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GERIATRIC PHARMACONSIDERATIONS

John C. Darnell PharmD, BCACP

Objectives

� Evaluate the safety and efficacy of various

medications in the older adult patient population

� Identify medications to be used cautiously or avoided altogether in older adult patients

� Recommend safer alternatives for specific conditions

Providence Health

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Providence Health & Services- Large, integrated health system

Oregon Region• 8 acute care facilities (25-500 beds)

• Providence Portland Medical Center (483 beds)

• Providence St. Vincent Medical Center (523 beds)

• Over 100 medical clinics (Oregon, SW Washington)

• Specialty Pharmacy and Home Services

• Ambulatory Geriatrics clinics

• Providence Health Plan- >400,000 member lives

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PMG Clinical Pharmacy Department

• A non-distribution pharmacy service providing

clinical, educational and operational support to the PMG employed physician practices

• Employs a combination of centralized and de-centralized services

• Goal: To support high-quality, evidence-based, cost-effective medication therapy

Acknowledgements

� Kristy Butler, PharmD, BCPS, BCACP, FASHP

� Jonathan White, PharmD, BCACP

� Chelsea Mannebach, PharmD, BCPS

� Vickie Poremba, PharmD

� Johanna Thompson, PharmD,

Outline

� Background

� Metabolic changes in the elderly

� Beers List Updates:

� Pearls in Prescribing:

� Diabetes Mellitus

� Hypertension

� Hyperlipidemia

� Benzodiazepines

� Anticoagulants

� Anticholinergics

� Take Home Principles

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Polypharmacy

� Unclear definition as there is no “minimum number”

� 5 – 10?

� Any inappropriate, unnecessary, or excessive medication

� Leads to numerous potential problems

� Drug/drug inx, adverse effects, “prescribing cascade”…

Google image. Polypharmacy.

Aging Population

� Of patient’s 65 years of age or older:

� 20% have five or more chronic diseases

� 50% are on five or more medications

� Account for 34-40% of Rx and OTC meds

� Increasing number of providers

N Engl J Med 2004; 351(27):2870

So why is this a concern?

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Polypharmacy Problems in Older Adults

� Overuse of Medications

� Underuse of Medications

� Non-adherence

� Use of potentially inappropriate medications

� Adverse drug events

� Drug interactions

� Changing pharmacodynamics…

J Am Geriatr Soc 2015;1-20.

Physiologic Changes with Age

Elliot DP. Pharmacokinetics and pharmacodynamics in the elderly. In: Schumock G, Brundage D, et al., eds. Pharmacotherapy Self Assessment

Program, 5th ed. Lenexa, KS: American College of Clinical Pharmacy, 2004:115-130.

Organ

System

Resulting Effect on PK

GI ↓ absorption of drugs and nutrients

Skin ↓ drug reservoir formation with

transdermal formulations

Body

Composition

↑ Vd of lipid-soluble drugs

↓ Vd of water-soluble drugs

Liver ↓ clearance of drugs with a high first-

pass metabolism

Renal ↓ renal elimination of many

medications

Pharmacokinetic Changes

� Absorption� ↑ risk ulceration from ASA, NSAIDS

� Transdermal formulations require a subQ fat layer to form a drug reservoir for absorption – caution in thin, cachetic pts

� Distribution� Lipid-soluble benzodiazepines have ↑ half life

� Albumin-bound drugs have larger fraction of free drug

� Metabolism� Changes in metabolism through phase I (oxidative) and

cytochrome P450(CYP) enzymes are variable

� Elimination� Drugs eliminated through glomerular filtration must be dosed on

the basis of individual estimated renal function

Elliot DP. Pharmacokinetics and pharmacodynamics in the elderly. In: Schumock G, Brundage D, et al., eds. Pharmacotherapy Self Assessment Program,

5th ed. Lenexa, KS: American College of Clinical Pharmacy, 2004:115-130.

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BEERS Criteria

� Published in 1991 by Dr. Mark Beers

� Expert consensus developed through extensive literature review and questionnaire evaluations

� Adopted by the CMS in July 1999 for nursing home regulation

� 53 individual medications or classes to avoid in the

elderly

� Not “contraindicated” but “potentially inappropriate”

� Use could be justified by special circumstances

Slide courtesy of Kristy Butler, Polypharmacy:Too Much of a Good Thing. Accessed 2/6/2015.

