Digital PharmD

Informatics in Pharmacy

Geriatrics

Dementia

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Cognitive Screening

  • Mini – Mental Status Exam – MMSE
  • Montreal Cognitive Assessment – MOCA
  • St Louis University Mental Scale – SLUMS

Mood screening:  Geriatric Depression.Scale
IADL: Instrumental Activities Of Daily Living

Diagnosing Dementia:

  • Rule out delirium and drug-related causes.
  • Other causes: vitamin B12 deficiency, hypothyroidism, depression, NPH, opioids, sedative-hypnotics, antidepressants, anticholinergics, antiparkinson’s drugs

Treatment:

Initiate a cholinesterase inhibitor in patients with mild to moderate Alzheimer’s disease.

  • Donepezil 5-10 mg daily
  • Rivastigimine 1.5-6 mg BID or patch
  • Galantamine 4-12 mg BID (renal adjustment)
  • Memantine 5-10 mg BID (not a CI,  NMDA Antagonist, but can be used alone or added to a CI in moderate and severe disease)
  • Herbal medicines are not effective, but diet and exercise may help.
  • CIs cause nause, vomitting, headache, insomnia, dizziness, bradycardia, orthostatic hypertension, syncope, incontinence, anorexia, falls
  • Memantine causes agitation, urinary incontinence, insomnia, diarrhea,
    dizziness, confusion, headache.
  • Can add SSRI/ SNRI or atypical antipsychotic for symptoms.

Osteoporosis

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All women over 65 and men over 70 should have bone mineral density (BMD) testing.  If fractures or risks, test sooner.

Initiate therapy if:

  • Hip or spine fracture and BMD T-score -2.5 or below at hip, spine or femoral neck
  • T-score is between -1.0 and -2.5 at femoral neck or spine and the 10-year probability of hip fracture (FRAX score) is 3% or greater
  • The 10-year probability of major fracture (FRAX score) is 20% or greater according to

Treatment:

  • Bisphosphonates: Standard.
    • Alendronate and risedronate are first line
    • Zoledronic acid, ibandronate and pamidronate are available in IV forms.
  • Calcium is recommended for all patients with osteoporosis. Give 1000-1200 mg/day
  • Vitamin D is recommended for all patients. Give 800-1000 IU daily
  • Raloxifene (SERM) reduces bone resorption
  • Conjugated estrogen and bazedoxifene is like a SERM.
  • Calcitonin is not first-line, but can be useful in bone pain.  Nasal route.
  • Teriparatide is reserved for high-risk patients.  Increases calcium concentration, but also increases digoxin toxicity
  • Denosumab inhibits bone resorption, alternate to first-line, can lead to cellulitis (subQ) and hypocalcemia

Urinary Incontinence

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Causes (DRIP):

  • Drugs, delirium
  • Retention, Restricted mobility
  • Impaction, infection, inflammation
  • Polyuria, prostatitis

Treatment:

  • Urge:
    • Anti-muscarinic and anticholinergic: oxybutynin, tolterodine, fesoterodine, trospium, solifenacin, darifenacin
    • B-agonist: mirabegron
  • Stress:
    • alpha-adrenergic agonists: pseudoephedrine, phenylephrine
    • topical estrogens if other signs of estrogen deficiency
    • SSRI/SNRI: only duloxetine
  • Overflow:
    • alpha-adrenergic agonists: alfuzosin, tamsulosin
    • 5-alpha-reductase inhibitors: finasteride, dutasteride
    • Parasympathomimetic: bethanechol
    • Phosphodiesterase inhibitor: tadalafil
  • BPH:
    • Meds that exacerbate: alpha-adrenergic agonists like decongestants, anticholinergic drugs (antispasmodics, antihistamines, tricyclics, phenothiazines), diuretics and testosterone.
    • Treatment:
      • alpha-blockers: doxazosin and terazosin are non-specific and also lower blood pressure.  Newer agents (tamsulosin, silodosin, alfuzosin)
        are more specific.
      • alpha- reductase inhibitors:  dutasteride and finasteride are reserved for men with large prostate volume (>40 grams).  Takes 6 months for full effect.
      • Phosphodiesterase inhibitors: tadalafil 5 mg

Glaucoma

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Angle-closure is a medical emergency: 1 drop of timolol, apraclonidine, pilocarpine stat until ophthalmologist.

Open-angle: brinzolamide, dorzolamide (carbonic anhydrase inihibitors) or latanoprost: prostaglandin

Arthritis

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Osteoarthritis:
Risk factors: age, female sex, obesity, genetics, sports, occupation, injury, acromegaly and other illnesses.
Treatment:

  • Lifestyle: weight loss, exercise, PT and surgery
  • Drugs:
    • APAP up to 3g daily
    • NSAIDS if APAP not working.  Take ASA at least 30 minutes before NSAID if on ASA.
    • Topical agents, especially for the knee (capsaicin, diclofenac 1% gel)
    • Intraarticular glucocorticoid injections with methylprednisolone or triamcinolone, 10 – 40 mg, may repeat every 3 months. *only for knee
    • Intraarticular hyaluronan *only for the knee and only 3-4 lifetime injections.
    • Glucosamine
    • Opioids like Vicodin are better than chronic NSAIDS.

Rheumatoid Arthritis
Patients present with joint stiffness, fatigue, warmth, redness and/or swelling of joints. Lab tests will reveal a positive rheumatoid factor., elevated sedimentation rate a, C-reactive protein and normochromic, normocytic anemia.

Treatment:

  • Lifestyle changes: rest during disease exacerbations, PT, maintain a normal
    weight, surgery
  • Start DMARD within 3 months of diagnosis.
    • Methotrexate is preferred. Start with an anti-inflammatory drug and reduce the anti-inflammatory slowly.
    • Methotrexate is followed by hydroxychloroquine (slow onset) and sulfasalazine (DOC in pregnancy).  Can also use leflunomide.
    • Biologic DMARDs used in combo with methotrexate in severe disease
      • TNF inhibitors: etanercept, infliximab, adalimumab, certolizumab,
        golimumab
      • Non – TWF: abatacept, anakinra, rituximab, tocilizumab
      • Biological kinase inhibitor: Tofacitinib
    • Methotrexate: Takes 3 – 6 weeks to see onset. Anything that changes
      kidneys function interacts.

ACR RA Classification Guidelines

  • RA Classified with synovitis in 1 joint or more in absence of a better diagnosis that explains the symptoms and a score of 6 or more in the following domains:
    • Large joint involvement: 1 = 0 pts, 2-10 = 1 pt
    • Small joint involvement: 1-3 = 2 pts, 4-10 = 3 pts
    • Any joints:  >10 = 5 pts
    • Low positive RF or ACPA = 2 pts
    • High positive RF or ACPA = 3 pts
    • Abnormal CRP or ESR = 1 pt
    • Symptoms greater than 6 weeks = 1 pt