Kroustos

1. Identify opportunities to perform a medication review in the elderly population when

a new symptom and/or health related complaint presents in an elderly patient.
a. Any chance you have, you should do it
b. 28% of ADEs were preventable if a med review was done
i. Most common
1. Prescribing
2. monitoring

2. Identify the role of the medication use criteria within the health care system and the
care of senior patients.
a. Improve medication selection, educate clinicians and patients, reduce ADEs and
serve as a tool for evaluating quality of care, cost and patterns of drug use of
older adults

3. Understanding the elements involved in inappropriate prescribing

a. Inappropriate prescribing involved acts of commission and omission
i. Commission: way too much
ii. Omission: not enough
iii. Based on implicit and explicit criteria
1. Risks do not equal benefits
2. Duplication and drug-drug interactions
b. Rational prescribing: prioritize based on the following information
i. Time until benefit
ii. Goals of care
iii. Treatment targets
iv. Remaining life expectancy

4. Review which medication use criteria alerts prescribers to the indicated medication
although it is not prescribed
a. START (Screening Tool to Alert doctors to the Right Treatment) criteria
i. Focuses on multiple acts of prescribing omissions
ii. Looks at prescribing indicators

5. Anticipate medication related responses and/or clinical outcomes in the elderly

patient for CV medication
a. Decreased stroke vol, cardiac output, organ profusion
b. Increased risk of HF and increased arterial stiffness
c. Peripheral alpha1 blockers (Doxazosin, Terazosin)
i. Orthostatic HTN
6. Identify the role of nutritional supplementation and the ideal administration of this
intervention in the senior population.
a. Change in appetite
i. Changes in GI system and metabolism
ii. Taste is altered
iii. Altered dentition
iv. Socioeconomic
v. Isolation/depression/mobility
vi. Disease states/Medications
b. Body composition
i. Decreased lean muscle mass, serum albumin, total body water
ii. Increased body fat
c. Intake requirements
i. Prone to dehydration
1. 30 mL/kg or 1.5-2 L/day
d. Liquid calorie supplements= Ensure
i. Used between meals

7. Understand the specific population the medication use criteria was designed to
evaluate
a. Identifies Potentially Inappropriate Medication (PIM)
b. Risk vs. benefit
c. Duplication and drug-drug interactions
d. ALL settings of geriatric care

8. Recognizing the impact of declining renal function in the elderly patient

a. Function decreased 1% for every year after 40 yo or 7% per decade after 30 yo
b. Scr is a poor indicator of renal function
i. Decrease in renal blood flow and CrCl
ii. Scr appears normal due to decreased muscle mass
iii. CrCl=(140-age)(weight) /[72(Scr)]
1. If female multiply by .85
c. Decreased renin activity
d. Decreased urinary aldosterone
i. Decreased Na re-absorption helps contribute to hypovolemia
e. Decreased excretion speed
i. Increased time urine sits in bladder, increased chance for UTI
f. Decreased sphincter muscle tone incontinence
9. Relating side effects of medication and pathophysiologic changes to risk factor for falls
a. Antiepileptics (clonazepam, lamotrigine, valproate, gabapentin), antipsychotics
(risperidone, quetiapine, olanzapine, aripiprazole), BZD (alprazolam, diazepam,
lorazepam), non-BZD (zolpidem), TCAs (amitriptyline), SSRI (citalopram,
escitalopram, paroxetine, fluoxetine, sertraline), SNRI (duloxetine, venlafaxine),
opiods
b. Ability to produce ataxia, impaired psychomotor function, syncope and
additional falls (short acting BZD not safer than longer acting)
c. Rec: avoid unless alt not available; avoid anticonvulsant except for seizure
disorder

10. Recognize secondary issues surrounding delayed gastric emptying in the elderly
a. Increased intestinal transit time
b. Appetite is decreased (early satiety)
c. Delays onset of action of some medications

11. Understanding anorexia-cachexia syndrome and response to treatment

a. Characterized by:
i. Significant weight loss, alterations in body composition, anorexia, early
satiety, weakness, edema
b. Due to chronic disease (NOT diet)
c. Decreased nutritional intake stimulates increased endorphin production
d. Decreased fluid intake stimulates increased dynorphin levels
i. Natural analgesics
e. Anorexia leads to ketoacidosis feel full
f. Replace “need to feed” with “ways to help”

12. Selecting medication used to increase appetite

a. Mirtazapine (Remeron): 7.5-15 mg QHS for 4-8 wk
i. Increases serotonin and NE release
ii. Increase appetite, promote weight gain
b. Metoclopramide (Reglan)
i. Increases gastric emptying (will NOT increase food intake)
ii. EPS is limiting side effect (>40mg but elderly more sensitive)
c. Dronabinol (Marinol): 2.5-5 mg BID
i. Indicated for treatment of anorexia in pts with AIDs
ii. ADE: dizziness, confusion, somnolence, tachy
d. Magesterol (Megace): 400-800 mg/day
i. Treatment of cachexia in pts with AIDs or cancer
ii. Increased risk of thrombotic events
e. Steroid (Prednisone 10-20 mg or Dexmethasone 2-4 mg)
i. 50% respond but generally only last a few weeks
ii. Energy, mood, pain relief, help with breathing
 13. Anticipate potential medication-related issues in an elderly pt with advanced COPD
a. Proper medication use (proper inhalation)

14. Understanding medication-related risks associated with management of symptoms in

an elderly patient with heart failure
a. Diuretics (furosemide) dehydration, hypokalemia
b. BB (carvedilol, metoprolol) hypotension, bradycardia
c. ACEI (lisinopril, enalapril) dehydration, sepsis, increased renal toxicity
d. Aldosterone Antag (spironolactone) hyperkalemia if renal insufficiency
e. Inotrope PO (digoxin) toxicity (N/V, anorexia, confusion, arrhythmia)

Leonard
1. MRSA nasal screenings can be useful for d/c of anti-MRSA therapy in certain patients
if the screen is negative. A positive result requires a follow up culture because positive
predictive value is not high.