BEERS Criteria

� Focus on “high(est) risk” medications

� Benzodiazepines

� Tertiary-amine TCAs (amitriptyline, imipramine, doxepin)

� Metoclopramide, chlorpromazine

� Anticholinergics/antihistamines

� Narrow Therapeutic Index

� Phenytoin, digoxin, lithium, theophylline

Slide courtesy of Kristy Butler, Polypharmacy:Too Much of a Good Thing. Accessed 2/6/2015.

Beers Criteria 2015 Update

� Use of nitrofurantoin has been extended to those with CrCl > 30 ml/min

� long term use still not recommended

� Z-drugs (zolpidem, et. al) are still bad

� risk of falls, fractures

� Avoid use of proton pump inhibitors beyond 8 weeks in the absence of justification

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Pearls in Prescribing: Diabetes

Pearls: Diabetes

� ADA goals do not specifically mention age

� Most adults A1c < 7%� Same for older patients that are functionally/cognitively intact

� Individualized goals are important

� Less stringent goals (A1c 7-8%) for those with:� History of severe hypoglycemia

� Limited life expectancy (<5 years)

� Advanced diabetes complications/extensive comorbid conditions

� Long duration of diabetes (>10 years)

� < 8.5% for “very complex/poor health”; limited life expectancy

Diabetes Care 2012; 35(12): 2650-2664

Diabetes Care 2015; 38(1)

Pearls: Diabetes

� Cohort study: all-cause mortality in age 50+

� “Happy place” = A1c 7.5%

Metformin plus sulfonylureas Insulin-based regimen

Lancet 2010;375(9713):481-9

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Pearls: Diabetes

Drug to Avoid Concerns Safer Alternatives

Glyburide

(Diabeta)

Prolonged hypoglycemia

(especially with renal

dysfunction)High “failure rate”

Glipizide, glimepiride

Other drugs: metformin,

sitagliptin, insulin

“Sliding-scale”

insulin

Risk of hypoglycemia

(dosing mistakes)

Poor efficacy

Fixed dose:

• Basal insulin +/- rapid-

acting meal-time insulin• Mixed insulin (70/30)

Pioglitazone

(Actos)

Edema, worsening HF Metformin, sitagliptin, insulin

What about the new drugs?

� SGLT-2 inhibitors (Invokana®, Farxiga®)

� GLP-1 agonists (Victoza®, Bydureon®)

� Generally:� Not good coverage � donut hole

� Not good candidates

� Stick to the basics � metformin, insulin, sitagliptan,

glipizide

Pearls in Prescribing: Hypertension

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Pearls: Hypertension

� Individualized goals are important

� BP goals from “JNC8”

Patient group Goal Initial therapy Notes

General population, aged

60+

< 150/90 Thiazide, CCB,ACEI, or ARB

If BP is < 140/90 and well-tolerated, do not need to adjust

Patients with DM or CKD, aged 60+

< 140/90* ACEI or ARB CKD = est. GFR < 60 ml/min or albuminuria (> 30 mg/dL)

*KDIGO recommendations for patients with CKD

• albuminuria < 30 = goal ≤ 140/90

• albuminuria ≥ 30 = goal ≤ 130/80

JAMA 2014;311(5):507-520.

Kidney International Supplements 2012; 2.

Pearls: Hypertension

Drug to Avoid Concerns Safer Alternatives

Alpha-blockers

(prazosin, terazosin,

doxazosin)

Orthostatic hypotension,

increased stroke risk

Thiazides (HCTZ)

ACEI (lisinopril)

ARB (losartan)

CCB (amlodipine)

BB (metoprolol, etc.)Clonidine Orthostatic hypotension,

bradycardia, drowsiness,

withdrawal syndrome

Vasodilators

(hydralazine)

Risk of syncope, frequent

dosing

Pearls in Prescribing: Lipids

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Pearls: Lipids/Statins

� Recommendations for patients > 75

� Continue statin if already taking and tolerating

� Use moderate-intensity statin for secondary

prevention

� Data do not clearly support statins for primary prevention

� Consider comorbidities, safety, priorities of care

Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic

Cardiovascular Risk in Adults. Circulation 2013.

