11146 SlUr. Coclnne nMiw. II RCT 1111 qulli.ftCT1rills.

Risk Factors
prior vaginal delivery anorectal surgery peMc radiation diabetes neurologic disease diarrheal conditions stool studies endorectal ultrasound colonoscopy, sigmoidoscopy, anoscopy anorectal manometry/functional testing

- . asnior. or ltler111d lvila in the cOIAITUiily. ........ IIIIa alfllls lllll"III1Wal

flllars.

l'lipllla SS.303PIIIieraoml0

-... ExertiN in raducil;rist 111d IIIII alfalls. I Dlllli-pralessianll 111m RIIUCIS ndss allllls liu1 not risk alfllls.linilld l't'idencl siiCMS IIIII 1111 idervenlionsmay nall"llkl:a rSk at rill al faiL Yilln"in Ddoes nal II(Jpell" Ill be ellectivein rellr;ing 1111 alfllll in 11 pllierO. Caroill: JIICilg in pllilnls with cntid silus hypneasMiy 1111 himv al syncupa or Ids
11111 afflls.llmn&-buad phylilllllllriP'f cloanatblnllit palilullwMh l'lrlci!a's .-ala l1illted mabity JIUI*ms. Exan:ise Aida riskal fills AddiliansiTeSelr1:h is carmn IIIII lllbollbllbe mrDidl in Yttich Diller inlelvrions ue eluciM.

Investigations (if cause not apparent from history and physical)

Management diet/bulking agent if stool is liquid or loose

disimpaction anti-diarrheal agents regular defecation program in patients with dementia counsel about biofeedback therapy (retraining of pelvic floor muscles)

Gait Disorders
see Neurology. N36

Toronto Notes 2011

Differential Diagnosea of Common Presentations

Geriatric Medicine GM7

Hazards of Hospitalization
Tabla 4. Recommendations for Sequelae of Hospitalization in Older Patients

No dielllry restrictions (except diabetes}, assist!rlce. dentures if necessary, eating out of bed Medication Rllliew, nmove environmantal barriers, discontinue use of catheter Routine icreening Medication Rllliew Orientation, hearilg aids, volume repletion, noise reduction, early mobilization, medication rvview, Low-resistance mattress, daly inspection, repositioning every 2 hours
Early mobilization, remove unnecessary IV lines, catheters, NG tubes Appropriate footwear, assistive devices. early mobilization, remove restraints, medication review Early recognition and repletion

Urinary ilcuntinence

................ ill'lliiiiiiOYeln lfA8aii'IIB NUf21lll; 358(18J:188H8 lludy: lllndomilld, ib.lllll-blnd, pllceboCGIIIroled. nUticeabt trill 3845 pllierQ who- Ml'181'S rlage .- aldlr 111"111 hid aiJSllinld sysiDi: bbld rl1&0nrilg-laiGMdfarallliiS11.8'j811S.
IIIIMIIIill: (IU!IIIinld IIIMie. 1.5mgl orllllk:linuHc:ebo. ThungiDIBisitCIIIMitiJr.llll!yllllinhiliiDrptrindoprill2ar4rngJ. .-lllltl:lq plll:ello, wu added I111Cessmy111 IChiiMifiU of15'*mmHv

Dep111$$ion
Adverse drug event

Confusionldeliium Pressure ulcers Infection

Falls

Mluyll'*- F111111 or nonfml!IIR .......:Tn.l!lllln IIIII of the pQI!sWI$ 83.6

.IJbxl

Hypotension/dehydration
of muscle strengtl\l'contractures

Diminished aerobic capacity/loss Early mobilization Decreased respiratory function Incentive spiumetry, physiotherapy

Hypertension
see Family Medicine. FM35 60-80% of elderly (>65 years old) have hypertension 60% of these have isolated systolic HTN non-pharmacologic treatments are first-line, then thiazide monotherapy is recommended add A CEilARB if also atherosclerosis, DM, CHF or chronic kidney disease add beta-blockers if also angina or CHF target BP: sBP <140, 65<dBP<90; for patients with DM: sBP <130, dBP <80

Ylfllland 1118111 bloadpr.IUII WU 173.ll'll.8mn'flg. At2J81l'l,1he l1l8lll bbxl JIIIIIUIIMillliiQwu15.G'6.11111ila liM' in lhe actNe bellmlld group 1lan in 1he GJ'IIlP. Ac1ivltrullnlltWI$ISIDCillld Mfl I m retb:lion ilthe rm o11a111 arnonfmlslroke iiiiiiYII Cl -1 fD 51; p=O.D6). lK Tecb;lbl il1he '* rl dedi from slroke 1M Cl, 11D 62; p=O.DSPI'I.IIductioa in the llllofdlllh fiamiiiY-fMCl41D35; p=D..02J,m Tecb;lbl ilthe 1'1111 rl dllllll from wdiomcull Cllll8l (!15'1. Cl-1 tD40; p=O.O&L IIIII Tecb;lbl il1he '*of helrt laiUI! 1M a. 42 fD 78; p<O.OOI). fMI!IIrilu ldwlll-.ts Will 1!pOIIId in 111e actiw-natmentgnKJp (358 vs. 448 ill the piiC8bo group; p=O.OOI). Cancbioal: AnlihPertensive lre*nenlwi1h indlplmillll111111illld rUa&L Mh or wilbout ]JIIindopll il PII1CIIII80 yars ci IGI or okllr nMb:es delth from stmlil, dllllh from lilY CIUI8 the inc:idenc:a rl halllfliU..