2. Review treatment of inpatient non-severe CAP

a. Beta lactam (cefepime, imipenem, meropenem, pip/tazo) + macrolide OR
respiratory FQ ALONE
b. IF SEVERE: beta lactam +macrolide or beta lactam + FQ

3. First is that if it is flu season (Dec-Feb) the patient should be tested for influenza.
Second is pick the appropriate CAP regimen
a. Outpatients
i. No comorbidities
1. Amoxicillin or doxycycline or macrolide
ii. Comorbidities
1. Amox/clav or cephalosporin AND macrolide or doxycycline OR
monotherapy FQ

4. Prevention is important and vaccinations are one of the easiest and best ways to do it
regardless of age
a. Both pneumococcal vaccines
b. Yearly flu (high dose)
c. Zoster vaccine

5. It is important to recognize that elderly patients may present differently than younger
patients and that the relative incidence of certain types of infections can be different
in the elderly population
a. Lethargy, confusion, worsening of other chronic disease state, fever
 6. Review the many mechanisms by which the immune system declines with age
a. Thinning of skin, diminished cough reflex, changes in genitourinary
anatomy/physiology that impair bladder capacity and emptying
b. Immunosenescence = decline in immune function brought on by natural age
i. Age related dysregulation of inflammation
ii. Decrease in TLR leads to decreased function of neutrophils, monocytes
and dendritic cells

7. Review the Cockcroft-Gault equation for creatinine clearance. Remember for elderly
with SCr < 1, you should use 1 g/dL. However, if the SCr is 1 or greater, use that #.
a. CrCl=(140-age)(weight/[72(Scr)]
i. If female multiply by .85

8. Fever definition in elderly

a. Blunted or absent fever may occur in up to a 3rd of infected older persons
i. A single oral temp of greater than 100 F
ii. Repeated oral temp greater than 99 F
iii. Rectal temp greater than 99.5 F
iv. Increase in temp more than 2 F from baseline

9. Clinical setting as diagnostic approach

a. Relatively healthy
i. Respiratory infections
ii. UTIs
iii. GI infections
b. Underlying diseases
i. Damaged heart valve endocarditis
ii. Rheumatoid arthritis septic arthritis
iii. Chronic indwelling catheter UTI/urosepsis
c. Hospitalized
i. Aspiration pneumonia
ii. UTI
iii. IV line
iv. Infected pressure ulcers

Musser
1. Some guilding principles for safe medication use, including cv meds, include:
a. Be aware elderly patients are more likely to experience side effects
b. Renal function decreases with age, so dosing should be evaluated for adjustment
c. Meds for CVD sometimes focus on reducing long-term risk, which may not be a
practical concern for geriatric patients
d. Doses should generally be started at lower doses and titrated slowly
e. Drug therapy should be carefully monitored and adjusted when needed based
on patient needs including side effects
 2. Despite the patients age, the first priority for treatment of a patient with afib is to
consider the need for anticoagulation using a risk stratification method (CHADS-VASc).
Geriatric patients are at increased risk for a stroke secondary to afib and would benefit
from anticoagulation. However, geriatric patients are also at increased risk for bleeding,
so individual evaluation of risks and benefits should be considered. Counseling should
include a discussion of bleeding risk and falls prevention/management. Anticoagulants
should be dosed properly including renal adjustments for DOAC agents and selecting
lower starting dose for warfarin. A secondary goal for patients include rate or rhythm
control of afib. Although rate control may be preferred in elderly patients due to a lower
risk of side effects, rhythm control may be needed in symptomatic patients. An
evaluation of risks and benefits of each method should be considered on an individual
basis.

3. It is essential to treat the patient, not the number when assessing BP. If your patient is
symptomatic (dizzy, falling) then this needs addressed. Options for patients with low
blood pressure include, assessing medications.

4. Ibuprofen use is not recommended due to causing fluid retention, worsening diseases
like HF, bad for the kidneys, and increasing bleeding risk which can be a complication for
patients on antithrombotic agent.

Sobota
1. Review falls prevention program that is supported by government and state business
partners
a. Falls Prevention Awareness Day sponsored by NCOA
b. Ohio Department of Aging
i. STEADY U
1. Meant for everybody
ii. A Matter of Balance
1. Free, community and lay-led small group workshops; tai chi
c. Ohio Department of Health
i. OIPP
1. Teaches Tai Chi and supports STEADY U and matter of balance
d. STEADI

2. Know the two program that seniors can complete in approximately 2 months the help
view falls as controllable, increase activity levels, and build strength to prevent falls.
a. A matter of balance
b. Stepping On

3. Know the STEADI program and its integration into your workplace
a. Created by CDC for HCPs; Stopping Elderly Accidents, Deaths and Injuries
b. Integration of STEADI is part of medical practice and reimbursed by Medicare