Pearls: Lipids/Statins

� Secondary prevention trialsStudy Population Patient

age

Comparison Outcomes RRR NNT

PROSPER Vascular dx or high

risk

70-82 Prava 40 vs. placebo

Death/MI/CVA

CHD death/MI

15%

19%

4848

SAGE CHD 65-85 Atorva 80 vs. Prava 40

CV eventsMortality

29%77%

--37

HPS, elderly

CHD or risk equivalent

75-80 Simva 40 vs.placebo

CV events 20% 18

4S, elderly

CHD 65-70 Simva 20 vs. placebo

Mortality

CHD death

CV events

34%

43%

34%

1617

10

Bold text indicates statistically significant result

Circulation 2007;115:681-683.

Clin Interv Aging 2008 Jun; 3(2): 299–314.

Pearls: Lipids/Statins

� Primary Prevention Trials

Study Population Patient

age

Comparison Outcomes RRR NNT

CARDS, elderly

T2DM 65-75 Atorva 10 vs. placebo

MortalityCV events

Stroke

22%38%

49%

--21

--

ASCOT-LLA,

elderly

HTN 65-79 Atorva 10 vs. placebo

CHD death/MI 36% 83

Bold text indicates statistically significant result.

Circulation 2007;115:681-683.

Clin Interv Aging 2008 Jun; 3(2): 299–314.

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Pearls: Lipids/Statins

� Adverse effects: trial data in older patients

� AST/ALT >3x ULN: 0.03-4.8%

� Myalgias: 5-10%

� CK > 10x ULN: 0-1%

� Rhabdomyolysis: 0-0.06%

� Monitoring

� ALT/AST and CK levels should not be routinely monitored; check if symptoms are present

Circulation 2007;115:681-683.

Clin Interv Aging 2008 Jun; 3(2): 299–314.

Australian Prescriber 2013; 36:79–82.

Pearls: Lipids/Statins

� Adverse effects: other concerns

� Cognitive impairment

� Lacking data to support an association

� If occurs, appears reversible on discontinuation

� Diabetes

� Moderate evidence that statins are associated with increased risk of diabetes

� Higher risk with higher potency or higher dose?

Circulation 2007;115:681-683.

Clin Interv Aging 2008 Jun; 3(2): 299–314.

Australian Prescriber 2013; 36:79–82.

Pearls: Lipids/Statins

� In older adults (think age 75-82)

� Secondary prevention

� Moderate-intensity statin

� Good evidence supports decreased CV events (1-3 years)

and mortality (5 years)

� Primary prevention

� Some evidence supports decreased CV events, mortality

� Look for key comorbidities: DM, HTN

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Benzodiazepine Use in Older Adults

Benzodiazepines: Older Adults

� High prevalence of use among patients > 65 years

of age (13-23%)

� Frequently prescribed for institutionalized pts

� United States National Nursing Home Survey: Of all the psychotropic prescribed for patients > 65 years of age, 41% anti-anxiety agents

European Journal of Clinical Pharmacology 59:669–676, 2003.

Practical Geriatrics 55:233-235.

Benzodiazepines: Older Adults

� Age-related alterations in CNS receptors

� Increased sedation, unsteadiness, memory loss, disinhibition

� Increased risk of additive adverse effects

� Simultaneous use of multiple medications

� Greater risk of sedation

� Dementia

Greenblatt DJ, Shader RI: Benzodiazepines in the elderly: pharmacokinetics and drug sensitivity, in Anxiety in the Elderly. Edited by Salzman C,

Lebowitz BD. New York, Springer, 1991.

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Benzodiazepines:

BEERS Recommendation

� Avoid if possible

� SSRI’s 1st line for anxiety

� Risks of benzodiazepine use� Dementia and cognitive impairment

� Falls or fractures� Risk factors: ataxia, impaired psychomotor function,

syncope, falls

� Shorter-acting benzodiazepines are not safer than longer-acting benzodiazepines

Drug Safety 21:101–122, 1999

CNS Drugs 825–837, 2003

Benzodiazepines:

Comparative Properties

ACCP: Updates in Therapeutics: The Pharmacotherapy Preparatory Review and Recertification Course, 2014 Edition.

Brand

Name

Generic Name Approved

Dose Range

(<65 yo)

Elimination

half-life

(hours)

Active

metabolite

Xanax Alprazolam 0.5-10 mg/d 12-15 Not significant

Klonopin Clonazepam 0.5-4 mg/d 20-50 Not significant

Valium Diazepam 2-40 mg/d >100 N-DMDZ

Librium Chlordiazepoxide 15-100 mg/d >100 N-DMDZ

Ativan Lorazepam 1-10 mg/d 10-20 None

Serax Oxazepam 30-120 mg/d 5-14 None

Restoril Temazepam 7.5-30 mg/d 4-18 None

Benzodiazepines:

Comparative Properties

ACCP: Updates in Therapeutics: The Pharmacotherapy Preparatory Review and Recertification Course, 2014 Edition.