Immobility
Complications
cardiovascular: orthostatic hypotension, venous thrombosis, embolism respiratory: decreased ventilation, atelectasis, pneumonia gastrointestinal: anorexia, constipation, incontinence, dehydration, malnutrition genitourinary: infection, urinary retention, bladder calculi, incontinence musculoskeletal: atrophy, contractures, bone loss skin: pressure sores psychological: sensory deprivation, delirium, depression

Immunizations
the following immunizations are recommended for people 65 years of age and older pneumococcus - 1 dose influenza - every autumn appropriate boosters (e.g. tetanus every 10 years)

Yll:cnllur l'rMitilw ... Eldlllr iJifJJba .sr.t /ltv 2006; 3:CIJXl4876 To IIVilw the IVideuc:e Ill etliclcy, llfltyof DIUIIIII ....r. il inlividulls aged 65 'I8I'S or older. Study SQ:Iian: Rlndonilld, qu.i-mdorriz8d, callo!t llld cm-comol Slulils IIQiinst irAiet'llJ. (illorltDrrccmnned la!ISI .. i-IIJ)

,...a:

.-Sitely.

._....: Sixty.fw sludies- iiQide:l in the

Malnutrition
Definition
involuntary weight loss baseline body weight or hypoalbuminemia, hypocholesterolemia

axprauad u abloUit llicecy (VE).In homas Ill' iiiiMdlllll (1'1i111 good vaa:ine mild! and high villi ciQU!ionlthe llflectivnu rl vmiiiiiiQiinll U wu 2:ft. (6\ 10 311\) IIIII

kg

Etiology
starvation decreased intake: financial, psychiatric, cognitive deficits, functional deficits, anorexia associated with chronic disease decreased assimilation: impaired transit, m.aldigestion, malabsorption
stress

Cl 0.431D 2.51).1n lidlltf ildMdLIIIIs iving in the CGIII!llnity, vacdnes were not sillnliclllllv llfactM llgli1ltinhv.l (RR O.II.IMCI 0.02 111 Z.OIL U IRR 1.05, IS'I.CI 0.58111 1.89L or pneul1l0lil (RR 0.118, Cl 0.64111 1.20). Vll:cine dilillll1ioa uuly incb:ed rjSflllic side lfacti!QII*II nllill, favar, na-. '"-IIICI!e) mcnfilq.llritf U.. Jilcebo, but IIIDIIICDml lhawed stJiisliCIIy sigliilalll-lbi. Cancbioal: .. long-1arm - flciitias, Mill

(HH

l.o4, !15'1.

acute or chronic illness/infection, chronic inflammation, abdominal pain mechanical dental problems, dysphagia

vacc:illllion is mostefleclive lila aims of the vaa:inlllioa CIITiplign 111 fllilld, It leu! il pill. The uslllul111111 rl vaccines in the CGri'I110ty is modest.

GMS Geriatric Medicine

o

Differential Diagnoses of Common Presentations

Toronto Notes 2011

Etiology of Malnutrition in the Elderly MEALS ON WHEELS Medications Emotional problems Anorexia Late-life paranoia Swallowing disorders Oral problems Nosocomial infections Wandering/dementia related activity Hyperthyroid/Hypercalcemia/ Hypoadrenalism Enteric disorders Eating problems Low-salt/Low-fat diet Stones

age-related changes appetite dysregulation, decreased thirst mixed increased energy demands (e_g_ hyperthyroidism), abnormal metabolism, protein-losing enteropathy

Risk Factors
o

o o o

mechanical: dental problems, medical illnesses interfering with ingestion or decreasing appetite nutritional: medical illnesses increasing nutritional requirements or requiring dietary restrictions functional: difficulty shopping, preparing meals or feeding oneself due to functional impairment social: economic barriers to securing food, lack of availability of high quality food psychological: depression, poor appetite history recent weight loss, decreased food intake, constitutional symptoms, GI symptoms, recent or chronic illness, social factors physical examination BMI <23.5 in males, <22 in females should raise concern temporal wasting, muscle wasting, presence of triceps skin fold CBC, electrolytes, Ca, Mg, P04 , Cr, LFTs (albumin, INR, bilirubin), B12, folate, TSH, transferrin, lipid profile, urinalysis

Clinical Features
o

',.}-------------------, ,
Calculating Basic Caloric and Fluid Requirements WHO daily energy estimates for adults >60 years: Female: 10.5 x (weight in kg) + 596 Male: 13.5 x (weight in kg) + 487 Maintenance fluid requirements for the elderly without cardiac or renal disease: 1500-2500 cc/24hrs.

