toronto notes 2011 - geriatric medicine

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

\•, Gerillric Giant. Memory Falls lnconlin1111C8 Polypilannacy

5 I• of Gerillric• Immobility Intellect Incontinence latrogenesis lmpairad hameollnil

...... , Malt Cornman Acat• Dilanl•rs lntM Ellhlrly Cardiovascular disease (CHF. r:vA, Mil Fracture (hip, vertllbree, wrist) Medicltion-f'lllallld I'Mumonill Sepsis

\•, Malt Cornman Cbranic Dilonl.,. lntM Ellhlrly Arthritis Catarscts Uld other visual problems COPD Cardiovascular disease Dillbatn Mallitul (Type 2) Hearing impainnent Hypertension Mllllal disordtlrs Orthapaedil: di&ordars Sinusitis

Seniors in Canada and the U.S.

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

1. Disaasas of the heart and citulatary aystam (3D.WJD.4%) 1. Hypartansion 2. MaliiJI&nl neopiiiSIIII (2D.0/22.D%) 2. Arthritis 3. Cerebrovascular disease (8.(117.4%) 3. Heart disease 4. Chronic loww respiraiDry disease (5.1/6.D%) 4. Diabetes 5. Accidents (2.9%)1 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

Neurologic Deaeased wakefulness, decreased bran mass, carabral blood flow

Spacill Sanes Daaeasad lacrimal gland sacration, lens 1111nsp111111cy, dark adapllltion, dacrB8Sad sense of smell and taste

Canliovalcular Increased sBP. dBP. decreased HR. CD Decreased vassal elasticity, cardiac myocyta siza and .-..mber, beta-achnergic responsiveness

RaiPilltory lnaeased lnlcheal cartilage calcification, mucous Pld hypertrophy Decreased elastic recoil, mucociiary claamnca, pLJmonary function reserve

Glltnlilleltiall Increased intestinal villous atrophy Deaeased esophageal peristalsis, gastric acid secretion, liver mass, hepatic blood flow, calcium and iron absorption

Ranlland urologi: lnaeased proteinuria, urinary frequency Deaeased renal mass, creatinine clearance, urina acidification, hydroxylation Ill

Reproductive

Endocrina

Musculoskelalll

lntegumenlllry

Psychiatry

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

Pllhologicll Chlnges Increased insomnia, neurodegenerative disease, stroke, decraasad r&llsx rasponsa Increased glaucoma, cataraels, macular dajjenaration, pnllbycusis, presbyopia, vartigo, oral dryness Increased atherosclerosis, CAD. ML CHF. hypartansion, arrhytlmias

Increased COPD, pneumonia, pulmonary embolism

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

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

Toronto Notes 2011 Differential Diagnosea of Common Presentations

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

Geriatric Medicine GM3

GM4 Geriatric Medicine

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

Four Syndromes in fllilure to lbrive My ... C...l Dril'l

Ph'f'ical impairment CognitiVI impainnant Depression

FunctiDul AM-mm (ADLI•miiADLI} ADLI: AIICDE-TT Ambulating Bathing ContiniiiCI Dressing Eating Transferring Toileting

IADLI: SHAFT-IT Shoppi"lg Housework Accountinw'Managing linlllCus Food preparation Transporllltion T1l1phona Taking mudications

Differential Diagnose5 of Common Presentations Toronto Notes 2011

Riskfacton • 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 of the 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 of the 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) -----------------------------------

Definition • declining independence and functional capacity with loss of vigor 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 l!H!!m PIE: Gl-i:onslipation Social Somatic Cardiac Ducreasud Energy f---+ Malnutrition +--- Respiratory

lncreasad Catabolism Cllgnitive inpairment Skin Changes Drugs Functional impairmant (decnasud mobility! S&nsory

... I Failura to Tlniva I ...

llll!llllilll1iiiDI lllllli& liltal May include laboratory and/or radiologic teal$, MMSE, ADL/IADL assiiSIIIlant. "Up and Go Till!." Geriatric Treat general

mudiclll Dupr811ion Scala, nutritionalan1111munt. mudication ruviuw, condition chronic disease evaluation, anvironmantalessassmant

... ... ... ... lillloilillllmaiaallll

M•ln!dritian Optimim livi1g conditions Dnarwiao SLP evaluation Treat undanying lilllldiiDIIImllliaalld

l'$ychothen;py Treat oral pathology depi"IIISion, Phy$ical1hurapy Antidep1811111nts lncraasa fnlquancy infection Occupational therapy

Modily environment of feedings Administer Modily environment Nutritional suppl&mants dementia-delaying

medications

I I I I ... ...

