Sol



How to conduct Mini-Cog- The Mini-Cog has been demonstrated to have comparable psychometric properties to the MMSE The primary advantage of the Mini-Cog is that it is shorter than the MMSE and measures executive function. It is composed of a three-item recall and the Clock Drawing Test (CDT) and takes about 3 minutes to administerThe Mini-Cog is a short dementia assessment that combines three-word recall with clock-drawing capability.Patients are given a total score reflecting accuracy in clock drawing and recollection of the given three words. A score of 0 to 2 is a positive screen for dementia Causes of delirium in elderly- Causes of delirium are numerous and in elderly hospitalized patients there are often multiple etiologies, including metabolic, infection, cardiac, neurological, pulmonary, sensory impairments, medications, and toxins. Regardless of cause, a consistent finding is significant reduction in regional cerebral perfusion during periods of delirium in comparison with blood flow patterns after recovery. A possible neurological common pathway may involve acetylcholine and dopamine, and the disruption in the sleep-wake cycle in delirium indicates melatonin as a possible factor. (Kennedy-Malone 59)AgnosiaLoss of ability to identify objectsADA criteria for diagnosing DM- FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.* 2-h PG ≥200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.* A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L).? ??Urinary incontinence- Involuntary loss of urine from the bladder? So common in women many consider it normal? Common in older men w/ enlarged prostateo Can affect quality of lifeo Significance-One of the most common complains w/ older adults, Distress & embarrassment, Cost burden to pt & society as a whole, Not life-threatening, may effect QOL, PCP essential to educating individualso Epidemiology- Increased prevalence w/ age in men & women, Nursing home population – 40-70%, Often a factor in placement? URGENCY UI is greater in men? STRESS UI is greater in womeno Terminology? UI- Unintentional voiding, loss or leakage of urine? Continuous incontinence-Continuous loss or leak of urine? Increased daytime frequency-More frequent during day than considered normal? Nocturia-Interruption of sleep one or more times due to the need to urinate – increases in frequency after age 50? Urgency-Sudden, compelling desire to pass urine that’s difficult to prevent? Overactive bladder syndrome- Urgency, frequency, nocturia w/ or w/o incontinenceo Risk Factors-Aging,Obesity,Smoking, Caffeine,Uncontrolled DM, Constipation,Use of diureticso Risk Factors by gender-Women:Aging, obesity, smoking, caffeine intake, DM, pregnancy, multiparity, estrogen deficiency, hx of pelvic surgery, diureticsMen:Aging, obesity, smoking, caffeine, DM, prostate dx, hx of prostate surgery, hx of UTIs, diureticso Physical changes w/ aging that contribute to UI? Lower urinary tract-Detrusor muscle over activity,Decrease in detrusor contractility, Increase in post void residual,Decrease in urethral blood flow? Women – decrease in urethral closure pressure,Low estrogen following menopause - leads to atrophy of ureteral mucosal epithelium & increase in urethral sensation? Men can experience constriction of urethra due to BPH which may result in bladder outlet obstructing symptoms- Initial clinical workup for UI in Meno PMH, PE, UA, DRE: Eval of prostate,PSA w/ new onset in men- UI workup in women:Exclude underlying causes,PMH, PE, UA, Pelvic exam, vaginal exam, perineal, Identify estrogen status of pt, Pelvic prolapse, fistula, -Cough test, Integrity of pelvic musculature, leaking of urine? Full bladder? Standing position? Asked to cough? If urine leak is observed, stress incontinence is confirmed- Red flags in maleso Higher level of suspicion for serious diseases, Refer to urology if Previous pelvic surgery, Pelvic radiation, Pelvic pain, Severe incontinence, Severe UTI symptoms, Recurrent urologic infection,Abnl Prostate exam,Elevated PSAo Be alert to these with NEW ONSET UI- Hematuria,Pelvic pain,Abdominal mass, Dysuria, Proteinuria, Glucosuria, CVA tenderness,Nodular prostate,Any new neuro symptoms- Goals of treatment: Reduce symptoms, Improve QOL, Increase social activity, Reduce leakage volumes, increase dryness, use less protection; Increase independence in incontinence management; Decrease caregiver burden- 1st line management guidelineso AHRQ guidelines for management of UI in women? Behavioral therapy? Lifestyle modification? Try for 3 months