Augmentation Strategies and Medication Management in Older Adults, Exams of Nursing

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Pharm 549 Nursing Comprehensive Exam

Questions with Verified Answers Latest Update

Geriatric syndrome - Correct Answer The term "geriatric syndrome" is used to capture those clinical conditions in older persons that do not fit into discrete disease categories. Many of the most common conditions cared for by geriatricians, including delirium, falls, frailty, dizziness, syncope and urinary incontinence, are classified as geriatric syndromes. Nevertheless, the concept of the geriatric syndrome remains poorly defined. What is one way to think about geriatric syndrome - Correct Answer It is multiple etiological factors interacting with multiple pathogen etic pathway leading to a unifeid minifestation Geriatric syndromes - Correct Answer •Swallowing problems •Malnutrition •Bladder problems •Sleep difficulties Delirium •Dementia •Vision impairment •Hearing impairment •Dizziness •Fainting •Gait problems •Falls •Osteoporosis •Pressure ulcers In a hosptial with the elderly you want to prevent the following - Correct Answer • Functional decline

• Falls
• Delirium
• Tethers
• (Nosocomial) Infection
• Malnutrition
• Pressure ulcers
• Venous thromboembolism
  • Adverse drug reactions Which drugs cause the most ADE in elderly adults - Correct Answer Warfarin Insulin THese are the two ones that have a lot ore then anyone else

Others are -Oral antiplatelet agents -Oral hypoglycemic agents -opoid analgesics -Digoxin -HEDIS -Beers criteria You mean to tell me thata with all of the work that we did on the beers criteria its that low on the ADE list for elderly - Correct Answer yup Beers criteria - Correct Answer common problems with assessing patients in the emergency department - Correct Answer • Atypical presentation

• Altered laboratory values
• Comorbities
• Polypharmacy
• Communication
• Aphasia
• Deafness or hearing impairment
• Altered mental status
• Delirium
• Dementia Problems that hte elderly can have in an emergancy department - Correct Answer • Lack of privacy
• Lying on stretchers
• Hard, slippery floors
• Lack of windows
• Harsh lighting • NOISE What are some structural solutions for this - Correct Answer • Soundproof curtains
• Hearing assistance
• Removal of noise distractors
• Reclining chairs or padded stretchers
• Clocks, calendars, names of staff posted
• Non-skid floor surfaces, hand rails
• Bedside commodes
• Visual aids
• Sky or ceiling lights POLST is a - Correct Answer • Serves as current physician orders for end-of-life care for the seriously ill.

• Easily recognizable portableform that travels with the patient, including: home, assisted-living facilities, and hospitals.
• Is NOT an Advanced Directive. It helps complement an Advanced Directive but is a separate document.
• POLST is a signed order written in agreement between boththe patient and either a Physician, PhysicianAssistant, or Advanced Registered Nurse Practitioner When do you have a polst - Correct Answer • Life expectancy less than a year.
• If one wishes for Do Not Attempt Resuscitation (allow natural death).
• Anyone wishing to limit medical intervention. Anyone entering hospice care. What does an advanced directive do - Correct Answer • A legal document
• Outlines type(s) and/or quantity of care desired
• Used onlyif patient is incapacitated
• Allows person to express values and desires related to end-of-life care
• Person may change his or her mind at any time examples of advance care planning documents - Correct Answer • Living will
  • Durable power of attorney for health care
  • Do not resuscitate (DNR) order
• Organ and tissue donation Who should you choose for a medical decision maker - Correct Answer • Family member
• Friend
• Lawyer
• Someone from the person's faith community (e.g., pastor, rabbi) Who should you share your advanced directives with - Correct Answer Medical decision maker
  • Alternate health care proxy
• Physician - document in medical record
• Hospital - document in medical record
• Key family members and friends
  • Attorney (if applicable) What is delerium - Correct Answer • A clinical syndrome characterized by a disturbance in level of awareness and reduced ability to direct, focus, sustain, and shift attention
  • A change in cognition (deficit in orientation, executive ability, language, visuoperception, learning, and memory)