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

If positive response, ... continua traatm&nt

I Repeat evaluations, if appropriate

Considlr discussion of and-of·lifl 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; 24:1072·1078.

I


Table 3. Common Medical Conditions Associated witiJ Failure to Thrive Medical Conlilian Cancer

CluH of flilureiD 11wivll Metastases, malnutrition, cachexia Respiratory failure Renal failura

Clnnic lung disease Clnnic 1111al ilsufficiency Clnnic steruid use Cin11osis, hepatitis

Steroid myopathy, diabetes, osteoporosis. vision loss Hepatic failure

Depression, other psychiatric disorder Diabetes Gastrointestillll surgery

Major depression, psychosis. poor functional status, cognitive loss Malabsorption, poor glucose homeostasis, end-organ damage Malabsorption, malnutrition

Hip, long bone fracture Inflammatory bowel disease Myocardial infarction, congestive heart failure Recummt Ull, pnaJII'IOIIia

Functional impairment Malabsorption, malnutrition Cardiac failure Chronic infection, functional impairment Chronic inllanmrtion Rheumatologic disease (GCA, RA. SLE)

Stroke Tlberculosis. other sys18mic infection

Dysphagia, depression, cognitive loss, functional impairment Chronic infection

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

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 • Identification of Pracipitating Al:livity

... ... ... ... l!llllli,lliiD IGii'ib:

W.lm•llfLIII Alcohol

Ellwiu 1!111[ IIIIIID Anticholinargics !lypgtansign Positive Romberg test Anticonvulsllnts Impaired chair sta'ld Orthostatic Slow gait Positive P ... l tiiSt Antihypertensives Poslprandial Poor vision Digoxin Poor &lair climbing Nitrates

Sadstivas • • • • hdl!!!lgljgn lnllmntjgn

Medication raviaw lf!bmnljpo lf!bmgljpn Madicstion miaw Behaviour changas Balance1n.ining Reduce or eliminlllll Rasistanceb'aining Widen SL41JlOrl bue nitrates, banzodiazapinas. (separata meals and Quadriceps (i.s. ihoes, cane, walksr) medicstions, exercise)

strengthening Corral:! vision antihypertensives (compression stockings, (if possible) lilllt inlllks)

I I I I • lflhnranllool AoamaEIIII fll[ All rdilllll!lllb E1ll1 EvaiUBtion and correction of loose rugs, cords, poor lighting,

movable furniture, bathtubs, 1hmholds, clutter

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. Tneai ME. Baker IJ. McAwy G, etal A 11111tif1ctorial illerwrdion 1D reib:e 1he risk Gf elderly people lilring in the CGIII'Tiunity. NEJM 19!14; 331(13):821-821.


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

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

llaultl: Cinically idlldlilbll risk fllcfml wn idinlilied ICIOI5 6 dimins: 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 1 aiU. 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 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 ..


..... ', .. hll Prenntion TIPI 1. Improve lighting. especially on stairs 2. Caution whill adjUiting 1D niW

bifllcal prescription (paar depth panceptionl

3. Sidenils in bathtubs 4. an Slaps 5. CaMact pati8nt 1D IWalina button

signalingsystlms 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

••Hilt 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. 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 .. d 1rill 11"1111111 inelllion crilaria. TIIIOUiron_ra_afalinZ2 IUiies and a 1r1ctre 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.

lnllmlllianl far I'IMIIilg Fill illldlr lilillinlber-Er CIJdrwle DlltJbae S)'lt 1/ev 2IJ09; 2:CCIIK11146 SlUr. Coclnne nMiw. II RCT 1111 qulli.ftCT1rills. l'lipllla SS.303PIIIieraoml0 -. asnior. or ltler111d lvila in the cOIAITUiily. ........

