Geriatric Medication Use

Question 1

What is the simultaneous use of multiple drugs by a single patient to treat a single condition

Accepted Answer

Polypharmacy

Question 2

Polypharmacy is often defined as ___ or more medications.

Accepted Answer

5

Question 3

Polypharmacy What is prescribing a new drug to treat the symptoms arising from an unrecognized adverse drug event?

Accepted Answer

Prescribing cascade

Question 4

Rx Cascade The patient presents with new onset gout. What BP medication could be causing this?

Accepted Answer

HCTZ

Question 5

Rx Cascade The patient presents with new onset HTN. What common OTC drug class may be causing this?

Accepted Answer

NSAIDs

Question 6

Rx Cascade The patient presents with new onset parkinsonism. What drug class may be causing this?

Accepted Answer

Antipsychotics

Question 7

Rx Cascade Patient presents with new onset cough. What drug may be causing this?

Accepted Answer

ACEi

Question 8

Polypharmacy What are the three major complications of polypharmacy?

Accepted Answer

- Non-adherence - Geriatric syndromes - Drug interactions

Question 9

Adverse Drug Effects What are the two most common drugs that lead to hospitalizations in elderly patients?

Accepted Answer

- Warfarin - Insulin

Question 10

What are the two screening tools to evaluate for inappropriate prescribing in geriatric patients?

Accepted Answer

- BEERs - STOPP/START

Question 11

Beers Criteria What is the age cut off for which the Beer's Criteria applies to?

Accepted Answer

Ages 65 and up

Question 12

Beers Criteria T/F: It applies to all patients 65 years old and up, regardless of the setting.

Accepted Answer

FALSE -- Does NOT apply to hospice or palliative care

Question 13

Beers Criteria What is the purpose of it?

Accepted Answer

The weigh the risk and benefits compared to alternative medications

Question 14

Beers Criteria Includes medications that are ______________ inappropriate, not ______________ inappropriate.

Accepted Answer

Includes meds that are potentially inappropriate, not definitely inappropriate

Question 15

Beers Criteria Optimal use involves identifying _________ and offering safer alternatives.

Accepted Answer

PIMs

Question 16

Meds to Avoid in ALL Older Adults Which antihistamine class falls under this category?

Accepted Answer

First generation: - Chlorpheniramine - Diphenhydramine - Hydroxyzine - Meclizine - Cyproheptadine

Question 17

Meds to Avoid in ALL Older Adults Why are first gen antihistamines included in this category?

Accepted Answer

- Highly anticholinergic - Clearance reduced with advanced age - Risk of confusion, dry mouth, constipation, urinary retention

Question 18

Meds to Avoid in ALL Older Adults Which anti-infective is in this category? Why?

Accepted Answer

Nitrofurantoin - Potential for pulmonary, hepatotoxicity, and peripheral neuropathy with long term use - AVOID in Crcl < 30 mL/min

Question 19

Meds to Avoid in ALL Older Adults What are the three main antidepressants in this category? Why?

Accepted Answer

Amitriptyline / Nortriptyline / Paroxetine - Highly anticholinergic, sedating, and cause orthostatic hypotension

Question 20

Meds to Avoid in ALL Older Adults Why are antipsychotics in this category?

Accepted Answer

Increased risk of cerebrovascular accident (stroke) and greater rate of cognitive decline and mortality in persons with dementia

Question 21

Meds to Avoid in ALL Older Adults Avoid antipsychotics for behavioral problems of dementia or delirium unless...?

Accepted Answer

Nonpharmacological options have failed or are not possible and the older adult is threatening substantial harm to self or others

Question 22

Meds to Avoid in ALL Older Adults When can antipsychotics be used in patients over 65?

Accepted Answer

- Schizophrenia - Bipolar disorder - Short-term use as antiemetic during chemotherapy

Question 23

Meds to Avoid in ALL Older Adults Why are benzodiazepines on this list?

Accepted Answer

- Older adults have increased sensitivity to benzodiazepines
- Decreased metabolism of long-acting agents
- All benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults

Question 24

Meds to Avoid in ALL Older Adults All benzodiazepines increase risk of what 5 things in elderly patients?

Accepted Answer

- Cognitive impairment - Delirium - Falls - Fractures - Motor vehicle crashes

Question 25

Meds to Avoid in ALL Older Adults When may benzodiazepines be used in elderly patients?

Accepted Answer

- Seizure disorders - Ethanol withdrawal - Severe generalized anxiety disorder - Periprocedural anesthesia

Question 26

Meds to Avoid in ALL Older Adults What agents commonly used for insomnia are in this category? Why?

Accepted Answer

Eszopiclone / Zaleplon / Zolpidem
- Adverse events like those of benzodiazepines in older adults (eg, delirium, falls, fractures)
- Increased emergency room visits/hospitalizations
- Motor vehicle crashes
- Minimal improvement in sleep latency and duration

Question 27

Since Z-drugs should be avoided in older adults, how should we manage insomnia in these patients?