Investigations
o

Osteoporosis
o

see EndocrinololO'. E43

Presbycusis
o

see OtolaryngololO', OT20

Pressure Ulcers
o

see also Plastic Surgery. PL14 extrinsic factors: friction, pressure, shear force intrinsic factors: immobility, malnutrition, moisture, sensory loss

ASystematic Raviaw of the Usa of Hydrocalloids in tha Traatmant of l'rassura Ulcers JC/inNtm2008; 17(9):1164-73 Purpose: To describe the current evidence in the field of pressure ulcer treatment with hydrocolloids and to give recommendations for clinical practice and further research. Study Salaction: Randomized controlled trials on the treatment of pressure ulcers with hydrocolloids. Results: Twenty-nine publications, dealing with 28 different studies, met the inclusion criteria and were included in the review. Hydrocolloids were most frequently used on pressure ulcers grades 2-3. Concerning the healing of the pressure ulcer, hydrocolloids are more effective than gauze dressings for the reduction of the wound dimensions. The absorption capacity, the time needed for dressing changes, the pain during dressing changes and the side-effects were significantly in favour of hydrocolloids compared to gauze dressings. Based on the available cost effectiveness data. hydrocolloids are less expensive compared with collagen, saline, and povidinesoaked gauze but more expensive than hydrogel, polyurethane foam and collagenase. Conclusions: Based on the studies included in this review, hydrocolloids are frequentily used in the treatment of grades 2and 3pressure ulcers and are more effective and less expensive than gauze dressings. Compared with polyurethane dressings, less-contact layers, topical enzymes, and biosynthetic dressings, hydrocolloids are less effective.

Risk Factors
o o

Table 5. Classification of Pressure Ulcers

Stage I Stage II Stage Ill Stage IV Changes include skin temperature, tissue consistency or sensation. An area of persistent erythema in lightly pigmented, intact skin. In darker skin, it may appear red, blue or purple. Partial thickness skin loss involving the epidermis, dermis or both. The ulcer is superficial and presents as an abrasion, blister or shallow crater. Full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia. Presents as a deep crater with or without undermining of adjacent tissue. Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures. May have associated undermining aml/or sinus tracts.

Prevention
o

pressure reduction frequent repositioning pressure-reducing devices (static, dynamic) maintaining nutrition, encouraging mobility and managing incontinence minimize pressure on wound analgesia wound debridement (mechanical, enzymatic, autolytic} and dressing application maintain moist wound environment to enable re-epithelialization treatment of wound infections (topical gentamicin, silver sulfadiazine, mupirocin)

Treatment
o o o o o

Toronto Notes 2011

Differential

of Common

Preaentations/Drlving Competency Geriatric Medicine GM9

swab wounds not demonstrating clinical improvement for C&S; biopsy chronic wounds to rule out malignancy stage IV ulcers typically warrant surgical repair consider other treatment options negative pressure wound therapy/vacuum-assisted closure (VAC) biological agents: application of fibroblast growth factor, platelet-derived growth factor to wound non-contact normothermic wound therapy electrotherapy

......

'

Sllltic devices distriblte pressure over a gr.Dr surfllc. arwa. Dynamic dwicn
use llllemating IIi' currents to shift

PraiSII'Hllllucila Dewices

pressure Ill diffarant body silas.

Urinary Incontinence

US

Epidemiology
15-30% prevalence dwelling in community and at least 50% of institutionalized seniors morbidity: cellulitis, pressure ulcers, urinary tract infections, falls with fractures, sleep deprivation, social withdrawal, depression, sexual dysfunction not associated with increased mortality

TriMillll c.- of lncllllinDIAPRS
Delirium lrnctlan

e'

A1ruphic urelhritlslvaginitis

Pathophysiology in general, occurs with age: decreased bladder capacity, increased post-void residual volume,
increased involuntary bladder contractions (urge incontinence) in elderly women: decline in bladder outlet and urethral resistance pressure promoting stress incontinence in elderly men: prostatic enlargement can cause overflow and urge incontinence

Phannac8Utic81s

Excessive urine oulplt

llllslricbld mobility SIDOiimpectian

Driving Competency
Reporting Requirements
physician reporting to the Ministry of Transportation is mandatory in all provinces and territories except in Quebec, Nova Scotia and Alberta, where it is discretionary in Ontario, drivers >80 years old are not automatically required to pass a road test in order to renew their driver's license unless there are indications to suggest road safety risks; all drivers >80 years old must have a vision and knowledge test and participate in a 90-minute group education session to renew their license every 2 years in the U.S., varies by states, please refer to the AMA Physician's Guide to Assessing and Counseling Older Drivers for American recommendations, www.ama-assn.org/ama/pub/ category/1079l.html