IIIIa alfllls lllll"III1Wal flllars. -... 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 D does 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.

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)

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

CThead

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

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

Risk Factors • prior vaginal delivery • anorectal surgery • peMc radiation • diabetes • neurologic disease • diarrheal conditions

Investigations (if cause not apparent from history and physical) • stool studies • endorectal ultrasound • colonoscopy, sigmoidoscopy, anoscopy • anorectal manometry/functional testing

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


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 Urinary ilcuntinence Dep111$$ion Adverse drug event Confusionldeliium

Pressure ulcers Infection Falls Hypotension/dehydration Diminished aerobic capacity/loss of muscle strengtl\l'contractures Decreased respiratory function

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 Early mobilization

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 CEil ARB 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

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)

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

Etiology • starvation

• decreased intake: financial, psychiatric, cognitive deficits, functional deficits, anorexia associated with chronic disease

• decreased assimilation: impaired transit, m.aldigestion, malabsorption • stress

• acute or chronic illness/infection, chronic inflammation, abdominal pain • mechanical

• dental problems, dysphagia


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

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

(HH l.o4, !15'1. 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 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

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

', , .}-------------------, Calculating Basic Caloric and Fluid Requirements WHO daily energy estimates for adults >60 years: Female: 1 0.5 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.

A Systematic 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 povidine-soaked 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 2 and 3 pressure 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.

Differential Diagnoses of Common Presentations

o age-related changes • appetite dysregulation, decreased thirst

o mixed

Toronto Notes 2011

• increased energy demands (e_g_ hyperthyroidism), abnormal metabolism, protein-losing enteropathy

Risk Factors o mechanical: dental problems, medical illnesses interfering with ingestion or decreasing

appetite o nutritional: medical illnesses increasing nutritional requirements or requiring dietary

restrictions o functional: difficulty shopping, preparing meals or feeding oneself due to functional impairment o social: economic barriers to securing food, lack of availability of high quality food o psychological: depression, poor appetite

Clinical Features o history

• recent weight loss, decreased food intake, constitutional symptoms, GI symptoms, recent or chronic illness, social factors

o physical examination • BMI <23.5 in males, <22 in females should raise concern • temporal wasting, muscle wasting, presence of triceps skin fold

Investigations o CBC, electrolytes, Ca, Mg, P04, Cr, LFTs (albumin, INR, bilirubin), B12, folate, TSH, transferrin,

lipid profile, urinalysis

Osteoporosis o see EndocrinololO'. E43

Presbycusis o see OtolaryngololO', OT20

Pressure Ulcers o see also Plastic Surgery. PL14

Risk Factors o extrinsic factors: friction, pressure, shear force o intrinsic factors: immobility, malnutrition, moisture, sensory loss

Table 5. Classification of Pressure Ulcers Stage I 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.

Stage II Partial thickness skin loss involving the epidermis, dermis or both. The ulcer is superficial and presents as an abrasion, blister or shallow crater.

Stage Ill 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.

Stage IV 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)

o maintaining nutrition, encouraging mobility and managing incontinence

Treatment o minimize pressure on wound o analgesia o wound debridement (mechanical, enzymatic, autolytic} and dressing application o maintain moist wound environment to enable re-epithelialization o treatment of wound infections (topical gentamicin, silver sulfadiazine, mupirocin)

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

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

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

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

...... ' PraiSII'Hllllucila Dewices Sllltic devices distriblte pressure over a gr.Dr surfllc. arwa. Dynamic dwicn use llllemating IIi' currents to shift pressure Ill diffarant body silas.

e' TriMillll c.-of lncllllin-DIAP£RS Delirium lrnctlan A1ruphic urelhritlslvaginitis Phannac8Utic81s Excessive urine oulplt llllslricbld mobility SIDOiimpectian

GMIO Geriatric Medicine

.,_...._.,Drilillllill:•d .. will ....... J Ani Gttitlr SGc 21m; 55:818-84 l"'lffee: To delermine MIChel persons wilh dlnntill• II gnlllr drivilg lilt and, W 10, 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.lhi•IIIJdrtllll 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

perfomuce. c..-.a.: DiYm wilh danntie 1111 PDOIW drivers lllllll)llllliile¥ 110111111 drilers, '-! sWes 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