before pharm managemento Weight loss, Smoking cessation(Tobacco is a bladder irritant),Less coughingo Dietary changes-Alcohol, soda, coffee with or without caffeine, acidic foods and spicy foodso Maintain adequate fluid balance to reduce constipation, provide adequate flow to kidneys- Behavioral strategies:Bladder training, Bladder control strategies,Timed voiding,Kegels, Pelvic floor training- 2nd line management - Medicationo Antimuscarinic medication: 1st line for women? Block the parasympathetic muscarinic receptors? Inhibit involuntary detrusor contractions? Side effects due to the effects on other muscarinic receptorso Outcomes unpredictable and side effects commono Common s/e: Dry mouth**, Blurred vision, Constipation,Nausea,Dizziness, Headacheo AntimuscarinicsMechanism of action● Blocks acetylcholine at muscarinic receptors, relaxes bladder smooth muscle, inhibits involuntary detrusor contractions (anticholinergic)● CYP3A4 substrates? Indications: UI and OAB? Contraindications: Untreated/uncontrolled narrow angle glaucoma,Gastric retention, Urinary retention? Precautions:CNS depression,Caution in elderly● Renal dosingo CrCl <30o Beta 3 Adrenergic Agonist – Mirabegron (Myrbetriq)? Also approved for UI and OAB? Clinical trials – significant reduction in incontinence and micturations● No anticholinergic s/e? Mech of action● Selectively stimulates beta-3 adrenergic receptors● Relaxes smooth muscle – bladder? Contraindications/caution: HTN- Do not use if SBP >180, DBP >100? Avoid severe renal/liver disease? Dose – 25-50mg PO QD? CrCl <30 – max 25mg- 2nd line of UI in Males – Alpha 1 blockerso Men, not women!o Alpha 1 blockers antagonize peripheral alpha 1 adrenergic receptorso Used in men d/t high incidence of BPH in aging meno Alpha antagonists? Alpha 1A – prostatic smooth muscle relaxation? 1B – vascular smooth muscle contraction? 1D – bladder muscle contraction and sacral spinal cord innervationo Meds? Doxazosin SE: Dizziness, dyspnea, edema, fatigue, somnolence? Terazosin SE: ?Asthenia, dizziness, postural hypotension? Tamsulosin SE:Abnormal ejaculation, asthenia, back pain, dizziness, increased cough? Alfuzosin- CrCl <30 use with caution, SE: Dizziness, URI? Silodosin SE- Retrograde ejaculationDifferentials as cause for erectile dysfunction- Differential diagnosis:Vascular, Endocrine, Neurological, Neurovascular, Substance abuse, End-organ disease, Psychogenic, Social causes (Kennedy-Malone 376)Elder abuse Types-Physical, Emotional, Sexual, Neglect, Exploitation, Abandonment, Self-NeglectRisk Factors- Age, Gender, Cognitive Impairment, Living Arrangement, Social IsolationSigns of abuse-bruises, slap marks, unexplained burns, increased accidents, lack of hygiene, failure to meet medical needs, weight loss, decubiti, changes in personality, decreased interaction, unexplained STDProvider responsibility in reporting abuseIf you suspect elder abuse perform a physical exam and order any necessary tests.Include a cognitive screen. Document your findings. This includes what the patient says and your objective findings. You may need to interview your patient and the caregiver separately to see if the stories are the same. Be aware of your state laws regarding mandatory reporting of suspected abuse.Differentials as cause for hematuria- Differentials per class notesDietary substancesCaffeine, spices, Tomatoes, chocolate, alcohol, Citrus, soy sauce, & some herbal medsMedicationBeta-lactam antibiotics, sulfonamide, NSAIDs, Cipro, allopurinol, Tagamet, & dilantinAnticoagulation and papillary necrosis Coumadin, Heparin, aspirin, & NSAIDsGlomerular nephritis Hydrocarbons (glue, paint) NSAIDsUrolithiasismensesTerazosin use(s)- Alpha blocker for BPH . 1-10 mg P.O. nightly. Caution in those with cataracts and in elderly. Side effects hypotension, priapism, dizziness, dyspnea, tachycardia. 2nd Line Management of UI in males***Alpha 1 BlockersPharmacologic agents for men with urinary incontinence differ from women; Alpha 1 blockers antagonize peripheral alpha-1 adrenergic receptors and commonly referred to as alpha 1 blockers*Lifestyle changes and Behavioral Management are first-line but when not effective alpha 1 blockers are initiated; *This difference in choice of medication for men is due to the high incidence of BPH associated with aging menAlpha 1 Adrenergic Receptor antagonistsAlpha 1A- Prosthetic smooth muscle relaxationAlpha 1B- Vascular smooth muscle contractionAlpha 1D -Bladder muscle contraction and sacral spinal cord innervationUTIs in men and womenUTI treatment