Conditions That May Impair Driving

alcohol patients with a history of impaired driving and those deemed to have a high probability of future impaired driving should not drive any motor vehicle until further assessed alcohol dependence or abuse: if suspected, should be advised not to drive alcohol withdrawal seizure: must complete a rehabilitation program and remain abstinent and seizure-free for 6 months before driving blood pressure abnormalities hypertension: sustained BP >170/110 should be evaluated carefully hypotension: if syncopal, discontinue until attacks are treated and preventable cardiovascular disease suspected asymptomatic CAD or stable angina: no restrictions STEM!, NSTEMI with significant LV damage, coronary artery bypass surgery: no driving for one month following hospital discharge NSTEMI with minor LV damage, unstable angina: no driving for 48 hours if percutaneous coronary intervention (PCI) performed or 7 days if no PCI performed cerebrovascular conditions TIA: should not be allowed to drive until a medical assessment is completed stroke: should not drive for at least one month; may resume driving if functionally able; no clinically significant motor, cognitive, perceptual or vision deficits; no obvious risk of sudden recurrence; underlying cause appropriately treated; no post-stroke seizure

GMIO Geriatric Medicine

Driving Competency

Toronto Notes 2011

.,_...._.,Drilillllill:d..
will .......

JAni GttitlrSGc 21m; 55:818-84 l"'lffee: To delermine MIChel persons wilh dlnntill II gnlllr drivilg lilt and, W10, tD estinae tile rlflis risk 11111 dellnnile Mlulhlrtau 1111 uffic:ac:iMIIIIflodslll CGQelllllllar01acconnodlle it

IWIIill rl drMrl Mila diagnosis

rldlmril. a.ulll: !Mil wittl dlmrilunimaly uhibitN pon pe!!ornwlce oaiOid tests nd limulltar Ml.illlin.lhiIIIJdrtllll USid 111 Cil)jediw 11111sae rl rdor whide cmhes IDIIIII lhlt the Cfllh risk il J*$01'11 Mil dtmeltilllill 21D 2.5 tines I,Witlfliln mllll:llell conlrols. No lludilswnflllld lhltawrinld tllllfficec:y llf

c..-.a.: DiYm wilh danntie 1111 PDOIW

perfomuce.

chronic obstructive pulmonary disease mild/moderate impairment: no restrictions moderate or severe impairment requiring supplemental oxygen: road test with supplemental oxygen cognitive impairment/dementia moderate to severe dementia is a contraindication to driving; defined as the "inability to independently perform 2 or more IADLs or any basic ADL" patients with mild dementia should be assessed; if indicated, refer to specialized driving testing centre; if deemed fit to drive, re-evaluate patient every 6-12 months poor performance on MMSE, clock drawing or Trails B suggests a need to investigate driving ability further MMSE score alone (whether normal or low) is insufficient to determine fitness to drive diabetes diet controlled or oral hypoglycemic agents: no restrictions in absence of diabetes complications that may impair ability to drive (e.g. retinopathy, nephropathy; neuropathy, cardiovascular or cerebrovascular disease) insulin use: may drive if no complications (as above) and no severe hypoglycemic episode in the last 6 months

drivers lllllll)llllliile 110111111 drilers, '-! sWes

drugs
be aware of. analgesics, anticholinergics, anticonvulsants, antidepressants, antipsychotics, opiates, sedatives, stimulants degree of impairment varies: patients should be warned of the medication/withdrawal effect on driving hearing loss effect of impaired hearing on ability to drive safely is controversial acute labyrinthitis, positional vertigo with horizontal head movement, recurrent vertigo: advise not to drive until condition resolves musculoskeletal disorders physician's role is to report etiology, prognosis and extent of disability (pain, range of motion, coordination, muscle strength) post-operative outpatient, conscious sedation: no driving for 24 hours outpatient, general anesthesia: no driving for hours seizures first, single, unprovoked: no driving for 3 months until complete neurologic assessment, EEG,CThead epilepsy: can drive if seizure-free on medication and physician has insight into patient compliance sleep disorders if patient is believed to be at risk due to a symptomatic sleep disorder but refuses investigation with a sleep study or refuses appropriate treatment, the patient should not drive visual impairment visual acuity: contraindicated to drive if <20/50 with both eyes examined simultaneously visual field: contraindicated to drive if <120" along horizontal meridian and 15" continuous above and below fixation with both eyes examined simultaneously

hM 11111 cnilllrtly dlran!IIDd a. Ctli:i nd poli;y nlkss IIIISIIIke these ildillgs irm illues perlilert tu drillln Mila diiQnosis of demerD.

lEI
Kay Fecton t. C.neider in Older

onw.r.