Driving Competency Toronto Notes 2011

• 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

• 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

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

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

Raidantill a] Seniol'l Aflanlallle Hou1ing

b) lkttire11111nVNuning Home

d) LDnlf"'llnn C.rWStllld Nunilg Ftcility

e) Holpice

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.) Divided into short ( <60-90 day5/year] and long (indefinite) stay 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 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 Around the clock nursing care and on-call physician coverage; often oilers occupational therapy, physiotherapy, respiratory therapy and rehabilitation senrices; may be used short·tarm 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

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



..... ', ........ Ride Noise caund by the OICiDIItDry movement of mucous secretions illhe upper airway with inspinrtion and opinltion.

...._,, NaaiCIIptin PHI Somatic: localimd to bonW"IkinfJDintl muscle; gnawing, dull pain Visceral: not wen localized; crampy pain, prvs8Uf8

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

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

Opilid POIIIII MO!Jhjna 10 Zll-30 mg Cadaira Not 186-240 m;

IICiliiii1Widlll Oxycadone Not 11mmg

IICiliiii1Widlll 2m; 4-6mg

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

..... ', 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.

It' Benzodm.,i- of Cqic1 inthiEiderly

LOT Lorwepam 0uzeplt11 Tamazepam

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 No•Ph•macalogic Management PharmKOiagic Management Constipation Rule out obstruction, impaction, anoreclill

disease; hydration and high fibre intake; increase mobility

0111111 Rlthl Oral suctioning lncntllld Pulmonary Discontinue unnecessary IV solutions Secretion•

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

Dry 1111111111 Oral hygiene q2h, ice cubes, sugarless gum Artificial saliva substitutes, plocarpine 1% solution as mouth rinsa

Hiccups

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 Dry sugar, bl'l!llhing in paper bag

Nausaaand Vamiting and small meals, avoid offensive strong odours, 1reat constipation if present

Plin

Pnubl

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

flexibility, strength and endurance

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

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

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

Alllorplion ncreased gastric pH (lass significant) Decreased splanchnic blood flow, Gl absorptive surface

and dermal vascularity; delayed gastric emptying Dislribution ncreased tollll body fat and alpha1-glycopratein

Decreased lean body mass, total body water and albumin

lmplic:atiln 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

Matabolism Decreased hepatic mass and hepatic blood flow; impaired Lower doses may be1hnpeutic (less significant) phese I reactions (oxidatiw system)

Eliminllion Decreased renal blood ftow, GFR, tubular secretion and runal mass

For every x% recklction in clennce, decrease 1he dose by x% !lid ilcrease tha intaMI by x%

Toronto Notes 2011 Geriatric Pharmacology

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)

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% of ADRs 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

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)


App111..:11 to ...._ i• 11111 Elll•ly NO TEARS Need 1nd Indication Open-ended qU851ionl {to gut patiunt·1 perspective an madicatiansl TM and monitamv (to·-di-e control I Evidence and guidelines Adverse 8Y8IIIs Risk reduction (of lclverse event1i such II$ fall$) Sinplilicatian/swltches

Principilll r.r "-c:ribi .. in the Elderly CAIE CawarVCampli1111C8 Ave [adjust dasqe far qe) Review regimen regulllrly Educate fon¥8, M. GIIM l'llrlrls. FA llbis Campurf, 199!.

... , .. Advers1 drug ructions In 1he liMrly may present as delirium, fills, fractures. urinary incontilencalretantian or fecal inconmence/impaclion.