guidelinesBPH- ?Progressive, benign hyperplasia of prostate gland tissueEtiology/incidence-Cause is uncertain, About 50% of men have it by 60, By age 85, 90% have itMost common cause of bladder outlet obstruction in men over 50Symptoms are attributed to mechanical obstruction of the urethra by the enlarged prostate glandSigns/Symptoms- Gradual worsening of the following, Frequency, urgency, urge incontinence, Nocturia, dysuria, Weak urinary stream, dribbling, hesitancy, Sensation of full bladder even after voiding, RetentionDiff Dx- Urethral stricture, Prostate or bladder cancer, Neurogenic bladder, Bladder calculus, Acute or chronic prostatitis, Bladder neck contractor, Medications that affect micturitionPhysical findings- Abdomen,May have distended bladder secondary to retention; Prostate,Nontender w/ asymmetric or symmetrical enlargement, gross enlargement atypical, Consistency is smooth, rubbery (eraser), Nodules may be presentDifferentiation from BPH and CA needs biopsyTests/FindingsUA-No hematuria or UTI, Urinary flow rate, Voided volume and peak urinary flow rate (uroflowmetry) may detect obstruction flow, Abdominal US – rules out upper tract patho, PSA, Consider PVR urine volume, Cr to assess renal function, elevated levels suggest urinary retention or underlying renal disease – refer this patientTreatment/Management- Refer men who have the following, Refractory urinary retention who have failed one attempt at cath removal, Recurrent infection, recurrent retention, refractory hematuria, bladder stone, large bladder, diverticula, or renal insufficiency related to BPH, ?Consider referral if complications exist or if patients have severe symptomsManagement-Men who have no indications for surgery, Discuss risks/benefits of all options, Watchful waiting (observation), Behavioral techniques to reduce symptoms, Limit fluid after dinner, Avoid medications such as Antidepressants, Antiparkinson drugs, Antipsychotics, Antispasmodics, Cold meds, DiureticsMedication TreatmentsAlpha adrenergic blocker – for smaller prostates5-alpha adrenergic blocker – larger prostatesCombo therapy is an alpha-adrenergic blocker and finasteride is used now for men w/ large prostatesSurgery has the best chance for relief of symptoms, but greater risksFollow up: Teach signs/symptoms of retention and obstruction, If observing for now, recheck every 6-12 months, In use of meds, recheck in 4-6 weeks, ?If post surgery follow up is at the discretion of the urologistAcanthosis nigricansA sign of insulin resistance that can be seen in African Americansassociated with colon cancer, obesity and DMDelirium treatment- Kennedy 560. Identify causes, prevent delirium though complications of identified disorders. \Focus on safety. Frequent reassurance and re-orientation. First generation --haloperidol. Second generation (olanazapine, risperidone, ziprasidone and quitiapine) antipsychotics to control behavioral symptoms.Essential tremor vs. Parkinson’s DiseaseEssential tremor is an action tremor 6 to 8 Hz, Parkinson’s tremor is a resting tremor which is 3 to 6 Hz. Kennedy p. 425Seizure causesIn older adults stroke is the most common underlying cause of seizures. Other causes include neurodegenerative disorders, brain tumors and head injuries. Kennedy p 438Hospice & palliative care-Hospice: Last 6 mos of life. Uses palliative care principles to support pt and family. Includes bereavement services. Covered by Medicare/Medicaid, most private insurance. Interdisciplinary care, medical service, supplies, drugs Palliative Care: To relieve pain and improve QOL. Used early in dz process. Interdisciplinary Care. Provides care for the entire dz process, from diagnosis to death, including bereavement services.Pain- Pain assessment tools:Visual Analogue ScaleNumerical Analogue ScaleWong Baker FACESPain Assessment in Advanced Dementia scaleTypes of pain:Somatic,Visceral,NeuropathicFramework for pharmacological interventions for pain:The WHO Step Ladder 1st step: NSAIDs and Tylenol for mild pain 2nd step: Opioids added, usually with APAP for moderate to severe pain with functional impairment and or decreased QOL 3rd step: Opioid pain meds, sometimes around the clock for severe painAdjuvant meds: Tricyclic antidepressants, Nortriptyline,Desipramine,Duloxetine,Gabapentinm, Pregabalin, Lidocaine 5% patch, Capsaicin cream, Corticosteroids, Calcitonin, BaclofenPain management in elderlyDelirium vs. dementia- Delirium-rapid onset (hours to days). Poor memory, disorientation, speech disturbance, perceptual disturbance.Typically fluctuates