WEDRIVE Safetyi"'Conl
AttEntion (e.g. concentndion lapses, IIPilod&l of di&orillllbltion) Family Ethanol abuM Drugs

IIHction time Intellectual impaimant Vision/Visuospatill fwlclion

Executive functions (e.g. plaooing. decision-lllllking. self-monituring bllhaviom) Adlpl!d !TOm: Wisem111 EJ. The older drMir: a hllldytuol btlildtllaMeel lilrilllit:s. 199(i1 :3l45

N .B. guidelines included refer specifically ro private driving; please see CMA guidelines for

commercial driving

Toronto Notes 2011

Health Care InstitutionaJPalliative and End of Life Care

Geriatric Medicine GM11

Health Care Institutions

names of community health care institutions, types of facilities and services offered vary between geographical locations factors to consider when seeking services/institutions include level of care required. support networks, duration of stay and cost
Table &. Classification of Health Care Services and Institutions

lnllitutiOili'Senice
Community Support Servica

Description Health en services offered at home for those who <*I live independently at home or under the care of fllmily muntsrs incklding pruf&ssio1111l care ssrvicas, pno1111l care and support (ADL assisllllce), homemaking (IADL assistance], comrwnity support services (e.g. transportation, meal delivery, day propns, cngiver relief, security checks, etc.)

Raidantill

Divided into short (<60-90 day5/year] and long (indefinite) stay

a] Seniol'l Aflanlallle Hou1ing Seniors who live independently and manage thei' awn care but prefar to live near other seniors; usually has accessibility faaturas and rant is adjusted based on income

b) lkttire11111nVNuning Home

Rasidants are fairly indapendent and require mini11111l support with ADL.s and IADL.s; often privately owned Rasidants require mi"li11111l to model'llllassislllnce with daily activities while living independently; often rental units in an apartment end mav offer some physiotherapy and rehabilitation services

d) LDnlf"'llnn C.rWStllld Nunilg Ftcility

Around the clock nursing care and on-call physician coverage; often oilers occupational therapy, physiotherapy, respiratory therapy and rehabilitation senrices; may be used shorttarm for caregiver re&pita or for supportive patient care to regain strength and confidence 5ter leaving the hospital Fraa-standing fllcility or designated floor in a hospital or nursing home for en of terminally ill patients and their families; focus is on quality of life and often requires prognosis

e) Holpice

Palliative and End of Life Care

Principles and Quality of Life
support, educate and treat both patient and family address physical, psychological, social and spiritual needs focus on symptom management and comfort measures offer therapeutic environment and bereavement support ensure maintenance ofhwnan dignity

End of Life Care Discussions

When to Initiate End of Life Care Discussions recent hospitalization for serious illness severe progressive medical condition(s) death expected within 6 to 12 months patient inquires about end oflife care Suggested Topics for Discussion goals of care (disease: vs. symptom management) advance directives, power of attorney, public guardian and trustee treatment options and likelihood of success common medical interventions mechanical ventilation antibiotic therapy feeding tubes resuscitation options and likelihood of success (Full Code vs. DNR status including preferences for CPR, intubation, ICU admission, artifi.cial hydration)

Power of Attorney
see EthicaL Legal and Or_ganizational AsJ?ects of Medicine. ELOAM4

GM12 Geriatric Medicine

Palliative and Bnd ofLife Care/Gerlatrlc Pharmacology

Toronto Notes 2011

Instructional Advance Directives

see Ethical.
and Orianizational Aspects of Medicine. ELOAM4

Symptom Management
.....

',

Table 7. Managamant Df Common End-of-life Symptoms

Symptom Constipation

NoPhmacalogic Management Rule out obstruction, impaction, anoreclill disease; hydration and high fibre intake; increase mobility

PharmKOiagic Management Stop unnacassary opioids and medications with anticholinergic side effects; provide stool softener (e.g. docusate sodium), inallllse peristalsis (e.g. sema), alter water and electrolyte secretion (e.g. magnesium hydroxide) Scopolamine SC ortransdermal

........ Ride
Noise caund by the OICiDIItDry
upper airway with inspinrtion and opinltion.

movement of mucous secretions illhe

...._,,

0111111 Rlthl Oral suctioning lncntllld Pulmonary Discontinue unnecessary IV solutions

Secretion
Dry 1111111111 Oral hygiene q2h, ice cubes, sugarless gum Artificial saliva substitutes, plocarpine 1% solution as mouth rinsa Frequent small feeds, ideally seated, keep head of bed aiiMII:ed for 30 minutas altar eating. suction as necessary 8evate head of bed, eliminate allergens, open window/use fa1
Hiccups
Dry sugar, bl'l!llhing in paper bag
and small meals, avoid offensive strong odours, 1reat constipation if present

