If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you...
Transcript of If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you...
![Page 1: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/1.jpg)
1
If you are viewing this course as a recorded course after the live webinar, you can use the scroll bar at the bottom of the player window to pause and navigate the course.
This handout is for reference only. It may not include content identical to the powerpoint. Any links included in the handout are current at the time of the live webinar, but are subject to change and may not be current at a later date.
![Page 2: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/2.jpg)
11/1/17
1
MedicationsinanAgingPopulation
MichelleA.Fritsch,Pharm.D.,CGP,BCACP
ObjectivesAsaresultofthisContinuingEducationActivity,readerswillbeableto:1)Asktherightquestionstodetermineallmedicationstakenbya
patientandhowtheyaretakenwithemphasisoncommonwarningsigns.
2)Describehowmedicationsimpactsenioradultsdifferentlythanyoungercounterparts.
3)Explainthecommonroleofmedicationsinfalls,negativecardiovascularevents,strokes,andotherlife-alteringevents.
4)Describewhymedicationregimensareoftensolargeandcomplicatedandwhatcanbedonetoreducerisksofcomplexregimens.
5)Usingcases,applytheinformationfromthepreviousobjectivestoriskreductionactionforpatients.
![Page 3: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/3.jpg)
11/1/17
2
Question
Whatisyourprimarypracticesite?a. Hospitalinpatientb. Hospitalbasedoutpatientc. Privateclinicd. Chainclinice. Schoolsystemf. Homebasedcareg. Other
Question
Whatpercentofyourpatients/clientsareoverage65?1. 0-9%2. 10-25%3. 26-50%4. 51-75%5. 76-100%
![Page 4: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/4.jpg)
11/1/17
3
GeriatricMedicationUse
AgingofAmerica
0
10,000,000
20,000,000
30,000,000
40,000,000
50,000,000
60,000,000
70,000,000
80,000,000
90,000,000
100,000,000
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
Num
ber o
f Per
sons
65+
Population 65+ by Age: 1900-2050Source: U.S. Bureau of the Census
Age65-74
Age75-84
http://www.aoa.acl.gov/Aging_Statistics/future_growth/future_growth.aspx#age
![Page 5: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/5.jpg)
11/1/17
4
Medication Interview• Generic and brand name• Use of each medication• Prescription medications• Over-the-counter medications• Vitamins• Supplements• Herbals/nontraditional• How used vs. how prescribed
Medication Interview• Open-ended questions vs closed-ended
questions• Patience• Reminder questions• Follow-up questions• Information-drawing questions
![Page 6: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/6.jpg)
11/1/17
5
Sensory Senescence
VisionHearing
Olfaction/TasteTouch
• Medications can impact these• These can amplify the risks for falls,
nutrition deficiency, dizziness, and more
StartLow;GoSlow
![Page 7: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/7.jpg)
11/1/17
6
WhenUsedProperly
• Medicationscan– Curemedicalconditions– Improvecontrolandoutcomesofmedical
conditions– Alleviatesymptomsofmedicalconditions– Improvefunction/IADLs– Enhancequalityoflife– Enhancequantityoflife
WhenNotUsedProperly
• Medicationscan– Worsenmedicalconditions– Causesideeffects– Decreasefunction– Decreasequalityoflife– Decreasequantityoflife
![Page 8: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/8.jpg)
11/1/17
7
TypesofMedicationRelatedProblems
Needingpharmacotherapybutnotreceivingit.Receivingtoomuchofthecorrectdrug.Receivingtoolittleofthecorrectdrug.Receivingthewrongdrug.Experiencinganadversedrugreaction.Experiencingadrug-drugordrug-foodinteraction.Notreceivingthedrugprescribed.Takingadrugwithnovalidmedicalindication.
![Page 9: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/9.jpg)
11/1/17
8
Question
Mostpeopletaketheirmedicinesasprescribedbytheirdoctorsa. Absolutelyb. Withrareexceptionc. Mostofthetimed. Rarelye. Never
Drugs don’’t work in patients who don’’t take
them.
C.EveretteKoop,M.D.