Accepted Answer

- Always incorporate non-pharmacologic interventions
- Use lowest effective dose and shortest duration (Zolpidem IR 5mg or 6.25mg CR)
- Monitor medication impact
- Consider use of low-dose antidepressants (mirtazapine)

Question 28

Meds to Avoid in ALL Older Adults When is insulin included in this category?

Accepted Answer

Sliding scale insulin - Insulin regimens containing only short- or rapid-acting insulin dosed according to current blood glucose levels without concurrent use of basal or long-acting insulin

Question 29

Meds to Avoid in ALL Older Adults Why is sliding scale insulin in this category?

Accepted Answer

Higher risk of hypoglycemia without improvement in hyperglycemia management - Very difficult to keep in range

Question 30

Meds to Avoid in ALL Older Adults What oral diabetes medication class is in this category? Specifically which drugs and why?

Accepted Answer

Sulfonylureas - Chlorpropamide - Glimepiride - Glyburide **Due to high risk of prolonged hypoglycemia**

Question 31

Meds to Avoid in ALL Older Adults Metoclopramide should be avoided in all older adults with what exception? Why?

Accepted Answer

Unless for gastroparesis with duration of use not to exceed 12 weeks - Extrapyramidal effects, including tardive dyskinesia - Risk may be greater in frail older adults and with prolonged exposure

Question 32

Meds to Avoid in ALL Older Adults PPIs should not be used longer than ___ weeks in older adults due to what 3 things?

Accepted Answer

8 weeks - C. diff - Bone loss - Fracture

Question 33

Meds to Avoid in ALL Older Adults What common OTC agents used for pain are in this category? Why?

Accepted Answer

NSAIDs (chronic use) - GI bleed risk - Increase bP - Kidney injury risk

Question 34

Meds to Avoid in ALL Older Adults T/F: Aspirin at any dose should be avoided in older adults.

Accepted Answer

FALSE -- Doses > 325 onyl

Question 35

Meds to Avoid in ALL Older Adults T/F: NSAIDs should be avoided at all times in older adults.

Accepted Answer

FALSE -- Chronic use should be avoided

Question 36

Meds to Avoid in ALL Older Adults Why are muscle relaxants in this category?

Accepted Answer

Anticholinergic adverse effects, sedation, increased risk of fracture

Question 37

Meds to Avoid in ALL Older Adults What are they?

Accepted Answer

- First-gen antihistamines
- Nitrofurantoin
- Antidepressants: Amitriptyline, paroxetine
- Antipsychotics
- Benzos
- Z-drugs
- Sliding scale insulin
- SUs: Chlorpropamide, glimepiride, glyburide
- Metoclopramide > 12 weeks
- PPIs > 8 weeks
- Chronic use NSAIDs (ASA > 325)
- Muscle relaxants

Question 38

Meds to Avoid What medications should be avoided in older adults with or at high risk of delirium because of potential of inducing or worsening delirium? (7)

Accepted Answer

- Anticholinergics - Antipsychotics - Benzos - Z drugs - Corticosteroids - Meperidine - H2RAs

Question 39

Meds to Avoid What medications should be avoided in patients with dementia and cognitive impairment due to adverse CNS effects? (4)

Accepted Answer

- Anticholinergics - Benzos - Z-drugs - Antipsychotics

Question 40

Meds to Avoid What medications should be avoided for use in behavioral problems of dementia unless non-pharm has failed and patient is a threat?

Accepted Answer

Antipsychotics

Question 41

Meds to Avoid What medications should be avoided in patients with a history of falls or fractures? (6)

Accepted Answer

- Antidepressants (TCAs) - Antiepileptics - Antipsychotics - Benzos - Opioids - Z-drugs

Question 42

Meds to Avoid What anti-emetic medications should be avoided in older adults with parkinson's? (3)

Accepted Answer

- Metoclopramide - Prochlorperazine - Promethazine

Question 43

Meds to Avoid What antipsychotics are allowed to be used in patients with parkinson's disease induced psychiatric disorders? (3)

Accepted Answer

- Quetiapine - Clozapine - Pimavanserin

Question 44

Meds to Use With Caution What two DOACs should be used with caution for VTE tx or AF in adults over 75? Why?

Accepted Answer

Dabigatran / Rivaroxaban: - Due to increase risk of GI bleeding

Question 45

Meds to Use With Caution Aspirin being used for primary prevention should be used with caution in patients over ___ years old.

Accepted Answer

Over 70

Question 46

Meds to Use With Caution What meds may exacerbate/cause SIADH or hyponatremia? (9)

Accepted Answer

- Antipsychotics - Carbamazepine - Diuretics (HCTZ in hyponatremia) - Mirtazapine - Oxcarbazepine - SNRIs - SSRIs - TCAs - Tramadol

Question 47

Meds to Use With Caution When should Bactrim be used with caution and why?

Accepted Answer

Use with caution in those on ACEi, ARB, or decreased CrCl: - Increased risk of hyperkalemia

Geriatric Medication Use

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