muscle; gnawing, dull pain Visceral: not wen localized; crampy

pain, prvs8Uf8

NaaiCIIptin PHI Somatic: localimd to bonW"IkinfJDintl

Treat painful mucositis (diphenhydramine: lidocaine: Maalox in a 1:2:8 mixture). candidiasis (fluconBZDie) OX'(lll!n, bronchodilators, opioids (e.g. morphine, hydromorphone) Chlorpromazine, haloperidol, metoclopramide, baclofen. marijuana Raised ICP: dexamethasone AnticipaiOry nausea, anxiety: lorazep1111 Vestibular disease, wrtigo: dimenhydrinate Drug induced, hepatic or renal failure: prochlorperazile, haloperidol GmD: PPI or H2 antagonist Gastric stasis: matoclopnmide Bowel obstruction: metoclopremide, dexamelhasone, octreotide Nociceptive pain: non-opioids (NSAIDs, acetaminophen), weak opioids (codeine, hydrocodone, oxycodone), strong opioids {morphine, hydromorphona, oxycodona, fentillyl) Ne110pathic pain: anticonwlsirrts (gabapentin, pregabalin), antidepressants ('TCAs. SSRis), steroids (deunethasone) Bony pain: non-opioids. weak opioids, bisphosphonates, radiation 1herapy Antihistamines, pheniJihiazines, IDpical corticosteroids, cal1111ina lotion Traat insomnia, anemia, depression; consider psychostimulants

Neu011111hic Pain Burning. shooting. radiating pain; localized to dermatome! regions

.....

,,

Nausaaand Vamiting

Opiald Equinlant 0 . . (to 10 11111 of IV morphine)

Opilid MO!Jhjna Cadaira

Oxycadone

10 Not IICiliiii1Widlll Not IICiliiii1Widlll 2m;

POIIIII
Zll-30 mg 186-240 m; 11mmg

Plin

4-6mg

ni:ropmih"

= morphine 90 mg P(V241w, h-isntlnyt 11k1112-16 hou111D lllllldylllfl SBU !)li;a! l'hlnriiCQbm 0'14 c1mt.

Hot and cold compresses, music 1herepy, relaxation techniques, individualized program of phy$ical activity dHigned to flexibility, strength and endurance

Pnubl

Bathing with tepid watar, avoid soap, bath oils; sodium bicarbonate fer jaundica Modify environmlllt and activities to decrease enargy expenditure

AGS Pinel an l'!niilantl'lin in01dll' Pmom The 11111111lemanlripar&5t&nt p11in in lilll'pe110111.JAm GRir SGc 2002; 50161: Supplarnent. Knawtas. S. SympiOnll management in pellilliva care. G! CmtiNing l'rlcti:e 1 993; ZDI11: 20-25.

.....

',

Geriatric Pharmacology
Pharmacokinetics
Table 8. Age-Associated Pllermecokinetics
lmplic:atiln Alllorplion (lass significant) ncreased gastric pH Decreased splanchnic blood flow, Gl absorptive surface and dermal vascularity; delayed gastric emptying ncreased tollll body fat and alpha1-glycopratein Decreased lean body mass, total body water and albumin Drug-ilrug 111d drug-food interactions are more likely Ill affect absorption Lipophilic drugs have a larger volume of dislriblllion Dacreased binding of acidic drugs, increased binding of basic drugs Lower doses may be1hnpeutic For every x% recklction in clennce, decrease 1he dose by x% !lid ilcrease tha intaMI by x%

S111U111 cralllinine does not raftact crelllinine clellniiCe in the elderly.

lnsiRd, use: CrCI -(weight in kall140- aqall1.231

(mUrninl (serum cralllinina in fiiiiOVll

Multiply by D.85 for females.

Dislribution
It'

Benzodm.,i- of Cqic1
inthiEiderly

LOT
Lorwepam

Matabolism Decreased hepatic mass and hepatic blood flow; impaired (less significant) phese I reactions (oxidatiw system) Eliminllion Decreased renal blood ftow, GFR, tubular secretion and runal mass

Tamazepam

0uzeplt11

Toronto Notes 2011

Geriatric Pharmacology

Geriatric Medicine GM13

Pharmacodynamics
Drug Sensitivity changes in pharmacokinetics as well as intrinsic sensitivity lead to altered drug responses increased sensitivity to warfarin, sedatives and narcotics decreased sensitivity to beta-blockers Decreased Homeostasis poorer compensatory mechanisms leading to more adverse reactions (e.g. bleeding with NSAIDs/anticoagulants, altered mental status with anticholinergic/sympathomimetic/ anti-Parkinsonian drugs)

App111..:11 to 11111 Elllly

NO TEARS

...._ i

Need 1nd Indication Open-ended qU851ionl {to gut patiunt1

perspective an madicatiansl TM and monitamv (to- di-e controlI Evidence and guidelines Adverse 8Y8IIIs Risk reduction (of lclverse event1i such II$ fall$)
Sinplilicatian/swltches

Polypharmacy
Definition prescription, administration or use of many medications at the same time Epidemiology in Canada, over 25% of elderly women and about 20% of elderly men reported using medications hospitalized elderly are given an average of 10 medications during admission