![Page 10: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/10.jpg)
11/1/17
9
Types of Nonadherence
• Failure to fill prescriptions• Failure to refill the prescription• Omission of doses• Increase in dose or frequency• Errors of dosage• Incorrect administration• Errors in time of administration• Premature discontinuation
Detection of Nonadherence
Insufficient regimen or underprescribingThe groupimportant toidentify
Adherent
Not adherent
Therapeutic goal reached
Yes No
Idealsituation
Overprescribing- or -incorrectdiagnosis
![Page 11: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/11.jpg)
11/1/17
10
Incidence of Nonadherence
• As many as 66% of patient fail to take prescribed medications as directed.
• 50% on chronic regimens stop them after one year• 20-30% of prescriptions never filled• Compliance rates are worse with more frequent
dosing/complicated regimens• Noncompliance rates are higher among low income
groups and those with disabilities• The World Health Organization estimated that by 2020,
the number of Americans affected by at least one chronic condition requirement medication therapy will grow to 157 million
Nonadherence—Economic
Directcostestimatedat$100billionto$289billionannually• Costs$2000perpatientinphysicianvisitsannually• Improvedself-managementofchronicdiseases
resultsinanapproximatecost-to-savingsratioof1:10
• Cost-relatednonadherence reportedby11.4%(~543,000individuals)ofstrokesurvivors,mostlyamongtheuninsuredandyounger(45to64years)
Sources:Ho2009,Circulation;Levineetal.2013,AnnalsofNeurology
![Page 12: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/12.jpg)
11/1/17
11
Adherence for Selected Illnesses
National Council on Patient Information and Education
0
10
20
30
40
50
60
70
DM & CHF
TB
HTN
Schizophrenia
PCN
Prescriptioninterpretation
Youareprescribedamedicationwithinstructionstotakeitthreetimesdaily.Howwouldyoutakeit?1. Threeinthemorning2. Morning,midday,bedtime3. Withyourthreemeals4. Every8hours5. Threeatbedtime
![Page 13: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/13.jpg)
11/1/17
12
CaseExample
• Whitemaninhis50’sinanadherencetrial• Bloodpressuremedicineprescribedthree
timesperday• Bloodpressuremuchdifferentatmorning
clinicvisitsthanatafternoonclinicvisits
Adherence Aids
![Page 14: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/14.jpg)
11/1/17
13
AutomatedDispensingOptions
PharmacokineticsWhatthebodydoestothedrug
![Page 15: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/15.jpg)
11/1/17
14
Absorption
Body
Water
Food
Medication
Commonmedicationscanimpactthis,butagingitselfhaslittleimpact
Distribution
FAT
WATER
Whereinthebodythemedicationgoes
Withaging,totalbodywaterdecreases,totalbodyfatincreases
![Page 16: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/16.jpg)
11/1/17
15
MetabolismBreakdown– howthemedicationisbrokendowninthebody
LiverToamoreorlessactivemetabolite,usuallyless
Someenzymesfailtoactuntilaboutage5;somediminishwithadvancedage
Excretion
Howthemedicationiseliminatedfromthebody- Feces
- UrineRenalfunctiongraduallydeclineswithageafteraboutage40- Medicalconditions(diabetes)- Medications- Othercanfurtherdecreaserenalfunction
![Page 17: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/17.jpg)
11/1/17
16
PharmacodynamicsRelationshipbetweendoseandtherapeutic
responseWhatthedrugdoestothebody
CellularEffects
• Examples– antibiotics– Biologicresponsemodifyingmedications
![Page 18: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/18.jpg)
11/1/17
17
SystemicEffects
• Upregulation ordownregulation ofreceptors• Alterationsinthephysiologicresponseto
medications– E.g.selectiveserotoninreuptakeinhibitorsfor
depression