... , , llellrs Crtt.la 48 madica!i0111 to IMiid in adub 65 and alcl.r due to safety concerns. For lui list of consult the falowing 1'11111rance: 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 Comincicati• SidaEII'eca Mec'-ism of Action Llllllim bllll AI-Bn1n1 on B!Jk.foming IIWI!ive psylliu11 Mellroocil' ltsp PO tid on. tw. fever,abdo pain. obslruclicn B!Jk.foming lllllive

Prodi.Jm Plail11 lrfpercholesterolenia dOCUIIIe Cola eel' 100 mg PO bid on Abdo pain. NN. fever Mid cramps Emollient. stool salbller

Docusoft& Not Ill be usad with mine111l oil llcbdole Clronulac11 15-30 cc PO dailyJtid hspltic Plllients on low galactose diabi Fliltus, cramps. na111111, 11111111111 Hyperosmolar agent. lowers

Ceph!Jacll encephalopathy, bowel Abdo pain. tw. fever pH of colon to dec:II!IISe blood Kristalose• evacuation followilg ammoria lewis

barium exam •n• Senok1J141/Ex-lax8 1-2 tabs PO daily or on Abdo pain. NN. fever CraiJliS. dependence StimlWI! lllllive

10-15 cc daily

billcadvl 5-15 mg PO (10 mg PRJ on Ileus. obsbuction, alxlo pail, CraiJliS. pail, dianhea StimlWII IIIXIIive tw. fever, severe dehydrati!n

Anligllb acellnioophen Tylenol' 325-650 PO q4-6h pm Fewr, mild pain Lower do&e& fur haplltic 111d 1111al Hepctotwcicity [in owrdo&e)

(up Ill 4 w'davJ disease, chroric alcoholism. intibition, no anti· known hypersensitiltity inflamn-.tory effects

illuprufen Advil11 200·800 rTJ;1 PO q4-6h pm Mid to modeme pain, Active Gl bleell/ule« disease. llyspepaa, nausea, dinrllea. Pro•ndin-S)'nlhesis Motrin11 (up to 1200 lll!t'day) inflllmma1llry disorders. known hypersensitiltity, IIMIRI cizziness, rash. Gl toxicity intibition, anti-inflammlllll'f

fever 1111111 or hepatic disease [!Jeer, perforation. bleed) effects Geriatrics: nm susceptible to adverse effects

calec:axib Celeb rex!! OA: 200 mg PO daly or Osteoarlllitis, Cardiovasc!Jar or cerebrovascUar Gl symptoms (pain, diarrllea, COX-2 intibitnr, anlllgesic. 100 mg PO bid rheumlloid ar11ritis, FAP disease, CABG (peri-op), dyspepsia, flatus), Gl billed, anti-inflaiD!IIIory and

s.Jtfonamida or serious cardiovascular IMinll anti-pyratic effects allergy, active Gl bleed/iJcer severe renal or hepatic clsease, hyperkalemia disease, lBO, 58'1818 renal or hepatic cisea&e, hyperkalemia

Anligllb [opiaid]-•IIIia! CPit Anli-llyplrllnsim tlliuide dillllic 12.5-25 mg PO daily Hypertensian, edema Anuria, heplltic coma. JR·coma, Hypotension, transient Inhibition of Ns/CI e.g. hydrochlorotliazide known sensitivity Ia 1hi11Zides hypokalenia and co-lnlnspcrter

atller elecbulyte disturbences, hyperuricemia, ti

ACEI Altace11 2.5·10 mg PO daily Essential hypertension, Known Hypotension, cough, heldache, Inhibition of e.g. ran'ipril post-MI. cardiovascular a"'!ioedema cizziness, asthenia, chest pain. angiotensin-conwrti"'!

!isease, renal protection nausea, peripheral edema. enzyme artlritis, dysiJie&. angioedema, hyperkalemia

ARB Cozaar" 50-100 daily Essential hypertension Known Dizziness, hypotension, fatigue, Antagonizes angiotensin II via e.g. losartan I± dillbete& headlchu, hyperkalemia blockade rJ 1ha angiotensil

type 1 receptor DHPCCB Norvasc' 2.5·5 mg PO daily Essential hypertension, Known IIMIRI Edema, muscle cramps. Calcium ion influx intibition e.g. amlodipile (initially) chroric stable angina hypotension, caution in aortic cizziness, headache,

stenosis constipation. hmbum

Toronto Notes 2011 Common Medications/Referencea Geriatric Medicine GM15

Table 9. Common Medications {continued) DrugNime Brand II• DDSi .. Schedule lndicllians Caltnildicllians Sl!llpilg Mlllicllians mpidone lmDVIIne" 3.75 mg PO qhs (iritiallyl lnsomria Kno'MI hypenansitivity, in