Brand

Name

Generic Name Approved

Dose Range

(<65 yo)

Elimination

half-life

(hours)

Active

metabolite

Xanax Alprazolam 0.5-10 mg/d 12-15 Not significant

Klonopin Clonazepam 0.5-4 mg/d 20-50 Not significant

Valium Diazepam 2-40 mg/d >100 N-DMDZ

Librium Chlordiazepoxide 15-100 mg/d >100 N-DMDZ

Ativan Lorazepam 1-10 mg/d 10-20 None

Serax Oxazepam 30-120 mg/d 5-14 None

Temazepam 7.5-30 mg/d 4-18 None

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Benzodiazepines: Tapering

� Taper can take months and should not be rushed

� Taper schedule should be individualized

� Sporadic or intermittent use may not require taper regimen

� Chronic daily use: Calculate the total daily dose and determine diazepam equivalent dosing, then:

� Taper by 10% total diazepam equivalent dose every 1-2 weeks until the dose is 10% of the original � then taper by 5% every 2-4 weeks

American Journal of Psychiatry 146:1242–1243, 1989

NEW ANTICOAGULANTS IN OLDER PATIENTS

Anticoagulation: Overview

� Warfarin has been the “gold standard” for many

years

� Since 2010, several new oral anticoagulants

(NOACs) have been approved:

� Dabigatran (Pradaxa)

� Rivaroxaban (Xarelto)

� Apixaban (Eliquis)

� Edoxaban (Savaysa) – approved 1/2015

CGS Journal of CME 2014; Vol 4, Issue 1: 18-20.

9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST Feb 2012.

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Anticoagulation: Assessment

Thrombosis Risk Factors

VTE: time of clot,

recurrence, thrombophilia

AF: CHADS2

Valve: depends

on type and

placement

Bleed Risk Factors

Previous stroke

Previous bleed(s)

Renal/liver disease

Age > 65

Drugs (antiplatelets,

NSAIDs, alcohol)

Anticoagulation: Overview

� Concerns about NOACs (especially in older

patients):

1. Is efficacy similar?

2. Is bleed risk similar?

3. Lack of reversal agents

4. Renal insufficiency

5. Drug interactions

Concern 1: Efficacy

� How many pts > 75 were studied?

� Thousands across the trials

� Recent meta-analysis

� Gathered data from various RCTs on NOACs in patients > 75 years

� Compared thrombosis and bleeding rates

Sardar P, Chatterjee S, Chaudhari S, et al. New Oral Anticoagulants in Elderly Adults: Evidence From a Meta-analysis of Randomized Trials. J Am

Geriatr Soc 2014;62(5):857-864.

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Concern 1: Efficacy

Trial Intervention Control Age > 75 on

NOAC, n

ROCKET-AF Rivaroxaban Warfarin 3,082

ARISTOTLE Apixaban Warfarin 2,743

RE-LY Dabigatran Warfarin 4,828

EINSTEIN Rivaroxaban Enoxaparin/warfarin 215

EINSTEIN-PE Rivaroxaban Enoxaparin/warfarin 441

AMPLIFY Apixaban Placebo 220

RE-MEDY Dabigatran Warfarin 140

Total 11,669

Sardar P, Chatterjee S, Chaudhari S, et al. New Oral Anticoagulants in Elderly Adults: Evidence From a Meta-analysis of Randomized Trials. J Am

Geriatr Soc 2014;62(5):857-864.

Concern 1: Efficacy

� Take Home Message:

� NOACs significantly reduced stroke and systemic embolism in AF versus conventional therapy (OR 0.65; 95% CI 0.48-0.87)

� NOACs significantly reduced VTE and VTE-related death versus conventional therapy (OR 0.45; 95% CI 0.27-0.77)

J Am Geriatr Soc 2014;62(5):857-864.

Concern 2: Bleed Risk

� Take Home Message:

� NOACs did not cause significantly more major or clinically relevant bleeding vs. conventional therapy (OR 1.02; 95% CI 0.73-1.43)

� Rivaroxaban and dabigatran “trended” toward more bleeding

� Apixaban appears to have lowest bleed rates

J Am Geriatr Soc 2014;62(5):857-864.

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Concern 2: Bleed Risk

� What about all those reports about more bleeding

with NOACs?