http://en.wikipedia.org/wiki/Reuptake#/media/File:Reuptake_both.png
Drug Related Morbidity and Mortality
1995: In the United States, drug related morbidity and mortality estimatedto cost $76.6 billion ($30.1-136.8)per year2001: $160 billionNearly 1:1 ratio – spent and treatment related M&MJohnson JA, Bootman JL. Arch Intern Med 1995;155:1949-56Ernst FR, Grizzle AJ. J Am Pharm Assoc 2001;41(2):192-99
![Page 19: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/19.jpg)
11/1/17
18
CaseExamples
StartingDose
• An81yearoldpatientwasexperiencingneuropathicpain
• Shewasstartedongabapentin300mg• Shetookherdoseanddrovetothemall• Acarpulledoutinfrontofherintheparkinglot• Shepushedthepedal…• Andlaunchedhercarontoanothercar
– Shereactedtooslowlytorealizeandchangepedals
![Page 20: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/20.jpg)
11/1/17
19
Mixingprn’s• Policeman’smother• Livedalong– usuallyfine• Onceinawhileneighborswouldcallpolice• Shewouldleaveherhousetoletherdogout,get
disoriented,gotoanotherhouse,getupsetwhencouldn’tgetinclaimingsomeonehadlockedheroutofherhome
• Oneveningswhenshedidn’tfeelgoodshewouldtakeprn painmedicine,sleepmedicine,andanxietymedicine
Alzheimer's• Advanceshavebeenmadetounderstandthe
condition• NOCURE• Bestoptionsmightbeabletostabilizeorslow
progression• Cholinergic
– Startatlowdoseandtitrateupslowly– Risksandbenefitsofsideeffectsandimpacton
disease• Morepromisingoptionsinthefuture
![Page 21: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/21.jpg)
11/1/17
20
donepezil
• Startat5mg• Iftoleratedafter2weeks,increaseto10mg• Perhaps60%noticeabledifferencein
progression• Considerations
– Highlyvariablerateofadvancewiththedisease– Muchdataextrapolation– Qualityvs quantityoflife– ethicalconsiderations
Osteoarthritis
• AmericanCollegeofRheumatologyguidelines2012
• Forpeopleoverage75,TOPICALnonsteroidalanti-inflammatorydrugs(NSAIDs)arerecommendedoversystemic/oralforms
• SystemicNSAIDrisks– Cardiovascular– bloodpressure,heartattack– Renal– decreasedkidneyfunction– Gastrointestinal– ulcers,irritation,bleeding
Hochberg,MC,Altman,RD,April,KT,etal.ArthritisCareRes(Hoboken).2012;64:465-474.)
![Page 22: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/22.jpg)
11/1/17
21
Evidence-Based Medicine (EBM)Why
DiabetesRegimen:• Metformin• Sulfonylrurea - oralmedicine(e.g.glipizide,
glimepiride)• Basalinsulin(e.g.insulinglargine,detemir)• Aspirin• Statinforcholesterol(e.g.simvastatin,
rosuvastatin)• Manyandgrowingnumberofoptions
Evidence-Based Medicine (EBM)Why
HeartFailureRegimen:• Betablocker(e.g.metoprolol succinate,carvedilol)• ACEInhibitororARB(e.g.lisinopril,ramipril)• Loopdiuretic(e.g.furosemide,torsemide)• Thiazide-typesdiuretic(e.g.metolazone)***• Statinforcholesterol(e.g.simvastatin,rosuvastatin)• Aspirin• +/- Digoxin
![Page 23: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/23.jpg)
11/1/17
22
Metolazone
• Thiazide-typediuretic• Unlikeothersinitsclass,stilleffectivewith
diminishedrenalfunctionCrCl <30ml/min• Potent,powerful• Whilepromotingremovalofsodiumand
water,alsoremovingpotassium• Mathteacherexample
PrescribingGuidance
• START• STOPP• Beer’sCriteria
![Page 24: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/24.jpg)
11/1/17
23
BeersCriteria• Developed1991todecreasepotentiallyinappropriatemedications
innursinghomeresidents– Updated1997,2003,andbyAmericanGeriatricSociety2012– Expandedtootherpracticesettings
• Explicitcriteria;validatedinmultiplestudies• Nowincorporatedintopolicies• Medicationstoavoidinolderadults• Medicationpotentiallyinappropriateinolderadultswithparticular
medicalconditions• Medicationstousewithcaution*
– *newin2012update
JAmGeriatrSoc.2012April;60(4):616–631.doi:10.1111/j.1532-5415.2012.03923.x.