(Canada) myasthsia IJIVis, severe hepatic dsease Geriatrics: dose l'llfllction

adwrn Mnlli] blllzeplll 15mg POqhs Shart-turm lllllllll!l&ment Known hypersensitivity, myasthenia

of insornia ,avis, sleep apne11 Geriatrics: dose reauction recommended

lai'IZipalll Aw' 0.5 mg PO qhs Anxiety, insomnia Known hypersensitivity, myasthenia (iniilllly, then increase] ,avis, narrow-angle

Geriatrics: dose reauction recommended

Cegmeflhancers dOMpuil Aricept4' 5-10 mg PO daily Mild to moderate Known hypersensitivity,

dementia of Abheimer'& in pumonary dill8ilse, sicbinU& type synlrome, semre disonler

galurtalllile Ramilyl11 8-12 mg PO bid Mild to moderale Known hypersensitivity, in demerrtia of Abheimer's sick sinus syndn111e, seizlre cisorder, type pulmonary disease, law body weight

rivutigllill Exelon8 1.5 mg PO daily (slllrting] Mild to moderate Known hypersensitivity, severe up to 6 mg PO bid dementia of Abheimer's hepatic disease, in sick sinus

type synlroma, cisease. seiZIIre cisorder

me1111111i1e Ebix.a11/Namanda11 5 mg PO daily (sllrtingl ModaRitu to sMre Known hypenansitivity, conditions (CdnV(US) up to 10 mg PO bid dementia of Alzheimer's that alkalirize urine. il

type conditions o\giiiJ - ... fUmlur, N27

References lladhllllus Heron M. Deaths: l!adilg Cues for 2004. Heelth E-smts. Released Nil¥ 20. 200'1.

Dl. H111011 M. Murphy SL. Kung HC. (2006]. Dalllhs: final ddl for 2003.11111111 E-11111. Rallnld JIIIIIIY 19, 2006. Slltistics CanlldL [2005]. Deaths. by seleelld QIOUped c:auses 11111 Ill\ Canada, llfGVinces and territuries, annual Otllwa: Cndl.

Phpiulagy• PathllaolfJaill Braui!WIId, E. Fauci. AS. Hu.; SL lJil'QII. II.. J1111111m. JL.IEds].l2004]. Hurison's af 1ntam1l Madicina. NIIW Yllltc McGraw-Hill

Constipatien Higgns PDR. Joh•onJF. Epiderricqy in No!thAmericl: A SVstamatic RaviiW. Am J Gulroentlrol, 99:750-759.

Danm, Dallllllil,•dD ........

SideEfflcts

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

sweatilg

Drow&ile&&, dizzile&&. impairvd coortinatian, hqover.letlurgy, dependence

Dizzine&&, drowsile&&. lethargy, dependence

rwv, dianhea, anorexia

rwv, dianhea, anemia

rwv, dianhea, anorexia

Agitation, fatigua, cmilass, headache. hypertension. constipation

Garilltricl Sociu!y and Rllflll Collage of Phylicin. [2006). Qlidsliles for cilgll01i5 u.t rrmnagamsnt rl diJirilm il olda' peapls. Conci&e guidance to good practice IIIias. No. &. lniiU'f8, SK. [2007). Tba HDS!liml Elder lift Pragrn Ra1riMd Mav4. 2010 110m lttp:/leldldfl.ll'lld.yaluduf)Uitt1iftstyla .• ?pagaid=01.01.02.

Elder Allllll Hsalth CanlldL 1.2002). ThiJ Canllian !iuids1D Clinicall'llllantltive Haalth Cara. Otllwl: Canldian Tut Fon:u 1111 Pravantlli\111 Hallllh Cars. lr.e!Qoat. MJ.I2tol). Prwentative Heahll Care in 1lle Bdedy. The Canadian Jounal af CME. tact. MS, Pllemar K. (1115]. Abu11111d neglect of alderlypersons. NEJM, 332[7]:437-443. tact. M, Pillmar K. Eldllr Abull.l.ancat,1192-1263. l'ariodic hllllth IDCirrlinlllion, 1894 updllla: 4. Second.y-JifWBI11ion rl aldar llbuia CMAJ. 151[10):1413-1420. Sobll HN. [2008). Bdarabusl. UpTollatu. SchmorlariE Silman JS. &Jer liMe. Up loDe.