� Many included individuals with multiple comorbidities, like renal impairment

� Bleed risk may be more related to comorbidities (CKD, low weight, drug interactions) than age alone

J Am Geriatr Soc 2014;62(5):857-864.

Concern 3: Reversal

� Yes, there are no specific reversal agents

� However:

� NOACs have short half-lives

� Unclear whether hemorrhage on warfarin is less devastating

� Can rapidly reverse INR � but morbidity and mortality remain high

J Am Geriatr Soc 2014;62(5):857-864.

Concern 4: Renal Insufficiency

� All NOACs are renally cleared

� Renal function declines with age

� Dose must be adjusted based on CrCl

Drug CrCl > 50 CrCl 30-50 CrCl 15-29 CrCl < 15

Dabigatran(Pradaxa)

No adjustment

No adjustment US: 75 mg BIDOther: AVOID

AVOID

Apixaban(Eliquis)

No adjustment

No adjustment A-fib: see below*

AVOID AVOID

Rivaroxaban(Xarelto)

No adjustment

A-fib: 15 mg daily

AVOID AVOID

Edoxaban(Savaysa)

AF: do not

use if > 95

No adjustment 30 mg daily* AVOID

Lexi-Comp Drug Database. Accessed via Up-To-Date through PMG Intranet

9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST Feb 2012.

*If 2/3 present: Age > 80, SCr > 1.5 mg/dL, or BW < 60 kg, reduce to 2.5 mg BID

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Concern 4: Renal Insufficiency

� NOACs not studied in advanced CKD/ESRD

� Trials excluded patients with CrCl < 25-30 ml/min

� Anticoagulant levels can be markedly increased and elimination significantly prolonged

� Choose an alternate anticoagulant (e.g. warfarin) for

advanced CKD

Lexi-Comp Drug Database. Accessed via Up-To-Date through PMG Intranet

9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST Feb 2012.

Concern 5: Interactions

� Drug interactions

� Not as many as warfarin, but still problematic

� Increase: Amiodarone, ketoconazole, itraconazole, clarithromycin

� Decrease: rifampin, carbamazepine, St. John’s Wort

� Look them up; there are lots of nuances!

� Example: Renal insufficiency (CrCl 30-80 ml/min) + a drug that increases anticoagulant levels = may need to avoid

NOAC

Anticoagulants: Bottom Line

� Effective for preventing thrombosis

� Respect quality of life!

� Similar bleed risks vs. conventional therapy

� Apixaban appears to have lowest bleeding rates

� Dabigatran and rivaroxaban “trend” toward more bleeding

� More GI bleeding seen with both in pivotal trials

� Be wary of renal dysfunction

� Look up drug interactions!

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Anticholinergics in Elderly

Anticholinergics: Overview

� Retrospective review found almost 25% of all community dwelling patients > 65 were on a “clinically significant” anticholinergic drug

� Adverse effects associated with anticholinergic drugs include: � Memory impairment

� Confusion

� Hallucinations

� Dry mouth

� Blurred vision

� Constipation

� Nausea

� Urinary retention

� Tachycardia

Drugs Aging. 2013 Oct(10):837-44. Image from: http://sketchymedicine.com/2012/01/anticholinergic-mnemonic/

Indication Offending

Medication Class

Recommendation

Urinary incontinence

Antispasmodic Agents(ie: oxybutynin)

- Avoid in patients with hx of dementia or cognitive impairment

- Use more selective antispasmodic agents such as darifenacin, solifenacin, or trospium

- Avoid in males w/ BPH

Allergic rhinitis 1st generation antihistame

(diphenhydramine –Benadryl®)

- Intranasal saline flushes - Intranasal corticosteroid

- 2nd generation antihistamine (loratadine –Claritin®, certirizine – Zyrtec®, fexofenadine –

Allegra®)

Insomnia TricyclicAntidepressants (ie

amitriptyline, imipramine, doxepin)

- Non-pharmacologic therapy

- melatonin

- low dose trazodone- Low dose secondary amine tricyclic

antidepressant (nortriptyline, desipramine)

Skeletal muscle pain

Muscle relaxants - Short course NSAIDs (topical > oral) - Topical cream (capsaicin cream)

J Am Geriatr Soc 2015;1-20.