• The disturbance develops over a short period of time and tends to fluctuate in severity during the course of the day
• Attributable to general medical condition
• An independent risk factor for prolonged hospitalization and mortality in critically ill patients
• "Brain failure" delerium - Correct Answer delirium - Correct Answer delirium - Correct Answer other names for delirium - Correct Answer • Mental Status Change
• Acute confusional state
• Neurologic impairment
• ICU psychosis
• Septic encephalopathy
• Acute brain failure
• Toxic metabolic state
  • CNS toxicity
• Cerebral insufficiency
• Organic brain syndrome What are the leading cuases of delirium in hospital - Correct Answer • Hip fracture 28- 61%
  • Surgery 15-53%
• Medical pts 3-29% how prevalent is delirium at certain medical places - Correct Answer • ICU 20-80%
• Hospice 29%
• Community (85+) 14%
  • At hospital admission 10-31%
• LTC facility 1-60% What is the average course and prognosis of delerium - Correct Answer • Average duration 3-20 days; can be longer
• Hours to months to resolve
• Full recovery lags behind normalization of laboratory and test results
• Some patients may never fully recover
• Associated with higher mortality

on tests how to distinguish between deelirium and dementia - Correct Answer delirium course is fluctuating, its onset is acute or sub acture, and it occurs in the provess of a medical illness or a netabolic derangement. Whereras demetia is a slow and steady decline, with a chronic onset Hypoative-hypoalert level of alert - Correct Answer Drowsy, lethargic; may fall asleep between questions; is stuporous motor activity in hypoactive-hypoalert - Correct Answer decreased amount of activity perform more slowly hypoactive hypoalert ability ot follow commands - Correct Answer Able to follow simple commands; passively cooperates with requests abd how is your thinking ability - Correct Answer Difficulty focusing attention; disorganized; inappropriately silent; no clear speech Delerium mnemonic is - Correct Answer D= drugs E=eyes or ears L= Low oxygen states I= infection R=retention I= ictal U = uncontrol pain M= metabolic (s) = subdural D = - Correct Answer Drugs E = - Correct Answer Eyes ears or emotions L = - Correct Answer Low oxygen state (ami, stroke, PE) I = - Correct Answer Infection R = - Correct Answer Retention ( of urine or stool) I= - Correct Answer Ictal (i.e; post ictal states) U = - Correct Answer uncontrolled pain M= - Correct Answer Metabolic (S) - Correct Answer subdural

medications delirium - Correct Answer What are the high risk drugs for delirium - Correct Answer Benzo's Diphenhydraimine Dopamine agoinists Meperidine Muscle relaxants Neuroleptics Scopolamine What are the highlighted drugs for on the delerium list - Correct Answer Anticholinergics Benzodiazepines Muscle relaxants opioids corticosteroids metoclopramide predisposing factors for delirium - Correct Answer predisposing factors for delirium - Correct Answer • Age

• Male sex
• Cognitive status
• Functional status
• Sensory impairment
• Decreased oral intake
• Medications
• Multiple psychoactive agents
• Polypharmacy
• Alcohol abuse Coexisting medical conditions - Correct Answer • Severe illness
• Multiple comorbidities
• Chronic renal or hepatic disease
• History of stroke
• Neurologic disease
• Metabolic derangements
• Fracture or trauma
• Terminal illness
• Infection with HIV How o treat delirium - Correct Answer • Treat or reverse underlying medical cause(s)
• Thorough review of medications
• Non-pharmacologic approaches
• Pharmacologic agents

• Haloperidol
• Atypical antipsychotics
• Benzodiazepines (?) Pharm treatment for delirium Haloperidol - Correct Answer initial 0.25-0.5mg with a max of 3mg Oral, IM, IV risk of EPS increase is faily dose exceeds 3 mg This is the longest used one with the most large trials Agitated delirium Risperidone - Correct Answer initial 0.25-0.5mg with a max of 3mg Oral, or IM Cones with slightly less risk of EPS then with haloperidaol aat low doses Only small studies but considered similiar to haloperidol Olanzapine - Correct Answer initial 2.5-5 mg with a max of 20mg Oral, Sublingual, or IM OLanzapine in more sedating the haloperidal only small trials and oral reute is less effective then haloperidol Quitapine - Correct Answer initial 12.5-25mg with a max of 50mg Oral Much more sedating then haloperidol, with risk of hypotension Ziprasidone - Correct Answer Initial 5-10mg max of 40 Oral or IM It is more sedating han haloperidolk risk of cardiac arrhytmia heart failure and agranulocytosis Due to the above mentioned risk pretty much only used in the ICU as a last line option

Lorazapam in treatment of agitiated delirium - Correct Answer intital 0.25-.5 mg with a max of 2mg Oral, IM, IV More paradoxical excitation and respiratory depression than with haloperidol this is a second line agenst, it is used with your brother due to alcholo withdrawl or if patient has history of the neurolepti malignt syndrome agitated delirium - Correct Answer Precations with antipsychotic medications - Correct Answer • QT prolongation