over course of day. History may reveal cause-medical condition, intoxication or withdrawal, use of med, toxin exposure or combination. (Kennedy 558). ??Dementia- Alz Disease most common. An acquired persistent intellectual impairment with compromise in multiple spheres of mental activity.Signal symptoms: confusion, impaired short term memory, cog dysfunction. Progression is typically slow. Could be reversible (secondary to treatable systemic disorder), or irreversible (primarily caused by progressive systemic or neuro disorder). ***hallmark*** anosognosia- the patient is unaware of impairment and denies illness(kennedy, p.562)Alz. ChEIs - cornerstone of pharm therapy as acetylcholine is important for brain cell function.Steps of the grieving processGrief is the emotional response to loss, Mourning is the outward social expression of lossTypes of grief: Anticipatory-experienced before death, can be experienced by everyone including the patientNormal- encompasses the typical emotional, physical, cognitive, and spiritual reactions to a lossComplicated-chronic, delayed, exaggerated, masked or disenfranchisedStages of Grief: Notification and shockExperiencing the loss emotionally and cognitivelyReintegrationTasks of grieving:Acknowledging the reality of deathSharing in the process of working through the pain of griefReorganizing the family system, restructuring the relationship with the deceased, and reinvesting in other relationships and life pursuits Kennedy p. 631Alzheimer’s treatmentSigns and symptoms-Preclinical can last 2-4+ years, impaired memory (excused or covered), poor judgement, decreased spontaneity, increased social anxiety, insidious instrumental ADL losses (bill paying, money handling), preserved basic ADLsMild/Moderate-lasts 2-10 years, obvious memory impairment, overt instrumental ADL impairment, basic ADL failing, behavioral difficulties, shortened attention span, language difficulty, variable social skills, supervision required Severe- last 1-2+ years, memory fragments only, no recognition of familiar people, requires assistance with basic ADLs, reduced mobility, weight loss, fewer troublesome behaviors, infections, seizures, dysphagia, incontinence, groaning, moaning, gruntingFirst line pharmacological treatment-Cholinesterase inhibitors donepezil (Aricept) Memantine (Namenda) added at the moderate to severe stage Kennedy p 567-568Sexualitysundowningmetformin side effects- GI side effects take with supper. Most patients adjust to these SE. ADVERSE effect- Lactic acidosis. ?B12 deficiencyBiguanides (Metformin) has become a cornerstone of drug treatment for type 2 disease, based on its proven efficacy not only in controlling glucose intolerance but also in significantly reducing risk of important macro- and microvascular outcomes, especially in overweight and obese patients (as found in the UKPDS study referred to earlier and below). In glycemic treatment algorithms for type 2 disease, initiation of metformin is recommended at the time of diagnosis along with diet and exercise.Mechanism of Action. Metformin differs from the traditional oral hypoglycemics (i.e., the sulfonylureas) in that it does not stimulate endogenous insulin secretion; rather, drugs of this class enhance tissue responsiveness to insulin. Consequently, biguanides are less likely to induce hypoglycemia and are particularly effective in the treatment of overweight patients with tissue resistance to insulin. Biguanides facilitate insulin uptake by peripheral tissue, especially muscle and liver, and decrease hepatic gluconeogenesis and basal glucose output, thereby helping to lower fasting glucose levels. Glucose utilization also improves in adipose and intestinal tissues. The net result is an improvement in fasting and postprandial hyperglycemia. Insulin demand declines as glucose utilization improves. Serum lipid abnormalities also improve.Preparations. Metformin is the only biguanide approved in the United States for the treatment of type 2 diabetes. The drug is rapidly and well-absorbed in the small intestine, with peak plasma concentrations in 2 hours. It is rapidly excreted unchanged by the kidneys. Impaired renal function (creatinine >1.5 mg/dL in men and >1.4 mg/dL in women) is a contraindication for use, especially at full doses. The drug is not metabolized by the liver. The original biguanide, phenformin, is no longer marketed because of its associated risk for lactic acidosis and an excess cardiovascular mortality (see later discussion).Dosing. The starting dose of metformin