Ftiln1Dnrill llobarbion RG, Montagriri M. Game liiY.a to thriva. Am flm Plrys. 70[2): 343-348. Sartilian CA. Laches MS. "Faillre 1D 1llive" in oldeudults. Am tdem Med. 124: 1072·1078. VerderyRB. (1917]. Clinical BVIIuation fd.na to thrive in otlar paople. Cin Garillr Mild, 13:76!-78-

flllll Close .I, BisM,IbparR. Glucklmlll E,JICbon S. Swift C. [1999). Pravantion of fils india aldldrtrial [PIIOFE1}: a!Widoniz&d centn1lld1rial. Lancat, 353[9147): 93-7. Fllllet G.l2001]. Falsi! the elderly. Am hm PlrA 61171: 215!-2172. Ganr. DA. Baa Y. Shakall PE. lZ [2007]. Wil my petiant fliP. JAMA. 297: 71-86. Gilespie lD. Gil!spie WJ, Rabel1sun MC, Lamb Sf, Qmnning RG.IIlMre BH. [2003].1nterventians for preventing fills in elderly people. Tile Coclnne Dlltabll5e Dl Systame RIMIIIW, 4. Goldlist B. Turpic l Borins M.l1997]. Essential Geriatrics: 6 conditions: Patient Care Cllllllil. 8(9): 61-74. Hartbnall s.L6nmo01 E. LlUiiwori 1<.(2007]. Medication au rilkfllctor fwflllla: critical_. f8Vilw. J Gerontal A Bioi Scl62(10]: 1172-81. Kialll! 12005]. !MNiaw allah in thuldllty. UpTollatu. R1111, BillEd]. UpTalllllll. Wlllasly, MA. Tnalli Mf. B1kar Dl McAvlyG. el:ll. (1984].A nUthctorial eldatti in thacomrn.mily. NfJM. 331(13]:821-827.

Mllchlni1111 of Aclilln

Short-acting hypnalic (no tolerance effects]

BenzodiiZIIpine: gentnlized CNS dejRSsion mediated byGABA

Benzodiepine: generalizl!d CNS dejRSsion mediated byGABA

Reversille inhibition of acetytchoinll&leRise

Reverdlle inhibition of acetytchoinesteRise

Acetoilcholinesterase inhibition (reversible but vary slow)

NMIJA.recaptlr anhlgonist

GM16 Geriatric Medicine References Toronto Notes 2011

H-.11 rlllllpildrJiial Cn1di111r MC. Hmnls of Hospi1dmtiall aftiiiEidlrly. Ann lntam Med. 118(3]: 219-223. lnouya AK. Bogardus ST. Chlrplntilr PA. at Ill (1199]. A infiMntian tD pliYIInl dlllrium in hDspitalizlld lilar patillnll. 340(1]:669-676. Sager MA. Fninke T, • SIC. et Ill (1996]. Functionai!Mcomes al ac:ute medical itless and hospitalizltion in older peniOill. Arch lntemal Me d. 156{6]:66-52.

AllHAT officers and coordinatm far the AllHAT callbarllive re.n:h grwp. (Z002). TIE lllllillypertensive and lipili-lawelilg 11u1merrt tD prevent hat llllck trill. Major in ilyplrtansiva patilniJ randanizld tD an!lillllnsin-convarting lnl¥RW inhibi111r or calcium charmll blocbrvs. dintic: Thl Antilryparbmliw and Lipill-llrNaring T1111bnant tD l'rM1It llaart Altack Trial (AUJtAl}. JAMA. 20021lac 18;288(231:2181-17.

