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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
Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).
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.
Pharmacological Treatment
Pressure Ulcers
Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).
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.
Non-Pharmacological Treatment
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.
Pharmacological Treatment
Sleep Issues
Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).
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”
Rodriguez et al. Med Clin North Am. 2015;99(2):431-439.Wennberg e tal. Maturitas. 2013;76(3):247-252.
Non-Pharmacological Treatment
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
Rodriguez et al. Med Clin North Am. 2015;99(2):431-439.Wennberg e tal. Maturitas. 2013;76(3):247-252.
Pharmacological Treatment
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
Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).
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
Alves et al. World J Clin Cases. 2013;1(8):233-241.Inouye et al. Lancet. 2014;383(9920):911-922.
Non-Pharmacological Treatment
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)
Alves et al. World J Clin Cases. 2013;1(8):233-241.Inouye et al. Lancet. 2014;383(9920):911-922.
Pharmacological Treatment
Vision / Hearing Issues
Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).
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.
Vision/Hearing Issues
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.
Non-Pharmacological Treatment
Vision/Hearing Issues
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.
Pharmacological Treatment
Dizziness/Falls
Sleeper. Consult Pharm. 2009;24(6):447-462 (used with permission).
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.
Non-Pharmacological Treatment
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.
Pharmacological Treatment
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
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