STOPPCriteria• TheScreeningToolofOlderPersons’Prescriptions• Medicationstostopingeriatricpatientswith7organ
systems,fallsrisk,analgesics,andduplicativetherapies
• Examples
Int JClin Pharmacol Ther.2008Feb;46(2):72-83
![Page 25: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/25.jpg)
11/1/17
24
STARTCriteria• ScreeningTooltoAlertdoctorstoRight
Treatment• Evidence-basedtherapiestostartforspecific
conditions– Organizedin7organsystems– Cardiovascular– Respiratory– CNS– GI– Locomotor– Endocrine
Screening tool to alert doctors to the right (i.e. indicated, but not prescribed) treatment for older people (START).
Barry P J et al. Age Ageing 2007;36:632-638
Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.
![Page 26: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/26.jpg)
11/1/17
25
Somanyotherfactors
EmptyNest• Formothers,oncethechildrenaregrown
– Youngerkidsas‘onlykids’foratime– Collegetransition– Attentionandcontrol– nolongertheconstantvigilanceover
thechildren– Socialchanges
• Nolongersocializeatchild-relatedevents• Pointofconnectionwithothermotherschanges
– Diet– Transportation– Householdduties– Shopping– Budget
![Page 27: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/27.jpg)
11/1/17
26
PersonalHealth
• Selfimage• Dealingwithhealthchanges
– Whatmightthesebe?• Exercise
– AJisa60yearoldwomanwhohasrecentlylostherhusband.Hertwochildrenareincollegeindifferentstates.Priortothistimeshepracticedsportswithandbikedwithherchildrenuntilgrown.Thenshewalkedmosteveningswithherhusband.Nowwhat?
RelationshipChanges• Growing/grownchildren
– Stories– Roleofchildrenchangesinpersonalhealth– https://www.youtube.com/watch?v=Aw2Bb7d3hSk
• Marriages– childrenin-law• Grandchildren• Agingparents
– Care,concern,loss– ‘Sandwich’stage– https://www.youtube.com/watch?NR=1&v=yMJ4ao-
Zsr8&feature=endscreen– https://www.youtube.com/watch?v=RVj888PT4L8
• Agingspouse
![Page 28: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/28.jpg)
11/1/17
27
RelationshipChanges
Lossofspouse• Responsibilitiesanddecisionsattimeofdeath• Matriarchoffamily– supportvs owngrieving• Surroundedbyfamilythenoftensuddenly
gone– (experiences)
Function
Laterlifefunction=selfcare+environment+genetics
Whatcanbecontrolled?Whendoesthatcontrolexist?
![Page 29: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/29.jpg)
11/1/17
28
ActivitiesofDailyLiving(ADLs)
• Eating• Dressing• Gettinginoroutofbed• Gettinginoroutofachair• Bathing• Usingthetoilet
InstrumentalActivitiesofDailyLiving(IADLs)
• Preparingmeals• Managingmoney• Shopping• Doinghousework• Usingatelephone
![Page 30: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/30.jpg)
11/1/17
29
Care/LivingEnvironments• Independentliving
– Ownhomeorapartment,sameasprioryears– Seniorcomplexorhousingarea– ContinuousCareRetirementCenter(CCRC)
• AssistedLiving– Facilitywherecleaning,food,dressing,bathing,orotherneeded
servicesareprovided– IsacomponentofaCCRC
• Homecare– ProgramofAll-inclusiveCarefortheElderly(PACE)
• Longtermcare– SkilledNursingFacilities(SNFs)– AlsoPACE– Medicaid’sProgramofAll-inclusiveCareforthe
Elderly
Over-the-CounterMedications
![Page 31: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/31.jpg)
11/1/17
30
Whattotakeforpain?