• Polymorphic ventricular tachycardia
• Extrapyramidal symptoms/acute dystonia
• Neuroleptic malignant syndrome
• Hypotension, if hypovolemia is present
• Anticholinergic effects
• May lower seizure threshold
• Black box warning for dementia patients Life time prevalence of major depression in 60+ - Correct Answer 10.6 % How ever the 50+ age group has a lower rate of depression then the younger folds - Correct Answer thats not even a question Whata re the rates of dpression in community dwelling seniors - Correct Answer about 5% What if they are in an instituation - Correct Answer 15-25% what % of americans over the age of 50 have a mental health disorder - Correct Answer 20% What is the neumonic or depressionn - Correct Answer SIGECAPS SIGECAPS - Correct Answer -Sadness -Interest loss of pleasure or activities -Guilt or worthlessness -Energy -Concentration, or lack of -Appetite gain or loss -Psychomoter retarditaiton or agitation -Suicidility S = - Correct Answer Sadness

I = - Correct Answer Interest/ pleasure or loss of G = - Correct Answer Guilt or worthlessness E = - Correct Answer Energy, loss of C = - Correct Answer Concentration or lack there of A = - Correct Answer Appetite Wt gain or loss P= - Correct Answer Psychomotor retardation or agitation S = - Correct Answer Suicidility Which are the two that for a diagnosis you need to have a lest one of - Correct Answer

1. Sadness
2. Loss of interest or pleasure the 5 other ones are minor symptoms, but you need to have for the diagnosis at least a positive for #1 or # Bereavement controversy - Correct Answer -Included as a condition in DSM IV -Referred to as "bereavement exclusion" -MDD dx not given unless symptoms of grief persist for 2 months+ Wht happenned in DSM 5 - Correct Answer DSM 5 removed Bereavement Exclusion Providers encouraged to carefully consider presence of MDD in addition to Bereavement Increased diagnosis of MDD?? Does depression in elderly look like depression in the general population - Correct Answer No there is a decreased responsivness What are the inflammatory changes induce "Sickness behavior" - Correct Answer -Pro- inflammatory cytokines (TNF-alpha, IL-1 IL-6) -Mimic depressive or neurovegetative symptoms -↓ tryptophan and serotonin availability -↓mesocortical and mesolimbic dopamine systems -Stimulate HPA axis, and activate CRH

What are the neurological changes in the elderly - Correct Answer Hippocampal volume decreases Frontostriatal dysfunction Vascular changes in elderly associated with depression - Correct Answer "Vascualar depression" "White matter hyperintensities" Late life depression and medical comorbidities - Correct Answer -Higher rates of depression dx in... -History of MI, History of CHD, those undergoing cardiac catheterization, etc............ -Cancer dx = 4x increase in MDD dx within 2y -Poorer physical health outcomes in those with depression -Increased mortality in those with BrCa + MDD -Higher costs of care for those with dual diagnoses -92% higher total health care costs for CHF + MDD v. CHF alone With neurology is it depression or a medical cormibidity - Correct Answer Like the difficulity o distinguishing dementia, TBI, Seizures, CVA, parkinson from depression What could be a issue with endocrine system causing depression - Correct Answer Diabetes and hypothyroidism each can have symptoms that can resemble depression nutritional issues could also lead to diabetes - Correct Answer -Iron deficient anemia -Vitamin B12 deficiency vitamin B12 deficiency - Correct Answer medication induced depression - Correct Answer Clonidine Methyldopa Reserpine Topirmate Vigabatin Levetiracetam Phenobarbital Phenytoin Clonidine - Correct Answer

Clonidine - Correct Answer Clondine incidence of inducing depression - Correct Answer 1.5% Clonidine mechansim - Correct Answer Reduces NE output cii Alpha 2 receptor Methyldopa - Correct Answer incidence of drug induced depression with methyldopa - Correct Answer 3.6% Methyldopa mechanism in depression - Correct Answer Partial agonism of the NE receptor Reserpine - Correct Answer reserpine - Correct Answer reserpine incidence of drug induced depression in the elderluy - Correct Answer 7% reserpine mechanism of action for elderly deression - Correct Answer Depletes neuronal NE, DA, 5HT Topiramate incidence of drug induced depression - Correct Answer 3-9% topiriamte MOA for depression - Correct Answer Increased GABA, attenuates glutamate Vigabatrin - Correct Answer Vigabatrin moa for inudcing depression - Correct Answer increased GABA Levetiracetam mechanism for inducing depression - Correct Answer Increased GABA, and also increases suicidility what is the incidence of levitracetam induced depression - Correct Answer 3-5% Random status elipiticus stuff with phenobarbital - Correct Answer What is the rate of drug induced depression with phenobarbital - Correct Answer 1- 40%, really this is one hell of a band here Does phenytoin cause drug induced depression - Correct Answer Probably not, there are only case reports. phenobarbital - Correct Answer