Risk Factors for Non-Compliance risk of non-compliance correlates with medication factors, not age number of medications - compliance with 1 medication is 80%, but drops to 25% with medications dosing, frequency labelling, instructions, container design financial constraints- medication cost and coverage (insurance, drug benefit plans) cognitive impairment sensory deprivation Adverse Drug Reactions (ADRs) any noxious or unintended response to a drug that occurs at doses used fur prophylaxis or therapy risk factors in the elderly intrinsic: co-morbidities, age-related changes in phannacokinetics and pharmacodynamics extrinsic: number of medications, multiple prescribers, unreliable drug history 90% ofADRs are from: ASA, other analgesics, anticoagulants, antimicrobials, antineoplastics, digoxin, diuretics, hypoglycemics, steroids Preventing Polypharmacy consider drug: safer side effect profiles, convenient dosing schedules, convenient route, efficacy consider patient other medications, clinical indications, medical co-morbidities consider patient-drug interaction risk factors for ADRs review drug list regularly to eliminate medications with no clinical indication or with evidence of toxicity avoid treating an adverse drug reaction with another medication

Principilll r.r "-c:ribi.. in the Elderly

CAIE
CawarVCampli1111C8 Ave [adjust dasqe far qe) Review regimen regulllrly Educate
fon8, M. GIIM l'llrlrls. Campurf, 199!.

FA llbis

... ,

..

Advers1 drug ructions In 1he liMrly may present as delirium, fills, fractures.

urinary incontilencalretantian or fecal inconmence/impaclion.

Inappropriate Prescribing in the Elderly -----Epidemiology the estimated prevalence of potentially inappropriate prescribing ranges from 12-40% Beers Criteria examples include long-acting benzodiazepines, strong anticholinergics, high dose sedatives the elderly are also often under-treated (ACE!, ASA, beta-blockers, thrombolytics, warfarin)

... , ,

llellrs Crtt.la 48 madica!i0111 to IMiid in adub 65 and alcl.r due to safety concerns. For lui list

of 1'11111rance:

consult the falowing

FCkll'ot ltai.l.ipdllilgtlllillnCritlrillar pofrilly illpprapriniiTIIIIicltiDO 1.118 il aldlll'

ld.AirJJhM!Ued2003; 163:271&-2724.

GM14 Geriatric Medicine

Common Medications

Toronto Notes 2011

Common Medications
Table 9. Common Medications
DruaN

BnndN1118

Doli.. Schedule

lncicatiolls
on on. lrfpercholesterolenia
on

Comincicati

SidaEII'eca

Mec'-ism of Action
B!Jk.foming IIWI!ive B!Jk.foming lllllive Emollient. stool salbller

Llllllim bllll AI-Bn1n1

psylliu11 dOCUIIIe
llcbdole

Mellroocil' Prodi.Jm Plail11 Colaeel' Docusoft& Clronulac11 Ceph!Jacll Kristalose

ltsp PO tid 100 mg PO bid 15-30 cc PO dailyJtid

tw. fever,abdo pain. obslruclicn

Abdo pain. NN. fever Not Ill be usad with mine111l oil

Mid cramps

Plllients on low galactose diabi hspltic encephalopathy, bowel Abdo pain. tw. fever evacuation followilg barium exam
on

Fliltus, cramps. na111111, 11111111111 Hyperosmolar agent. lowers pH of colon to dec:II!IISe blood ammoria lewis

n
billcadvl
Anligllb

Senok1J141/Ex-lax8 1-2 tabs PO daily or 10-15 cc daily

Abdo pain. NN. fever Ileus. obsbuction, alxlo pail, tw. fever, severe dehydrati!n

CraiJliS. dependence CraiJliS. pail, dianhea

StimlWI! lllllive StimlWII IIIXIIive

5-15 mg PO (10 mg PRJ

on

acellnioophen

Tylenol' Advil11 Motrin11

(up Ill 4w'davJ

325-650 PO q4-6h pm Fewr, mild pain

Lower do&e& fur haplltic 111d 1111al Hepctotwcicity [in owrdo&e) disease, chroric alcoholism. known hypersensitiltity
cizziness, rash. Gl toxicity

intibition, no anti inflamn-.tory effects

illuprufen

(up to 1200 lll!t'day)

calec:axib

Celeb rex!!

200800 rTJ;1 PO q4-6h pm Mid to modeme pain, Active Gl bleell/ule disease. inflllmma1llry disorders. known hypersensitiltity, IIMIRI fever 1111111 or hepatic disease Geriatrics: nm susceptible to adverse effects OA: 200 mg PO daly or Osteoarlllitis, Cardiovasc!Jar or cerebrovascUar rheumlloid ar11ritis, FAP disease, CABG (peri-op), 100 mg PO bid s.Jtfonamida or allergy, active Gl bleed/iJcer severe renal or hepatic clsease, hyperkalemia disease, lBO, 58'1818 renal or hepatic cisea&e, hyperkalemia

llyspepaa, nausea, dinrllea.