SleepAgents
Diphenhydramine
Melatonin
![Page 32: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/32.jpg)
11/1/17
31
Complimentary&AlternativeMedicines(CAM)
• ‘Natural’• Littlecriteria,oversight
– Notregulated byFDA
• Eachstillwithsideeffects• Limitedscientificevidenceforsafetyorefficacy
- glucosamine - fishoil- probiotics - soy- st. John’swort - chondroitin
AsNeeded‘prn’Medications
• Sleep• Cold• Flu• Headache• Jointpain• Nails• Hair• Vision
• Injury• Allergies• Stomachache• Indigestion• Diarrhea• Constipation• Weightcontrol• Overallhealth
![Page 33: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/33.jpg)
11/1/17
32
SubstanceAbuse
• Alcohol– Liver• Tobacco– Lungs,heart• Marijuana– Lungs,brain• Opiates– GI,brain• Heroin– Brain,heart,GI• Cocaine– Heart,brain
Drugabuse.govhttp://www.politicspa.com/pa-gov-wolf-vows-to-sign-medical-marijuana-bill/63312/
SomeCommonMedicalConditionsApplication
![Page 34: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/34.jpg)
11/1/17
33
Constipation
Bulking Osmotic Stimulant Stoolsofteners
Emollient Chloridechannelactivator
Psyllium$ Magnesiumhydroxide$$
Sennosides$$
Docusatesodium$
Mineraloil$$
Lubiprostone$$$$$$$$
Methyl-cellulose$$
Polyethyleneglycol$$
Bisacodyl$ Docusatecalcium$
Poly-carbophil$$
Lactulose$$
Sorbitol$$-
AdaptedfromEoff JC,etal.OptimalTreatmentofChronicConstipationinManagedCare.JMCP2008;14(9):S3-15
IncreasefluidintakeAddfiber
Higherprevalencewithdecreasedbodywater,decreasedexercise,decreasedfluidconsumption,slowedperistalticmovement
Parkinson’sDisease
• Prevalence:Upto1millionpeopleintheUS• Annualincidence
– 10/100,000ages50-59– 120/100,000ages80-89
• Usualageatdiagnosis55-65• Presentation- Atleasttwoofrestingtremor,
rigidity,bradykinesia withasymmetricalpresentation;posturalinstabilitylater
![Page 35: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/35.jpg)
11/1/17
34
Symptoms
Motor• Decreasedmanualdexterity• Difficultyarisingfromaseated
position• Diminishedarmswingwith
ambulation• Dysarthria• Dysphagia• Festinatinggait• Flexedposture• “freezing”atinitiationof
movement• Hypomimia/maskedfacies• Hypophonia• Micrographia
Autonomic&Sensory• Bladderandanalsphincter
disturbances• Constipation• Diaphoresis• Fatigue• Olfactorydisturbance• Orthostaticbloodpressurechanges• Pain• Parasthesia• Paroxysmalvascularflushing• Seborrhea• Sexualdysfunction• Sialorrhea
Treatment
• Dopamine• Carbidopa/levodopa• Dopamineagonists• COMTinhibitors• MOA-Binhibitor
![Page 36: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/36.jpg)
11/1/17
35
69Cartoon:http://fb.img.v4.skyrock.net/fb9/e-ide/pics/2059425594_small_1.jpg
VIDEO- https://www.youtube.com/watch?v=sf1N0Zf5IqA&feature=related
EarlyManagementFig68-4DiagnosisPD
NonRx:EducationExerciseNutrition
Psychsocial support Considerrasagiline
Needforadditionalsymptomatic
control
Tremor
Bradykinesia,rigidity,tremor
Rx
Consideranticholinergicoramantadine
Consideramantadine
Addamantadine,dopamineagonistorcarbidopa/levodopa
Addamantadine,dopamineagonist,orcarbidopa/levodopa
<65years* >65years*
![Page 37: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/37.jpg)
11/1/17
36
EarlyManagement,Fig68-4
Managementofmotorfluctuations:•Increasedosingfrequencyof
levodopa•AddMAO-BinhibitororCOMT
inhibitor•Addadopamineagonist
Managementofpeak-dosedyskinesia•Reducedopaminergic drugdose
•Addamantadine
Needformoresymptomaticcontrolofmotor
complications(despiteoptimizedpharmacotherapy):
Considersurgery
Frompreviousslide
Incontinence
• 200millionpeopleworldwide• Prevalenceashighas55%(dataranges20-70%)• Relationshiptoisolation• Relationshiptodepression• Relationshiptodehydration• Manyofthemedicationshaveanticholinergic
action(drying– impactsvision,drymouth,constipation,urinaryoutflow)
WoodLaurenN,AngerJenniferT.UrinaryincontinenceinwomenBMJ2014;349:g4531
![Page 38: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/38.jpg)
11/1/17
37
TypesofIncontinenceStress Urge Overactive
BladderOverflow Functional Mixed
Urinarysphincter
Detrusormuscleoveractivity
Detrusormuscle,ifincontinence
Urethraloveractivity&/orbladderunderactivity
Physicalorcognitivereasons
Combinationoftypes
α-adrenergicblockers;topicalestrogens;SSRIorSNRI
Antimuscarinic/anticholinergicorTCA
Sameasagentsforurge
α-adrenergicblockers;5-α reductaseinhibitors orantispas-modics;Cholino-mimetics
Removebarriers,useschedules,reviewneedforassistance
OwensNJ,EstusEL.RenalandUrologicDisorders.In:HutchisonLC,SleeperRB,eds.FundamentalsofGeriatricPharmacotherapy.Bethesda,MD:AmericanSocietyofHealth-SystemPharmacists,Inc.;2010;page202.