W. Espeland, MA. Eisler, L Wilson. AC. Fonr, S.l.acy, Cll. (2001 ).lllects al retb:ed sodium inllle on hi'Pertensian contrul hi older inlhicbls: raults flom tha Trial of Nonpharmacologic in tha Bderly(lONE). Arclllntam Mid. 2001 Mar 12;161(5]:685·93. llac:ketl NS II al (2008(. Treatmantal hypei1Bnlion il patianli 80 ¥1J1r& alage •lilar. 358(18):1887-98. Fan KC. S. Cutllr. Sociln and Wlijrt loa in tha11111m1nt af hypartansion in Iiiii" penons: 1 randomimd cordnl .. d trial al qhannacologic illlllrwntians in tha aldlrly (T(IlEI. JAMA. 1998 Mar 1 8;279(11 ):83!1-46.

A. Baala H. V.ndllWIIII K.lleftoor T. (2008]. A IVI'iew of tha UBI of l¥*ocolklids il the 1r8llmant of P'lllln ulcer&. J Ctn NUnl. 17(9]:1164-73. WB. (1996). Blood cardiovaiiCIJiar riltfac1Dr: 1l8l1mlllt JAMA. 1996 MayZZ-29;275(201:1571·6.

Kaplan. NM. Rosa. Bll. T1111bnant of hfpartanlill in tha aldar1y. Uplolll18. Roa, BD (Ed). Uplollatll. Walllllr, MA. Mulnr.v C. Llu J. Cornell J. Brlrid M. IZ0021. hypertmion hi the elderly In: TIE Cochrane libn1ry,lssue 2. Wlllllon, PK. AppaL W. [splllnd. MA. Applage11, WB. Etting1t WH Jr. Kostis. JB. Kumanyika. S.lai:y, CR. Johnson, Canadilll Hyperfellsian Group (Z002]. The 2001 Canadian hypertension TeCOII1lllellllti!ns.l'elspectives in Cardiology. 38-16.

lrmuizlli• Riwtti D II al. (20061. Vaccines fur prwenting illluBl"IZI in tha aldarly. Cochrane Dllllb• Syd llav. 19;3:Cil004876

........... Hlll518d, CH. (2004). MU!u1rition and rubiionllassaament. Pp. 411-415. Hll"rison"s Principles of lnlamal Medicine. 16th edition. Kill*, DL

PnauwUU. Bnwill. D. PressUTe uk:ers: epileniology; pathogenesis; cili:aiiHIRifestltions. Uplolllle. Hose, BD (Ed). UpToDm. Wellesly, MA.

Drilir.CIIIplllni:J AMA.I2006). Physicillns Guide tu Assessing and Counsein; Dlder Drivels. National Highway Tllflic Slfety Administration. CMA. (2006]. Dalllrmining Medical fitness ID Driw: A Guide fur Grabowski DC, Campbell CM, Morrisay MA (2004]. Eldllly a an Lews and Motar 'I& hid& Fill lilies. JAMA. 281 (31: 284().2846. HoganllB.(20071. Synmatic IIYiewltdrMng risk and the ellicacy al carrtensaloryltlltegiel il pmcnwith denmiL JAm Geriatr Soc. 55:878-84.

H .... Caralnllbliau Government of (2007]. Reports on Lang.Tarm Cln1 Homes. Prilllrfor (Mtafio.

Pdllliw ul ml rl Lill Ciln AGS l'lnll on Pmilllnt Pain in Dldlr l'lnans (2002). The of par&iltent pain in oldlr peniOill. J Am Glriltr Soc. 50[61: KnlrNI11, S.(1113l. S)lmptDm man1gamrt in pdii!MI Clll. Dn Continuing l'rll:ticl. 20(1 ): 211-n.

Gariltric Pha•llldiiY Baar& MH criiBria fur datarmiling inappropma madicltion UBI bytha eldarly. An:h 157:1531-1536. Carla JE (1996).1'1rils of polyphlrrnKy: 10 m,.to prudllll prering. Geriatrics. 51(7):26-35. Fick DM, Cooper JN, Wada WE. Willi II" Jl. Macillll It Baars MH (2003).llpdll1ilg tha 811111 Critaril Ill polllllidy inappropri111 medicllion UBI in old II" Ill Wis. hQm Mad, 163: 271&-2724. Fordyce, M.(19991. Geriltric Pearls. Philllllelpbia: FA Lewis. T. (2004) Ulilg the t«l TEAilS tool fur medicltioll rwiert BMJ. 329(74631:434

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