is 500 mg once daily with dinner. After 1 week, the dose is increased to twice daily, given with the two largest meals of the day (usually breakfast and dinner) to minimize gastrointestinal upset. The dose can be increased by 500 mg every 1 to 2 weeks until treatment goals are met or the maximum dose of 2,000 to 2,500 mg/d is reached. An extended-release formulation is also available, which can help to improve compliance.Efficacy. When used as monotherapy in an obese person with moderate glucose intolerance, metformin’s efficacy in terms of glycemic control (i.e., lowering fasting glucose and glycosylated hemoglobin levels) is about the same as that of a second-generation sulfonylurea. Incidence of monotherapy treatment failure is less for metformin than for glyburide (21% vs. 34% at 5 years). A synergistic effect is achieved when combined with sulfonylurea therapy in patients who do not respond well to metformin alone. Unlike the sulfonylureas, metformin is effective even in severe fasting hyperglycemia (>300 mg/dL), indicative of poor beta-cell responsiveness. Plasma triglycerides and LDL cholesterol levels are decreased. In the UKPDS trial noted earlier, obese patients (>120% of ideal weight) with type 2 diabetes treated with metformin and attaining target glycemic control achieved clinically important, statistically significant, sustained long-term reductions in risks of microvascular disease and macrovascular complications (i.e., myocardial infarction, stroke, and cardiovascular death); all-cause mortality was also significantly reduced. These findings make metformin one of the few antihyperglycemic drugs with demonstrated ability to reduce macrovascular risk, the holy grail of diabetes management.Adverse Effects. The most common side effect of biguanide therapy is dose-related gastrointestinal upset (nausea, diarrhea, bloating, abdominal discomfort). The risk for serious prolonged hypoglycemia is minimal. Lactic acidosis represents the most potentially serious adverse effect. One of the original biguanides—phenformin—was taken off the market by the U.S. Food and Drug Administration (FDA) in 1977 because of its association with fatal episodes of lactic acidosis. The risk for lactic acidosis associated with metformin is greatest in the setting of hypoxemia, hypovolemia, and states with decreased tissue perfusion and in renal insufficiency (creatinine >1.5 mg/dL). Accumulation of the drug secondary to reduced excretion results in impaired hepatic metabolism of lactate. Other risk factors include binge drinking, use of intravenous radiologic contrast agents, hepatic failure (lactate is metabolized by the liver), and serious underlying illness, particularly heart failure.Long-term data on safety have yet to be accumulated. Because insulin secretion is not increased with metformin use, weight gain does not occur; some patients may even lose weight. Patients who are to undergo a radiologic procedure that requires intravenous iodinated contrast should have their metformin therapy held for a few days prior to the procedure and remain well hydrated.Patient Selection. Based on the landmark results of the UKPDS, obese patients should be considered especially good candidates for metformin therapy. The drug helps to reverse their insulin resistance, peripheral responsiveness to insulin improves, and insulin needs decrease, so hyperinsulinism and its adverse effects, including weight gain, are minimized. The typical candidate is a moderately obese person with type 2 diabetes who has persistent moderate hyperglycemia (fasting glucose between 140 and 240 mg/dL, glycosylated hemoglobin >7.0%) despite a full program of diet and exercise. Early addition of metformin is suggested. Other candidates for metformin include obese patients who do not achieve tight control while taking a sulfonylurea at maximal doses. In this setting, metformin is added to the oral hypoglycemic program to improve control through its complementary mode of action. The sulfonylurea dose is reduced to lessen the risk for hypoglycemia. Combination therapy is most effective when initiated before the onset of symptomatic hyperglycemia (fasting glucose >250 mg/dL). Nonobese patients are also reasonable candidates for metformin. Typically, metformin lowers fasting blood glucose by approximately 20%.Patients who started drug therapy with a sulfonylurea and become unresponsive to maximal doses have likely exhausted their beta-cell reserve and can be switched to metformin or considered for exogenous insulin therapy (sometimes in conjunction with metformin). The same pertains to the severely hyperglycemic obese patient (fasting glucose >300 mg/dL). Some diabetologists use metformin to supplement an insulin program in obese type 2 diabetics who require large insulin doses and have difficulty losing weight. The combined program helps to reduce insulin requirements and the appetite stimulation and weight gain that accompany hyperinsulinism. Caution and careful patient monitoring are required when a patient taking exogenous insulin is started on metformin; the insulin requirement may drop considerably, putting the patient at risk for hypoglycemia. Use in pregnancy is not associated with major congenital malformations.ACC 2017 Guideline for High Blood Pressure in Adults- 2017 HTN guidelinesNormal BP is defined as <120/<80 mm Hg Elevated BP 120-129/<80 mm Hg Hypertension stage 1 is 130-139 or 80-89 mm Hg Hypertension stage 2 is ≥140 or ≥90 mm Hg.Acute prostatitis kennedy 380. lower urinary tract symptoms-frequency, pain on urination or pain increasing with uriuiation. Acute bacterial prostatitis- presence of more than 10 WBC per high power field on mid stream urine collection. If acutely ill, hospitalization. Treat with Cipro 500mg BID x 10 days or Levaquin 500mg daily x 10 days. Choose a fluoquinolone - it penetrates prostate tissue well. EducationMay need a stool softener. Repeat UA is recommended. Avoid anal intercourse. Use condom to prevent reintroduction of bacteria into urethra.Beta blocker side effects in diabetics- Can mask the symptoms of hypoglycemia?How to diagnosis HF and COPD via CXR findings- Chest x-ray: for COPDThis exam can help support the diagnosis of COPD by producing images of the lungs to evaluate symptoms of shortness of breath or chronic cough. While chest x-rays may not show COPD until it is severe, the images may show enlarged lungs, irregular air pockets ( bullae) or a flattened diaphragm. A chest x-ray may also be used to determine if another condition may be causing symptoms similar to COPD. ?(Malone 207) – chest X-ray in advanced COPD with emphysema May reveal hyperinflation bullae or blebs and a flat hemidiaphragm.OAHF stages- ACCF/AHA STAGES: A: At high risk for HF w/o structural heart Dz or SxB: Structural heart dz w/o s/sx of HFC: Structural heart dz w/ prior or current sx of HF D: Refractory HF requiring specialized interventionsNew York Heart Association classes- I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath).II Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath).III Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.IV Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.Causes for insomnia – Anxiety, stress, and depression are some of the most common causes of chronic insomnia. Having difficulty sleeping can also make anxiety, stress, and depression symptoms worse. Other common emotional and psychological causes include anger, worry, grief, bipolar disorder, and trauma.Prescription for insomnia – Avoid caffeine for 12 hours before bedtime, d/c alcohol and unnecessary sleep interrupting drugs, OTC melatonin RX ramelteon can be tried, if ineffective initiate a short acting sedative-hypnotic such as zolpidem (Ambien) or zaleplon (Sonata) for 1 week or lessIf a benzodiazepine is used, temazepam (Restoril) is relatively short actingApproved pharmacological therapy includes temazepam for sleep onset insomnia, eszopiclone (Lunesta) for sleep onset and sleep maintenance, zolpidem CR and zolpidem for sleep maintenance, and saleplon and ramelteon for sleep onset insomniaKennedy p 597-588TABLE 232–4 Effective Drugs for InsomniaAgent (Brand Name)OnsetDurationDose (mg)Relative Cost (Brand)CommentsBenzodiazepine receptor agonistsMay impair AM performance; ? anterograde amnesia; modest potential for abuse, withdrawal, dependence; drug–drug effectsZaleplon (Sonata)aRapidShort5–10$ ($$$$)May be used for awakenings at night; possible interaction with inducers of CYP 3A4Zolpidem (Ambien)aRapidShort–intermediate5–10$ ($$$$)Potential interaction with inducers of CYP 3A4Zolpidem (Ambien CR)aRapidIntermediate6.125–12.5$$$ ($$$$)Intermediate-release preparation; greater risk of morning sedationZolpidem (Intermezzo) (sublingual)RapidVery short1.75–3.5$$$$Sublingual, for middle-of-night awakeningZolpidem (Zolpimist) (oral spray)RapidShort10$$$$? Faster onset of action; ease of use might lead to excess dosingEszopiclone (Lunesta)RapidShort–intermediate1–3$$$$$Bad taste, potential interactions with ketoconazole, nefazodone, and inducers of CYP 3A4BenzodiazepinesPotential