Vision
• Dryeyes• Uncorrectedvisionimpairment• Infection• Cataracts• Maculardegeneration• Glaucoma• Medicationsideeffects• Other
![Page 39: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/39.jpg)
11/1/17
38
Glaucoma– treatmentoptionsBeta-blockers Prostaglandin
analogsAlphaadrenergic
agonistsCarbonicanhydraseinhibitors
Cholinergicagents
AH production outflow AH production+outflow
AHproduction outflow
1st line Alternate1st
lineBrimonidine
alternate1st line2nd line
(systemicare3rd
line)
Lastline
MostBID At night MostBID-TID MostBID-TID MostBID-TID
Cautions:Heartfailure,bradycardia,asthma, COPD
Long-termusecanleadtomacularedema
Cautions:Cardiovascularorcerebrovasculardisease
Monitorwithage-relateddecreaseinrenalandhepatic function
Cautions:Parkinson’sdisease; longtermusemayleadtocataracts
AH– AqueousHumor
AdaptedfromJonesMD,Chapter61Glaucoma,inPharmacotherapyPrinciplesandPractice,2nd edition,2010:page1038
Osteoporosis
• Riskfactors• Calcium• VitaminD(buildingblocks)• Bisphosphonates
![Page 40: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/40.jpg)
11/1/17
39
OsteoporosisTreatmentForapatientwithaT-score<-2.5and/oralow-traumafracture-bone-healthylifestyle-Calcium1200mg/day-VitaminD800-1,000units/day-DrugTherapy
-1st line– bisphosphonates-2nd line– teriparatideorraloxifene-3rd line– intranasalcalcitonin
Reevaluatebonemineraldensity(BMD)in1-2years
AdaptedfromDiPiroJT,etal,eds.Pharmacotherapy:aPathophysiologicApproach,2011:figure99-3,page1567.
MetabolicSyndrome
Components• Diabetes• Hypertension• Cardiovasculardisease• Weight• Smoking• Diet• Excercise
Outcomes• Myocardialinfarction(MI)• Stroke(CVA)• Heartfailure• Neuropathy• Visiondecline• Wounds• Amputation
![Page 41: If you are viewing this course as a recorded course after the live … · 2018. 2. 2. · 1 If you are viewing this course as a recorded course after the live webinar, you can use](https://reader033.fdocuments.us/reader033/viewer/2022052015/602c77a6d19e3854dc09d856/html5/thumbnails/41.jpg)
11/1/17
40
Falls
Risks• Rugs• Pets• Steps• Otherenvironment• Cognition• MEDICATIONS
– Bloodpressure– Incontinence– Allergies– Mood– CNS– seizures,neuropathy,…– Manymore
Outcomes• Gaitchanges• Restrictedactivities• Surgery• Ambulationassistance
devices• Isolation• Dependence• Assistedliving• Skilledcare
MedicationsinanAgingPopulationSummary
• Thebodychangesphysiologicallywithage• Thesechangescanimpactmedicationeffect• Understandhowyourpatientactuallytakestheir
medications• Includethemedicinestheyselectforthemselves–
OTC,CAM,prn,vitamins,supplements• Considerlifestylechangesthatoftenaccompanyaging
impactingsleep,safety,isolation,nutrition,andmore• Remembertheadage,STARTLOW– GOSLOWiskeyto
medicationuseinanagingpopulation