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Anticholinergics: Bottom Line

� Difficult to avoid as many medications in many

different classes have anticholinergic side effects

� More important to recognize possible medication side effects vs symptoms of a separate disorder

Take Home Points/Principles

Take Home Points

� Avoid > 1 med in same class

� Consider meds that treat more than 1 problem

� Start low, go slow

� But keep going� ACE-Is, beta-blockers, antidepressants

� Or stay low� Li, anticonvulsants, digoxin, opioids, BZDs

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Take Home Points

� Stop/taper meds if not indicated/effective

� Taper 25-50% every 5 half lives

� Change one medication at a time

� Schedule f/u for monitoring of adverse effects, withdrawal, improvement, worsening

� Summarize changes in writing

� Once daily meds or combination products

Take Home Principles

� ALWAYS assess the evidence for its use

� ALWAYS assess the risk

� ALWAYS factor in quality of life

References

1. Ferner RE, Aronson JK. Communicating information about drug safety. BMJ 2006;333(7559):143.

2. Tinetti ME, Bogardus ST Jr, et al. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med 2004; 351(27):2870.

3. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. J Am Geriatr Soc 2015;1-20.

4. Elliot DP. Pharmacokinetics and pharmacodynamics in the elderly. In: Schumock G, Brundage D, et al., eds. Pharmacotherapy Self Assessment Program, 5th ed. Lenexa, KS: American College of Clinical Pharmacy, 2004:115-130.

5. Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991; 151:1825-32.

6. Kirkman MS, Briscoe VJ, Clark N et al. Diabetes in older adults. Diabetes Care 2012; 35(12): 2650-2664

7. Cefalu WT, Bakris G, Blonde L, et al. Standards of medical care in diabetes. Diabetes Care 2015; 38(1)

8. Currie CJ, Peters JR, Tynan A et al. Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective cohort study. Lancet 2010;375(9713):481-9

9. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA 2014;311(5):507-520.

10. Eknoyan G, Eckardt K, Kasiske BL, et al. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney International Supplements 2012; 2.

11. Stone NJ, Robinson J, Lichtenstein AH, et al. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. Circulation 2013

12. Gotto AM. Statin therapy and the elderly: SAGE advice? Circulation 2007;115:681-683.

13. Acharjee S, Welty FK. Atorvastatin and cardiovascular risk in the elderly – patient considerations. Clin Interv Aging 2008 Jun; 3(2): 299–314.

14. Hilmer S, Gnjidic D. Statins in older adults. Australian Prescriber 2013; 36:79–82.

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References

15. Holmquist IB, Svensson B, Hoglund P: Psychotropic drugs in nursing and old age homes: relationships between needs of care and mental health status. European Journal of Clinical Pharmacology 59:669–676, 2003

16. Bogunovic OJ, Greenfield SF. Use of benzodiazepines among elderly patients. Practical Geriatrics 55:233-235.

17. Greenblatt DJ, Shader RI: Benzodiazepines in the elderly: pharmacokinetics and drug sensitivity, in Anxiety in the Elderly. Edited by Salzman C, Lebowitz BD. New York, Springer, 1991.

18. Gray S, Lai K, Larson E: Drug- induced cognition disorders in the elderly. Drug Safety 21:101–122, 1999

19. Cumming RG, Le Couter DG: Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs 825–837, 2003

20. Schweizer E, Case WG, Rickels K: Benzodiazepine dependence and withdrawal in elderly patients. American Journal of Psychiatry 146:1242–1243, 1989

21. Budlovsky J, Wong RY. Novel Oral Anticoagulants in the Elderly. CGS Journal of CME 2014; Vol 4, Issue 1: 18-20.

22. Weitz JI, Eikelboom JW, Samama, MM. New Antithrombotic Drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST Feb 2012.

23. Sura SD, Carnahan RM, et al. Prevalence and determinants of anticholinergic medication use in elderly dementia patients. Drugs Aging 2013 Oct;30(10):837-44.

24. Sardar P, Chatterjee S, Chaudhari S, et al. New Oral Anticoagulants in Elderly Adults: Evidence From a Meta-analysis of Randomized Trials. J Am Geriatr Soc 2014;62(5):857-864.

Images from: http://eastpennfoot.wordpress.com/2013/02/01/edema-how-to-avoid-swollen-feet-and-ankles/http://onhealthyliving.com/archives/2009/02/21/natural-remedies-of-constipation

Start calcium

channel blocker

Furosemide AND KCl

Stomach upset

Tx with antacids

Anti-diarrheals

Dry mouth

More fluid intake

Edema from CCB

?Constipation