Prondin-S)'nlhesis intibition, anti-inflammlllll'f

effects

[!Jeer, perforation. bleed)

Gl symptoms (pain, diarrllea, dyspepsia, flatus), Gl billed, serious cardiovascular IMinll

COX-2 intibitnr, anlllgesic. anti-inflaiD!IIIory and anti-pyratic effects

Anligllb [opiaid]- IIIia!

Anli-llyplrllnsim

CPit

tlliuide dillllic e.g. hydrochlorotliazide

12.5-25 mg PO daily

Hypertensian, edema

Anuria, heplltic coma. JRcoma, known sensitivity Ia 1hi11Zides

Hypotension, transient Inhibition of Ns/CI hypokalenia and co-lnlnspcrter atller elecbulyte disturbences, hyperuricemia, ti Hypotension, cough, heldache, Inhibition of cizziness, asthenia, chest pain. angiotensin-conwrti"'! nausea, peripheral edema. enzyme artlritis, dysiJie&. angioedema, hyperkalemia Dizziness, hypotension, fatigue, Antagonizes angiotensin II via headlchu, hyperkalemia blockade rJ 1ha angiotensil type 1 receptor Edema, muscle cramps.
cizziness, headache,

ACEI

Altace11

2.510 mg PO daily

e.g. ran'ipril

Essential hypertension, Known post-MI. cardiovascular a"'!ioedema !isease, renal protection

ARB

Cozaar"

50-100

daily

e.g. losartan
DHPCCB

I dillbete&

Essential hypertension

Known

Norvasc'

e.g. amlodipile

2.55 mg PO daily (initially)

Essential hypertension, Known IIMIRI chroric stable angina hypotension, caution in aortic stenosis

Calcium ion influx intibition

constipation. hmbum

Toronto Notes 2011

Table 9. Common Medications {continued)
DrugNime

Common Medications/Referencea

Geriatric Medicine GM15

Brand II Sl!llpilg Mlllicllians

mpidone

DDSi.. Schedule

lndicllians

Caltnildicllians

SideEfflcts

Mllchlni1111 of Aclilln Short-acting hypnalic (no tolerance effects]

lmDVIIne" (Canada)

3.75 mg PO qhs (iritiallyl lnsomria

Kno'MI hypenansitivity, in
myasthsia IJIVis, severe hepatic dsease Geriatrics: dose l'llfllction adwrn Mnlli]

Bittar taste. palpitBiians. vomiting. anorexia. silllonllea, confusion, agit!tion, anxiety, sweatilg

blllzeplll

15mg POqhs

Shart-turm lllllllll!l&ment Known hypersensitivity, myasthenia ,avis, sleep apne11 of insornia Geriatrics: dose reauction recommended
Anxiety, insomnia

Drow&ile&&, dizzile&&. impairvd BenzodiiZIIpine: gentnlized coortinatian, hqover.letlurgy, CNS dejRSsion mediated byGABA dependence Dizzine&&, drowsile&&. lethargy,
dependence

lai'IZipalll

Aw'

0.5 mg PO qhs (iniilllly, then increase]

Known hypersensitivity, myasthenia ,avis, narrow-angle Geriatrics: dose reauction recommended

Benzodiepine: generalizl!d CNS dejRSsion mediated byGABA

Cegmeflhancers

dOMpuil

Aricept4'

5-10 mg PO daily

Known hypersensitivity, Mild to moderate dementia of Abheimer'& in pumonary dill8ilse, sicbinU& type synlrome, semre disonler

rwv, dianhea, anorexia

Reversille inhibition of acetytchoinll&leRise

galurtalllile

Ramilyl11

8-12 mg PO bid

Known hypersensitivity, in rwv, dianhea, anemia Mild to moderale demerrtia of Abheimer's sick sinus syndn111e, seizlre cisorder, type pulmonary disease, law body weight

Reverdlle inhibition of acetytchoinesteRise Acetoilcholinesterase inhibition (reversible but vary slow) NMIJA.recaptlr anhlgonist

rivutigllill

Exelon8

1.5 mg PO daily (slllrting] Mild to moderate Known hypersensitivity, severe rwv, dianhea, anorexia up to 6mg PO bid dementia of Abheimer's hepatic disease, in sick sinus type synlroma, cisease. seiZIIre cisorder ModaRitu to sMre Known hypenansitivity, conditions dementia of Alzheimer's that alkalirize urine. il type conditions
Agitation, fatigua, cmilass, headache. hypertension. constipation

me1111111i1e

Ebix.a11/Namanda11 5mg PO daily (sllrtingl (CdnV(US) up to 10 mg PO bid

o\giiiJ - ... fUmlur, N27

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Elder Allllll

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lrmuizlli
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PnauwUU.

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