for dependence, tolerance, abuse, rebound insomnia, psychomotor retardationTriazolam (Halcion)aRapidShort0.124–0.25$ ($$)Anterograde amnesiaDiazepam (Valium)aRapidLong2–5$ ($$)EstazolamRapid–IntermediateIntermediate1–2$Generic onlyQuazepam (Doral)aIntermediateLong15$$ ($$$$)Flurazepam (Dalmane)aIntermediateLong15–30$ ($$$)Lorazepam (Ativan)aIntermediateIntermediate1$ ($$$)Clonazepam (Klonopin)aIntermediateLong0.5–1.0$ ($$)Oxazepam (Serax)aIntermediate–slowShort–intermediate10–15$$ ($$$)Temazepam (Restoril)aIntermediate–slowIntermediate15$ ($$$)Melatonin Receptor AgonistsNo potential for abuseRamelteon (Rozerem)RapidShort8$$AntidepressantsDoxepin (Silenor)RapidLong3–6$$$Very-low-dose preparation may be helpful in elderly with chronic insomnia.GOLD criteria- Malone 207) Gold standard = Spirometry for measuring airflow limitation. GOLD Classification (post bronchodilator FEV1)GOLD1 (mild): FEV1 > 80% predictedGOLD2 (Moderate): 50-79% predictedGOLD 3 (Severe): 30-49% predictedGOLD 4 (Very Severe): FEV1 < 30% predicted Treatment = individualize according to stages, cormorbidities, and patient goals. Treatment is targeted towards improvement of health status, And functional status, prevention of disease progression avoidance of exacerbations or complications prevention of treatment side effects and management of exacerbation. COPD management program Risk factor reduction.Assessment and monitoring. Stable chronic management. Management of exacerbation.Smoking cessation is the most effective cost effective intervention and should be promoted every visit. No current drug therapy has proven to influence the progressive decline of COPD. Malone 208 - inhaled bronchodilators maybe useful and stable COPD patients. Arrhythmia evaluationSIG-E-CAPS- S: sleep (insomnia or hypersomnia)I: interests (diminished interest or pleasure); G: guilt: (excessive or inappropriate guilt; feeling worthless); E: energy (loss of or fatigue); C: concentration (diminished concentration or indecisiveness); A: appetite (decrease or increase; weight gain or weight loss); P: psychomotor retardation/agitation (move slow, agitated, restless); S: suicide (recurrent thoughts of death, ideation, or attempt)DEXA scan results findings- (Pg 499)BMD measurement is expressed as the number of standard deviations from the mean for normal young adults of the same sex (T-score) and as the number of standard deviations from the mean for persons of the same sex and age (Z score). The World Health Organization diagnostic criterion for osteoporosis is a T-score of less than -2.5. Osteopenia is defined as a T-score between -1.0 and -2.5. A Z score of less than -1.5 suggests a secondary cause of osteoporosisOsteoporosis: -2.5 or lower Osteopenia: -1 to -2.5 (lower than normal bone density w/o full osteoporosis)Anxiety treatment- Treatment for anxiety should reduce symptoms and improve functioning. Simply listening, being compassionate, and showing respect are important to improving outcomes. Treat comorbid depression and medical conditions that cause anxiety. There are no large-scale studies of pharmacotherapy for late-life anxiety disorders to guide treatment decisions.Start low and go slow with medication dosing to avoid risks from drug interactions, because older adults are more likely to take many medications and may have side effects from aging changes in absorption, metabolism, distribution, and excretion of medication. Evaluate and manage side effects, because as many as 25% of patients stop taking medication in the first 6 months due to side effects. First-line treatment is the selective serotonin reuptake inhibitors (SSRIs) citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft). In older adults, they have the least risk of drug interactions, side effects, or worsening existing medical conditions. Benzodiazepines, including lorazepam (Ativan), alprazolam (Xanax), and clonazepam (Klonopin), are effective according to research but are not the first choice due to the risk of falls and confusion. Research supports referral to psychotherapy for older adults, but this recommendation is limited to GAD and no other anxiety disorders (American Psychiatric Association, n.d.; Cassidy & Rector, 2008; Hollander & Simeon, 2008; Lenze et al., 2005; Lenze & Wetherell, 2009; Mohlman, 2005; National Institute of Mental Health, n.d.; Stanley et al., 2003; Wetherell, Lenze, & Stanley, 2005; Wetherell, Sorrell, Thorp, & Patterson, 2005). (Kennedy-Malone 553-554) ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download