What are other drugs that can cause mediation related depression - Correct Answer Metoprolol Digoxin Cimetidine Cortisteroids GnRh agonists Tamoxifen Interferon Alpha Vinvristine, vinblastine Alcohol and opioids What is Metprolol mechanism of induced deprression - Correct Answer Ne antagonism What is the incidence of metoprolol induced depression - Correct Answer Its about 5 % Is it a class effect with all beta blockers - Correct Answer Possibly but we dont have great evidence on it Do Digoxin and Cimetidine have know mechanism for medication induced depression, and how often does it occur - Correct Answer Unknown mechanism, and there are case reports only, so unclear if real issue How do corticosteroids induce medication depression - Correct Answer They elevate plasma cortisol What is the incidence of cortosteroids related medication induced depression - Correct Answer 1.3-15% What is the rate that GnRH agonists induce depression - Correct Answer 26-43% GnRH agonists - Correct Answer How do GnRH agonists cause medication induced depression - Correct Answer Reduction of Estrogen and Androgen production At what rates does Tamoxifen cause medication induced depression - Correct Answer 1-20% By what mechanism does tamoxifen cause an increasae in medication induced depression - Correct Answer The Reduction in estrogen functioning Interferon Alpha has an incidence of medication induced depression that is - Correct Answer pretty high at 13-33%

What cancer drugs are there case reports of medication induced depression - Correct Answer Vincristine, and Vinblastine What drug are stated to cause medication induced depression - Correct Answer alcohol, which is a CNS depressent, also, I believe this is used by many americans to treat depression :( What was the evidence for beta blockers - Correct Answer patients using beta blockers in the 90's had a higher rate of also getting anti depressents, the issue with this is that the studies were never repeated, without better study designs Other issue with the beta blocker studies - Correct Answer May be associated with decreased energy, sexual dysfunction, and fataigue, which can resemble depression So what about suiides in the elderly - Correct Answer They have a lower rate of suicidal ideation, but they are far more competent at it 1/4 are successful, white men as always the back bone of American competency have the highest rates Which drug classes almost universally have a warning for suicide ideation - Correct Answer Antidepressents How does this afect the elderly - Correct Answer There actually less likely to kill them selves when on these drugs then the youth. After all why rush it when the grim hand of death is coming down upon you by nature. Which antidepressents are sup dup easy to off your self with - Correct Answer MAO, and TCA MAOi serious interaction issues - Correct Answer Tyramine reaction, dietary requirment, and a low lethal dose MAOi list - Correct Answer TCA side effects are - Correct Answer Consitiputation Urinary retention orthostasis tachycardia sedation confusion THERE IS A LOW DOSE REQUIRED FOR SHUFFLING OFF THIS MORTAL COIL What are some of the common SE of Buproprion - Correct Answer GI Decreased sex drive

HTN

anxiety Headache SE of Mirtazipine - Correct Answer Sedation and weight gain whata re the three stages of treatmeent - Correct Answer Acute Continuation Maintaince How long is acute treatmnt - Correct Answer 8-12 weeks Goals of acute treatment - Correct Answer Response Remission Improve functioning how long is the continuation phase - Correct Answer 4-9 months What is your goal in continuation stage - Correct Answer maintain remission How long is the maintainence phase - Correct Answer 6-24 months, or until the bitter end How do you know if depression treatment is working - Correct Answer A response is a 50% or more reduction in baseline symptoms/scores ARemission is a score in the non depressed tange And a partial response is a 25% reduction in symptoms What are the tests that they are normally doing here - Correct Answer HAM-D HAM- MADRS PHQ- CSDD GDS PHQ-9 - Correct Answer PHQ-9 scoring - Correct Answer If you have a partial response to the depression what are your options. Also remember a partial response is a 25% reduction in symptoms - Correct Answer Switch or augment Switch - Correct Answer First med trial

<25% Response More time available Avoid polypharmacy Patient preference When do i choose to augment - Correct Answer Tried 2 or more meds before 25-49% response Initial med well-tolerated Less time Patient preference What are your most common augmentation agents - Correct Answer Quetiapine Aripiparazole Olanzapine Risperidone Side effects of Quetipine - Correct Answer Weight gain, metabolic monitoring reommended What are side effects of Risperidone - Correct Answer EPS risk, metabolic monitoring, wirely not FDA approved, but has RCT data If i am going to augment with Buspirone what is an issue - Correct Answer There is a delayed onset of about 2 weeks If i wish to augment with lithyronine what are the risks - Correct Answer Risks for hyperthyroidism, hypertension, tachycardia, and no good long term safety data out there What about augmenting Lithium - Correct Answer There is some risk of toxicity Bupropion is a great augmenting drug, what meidcal condition does concern me - Correct Answer Use it cautiously in seizure disorder What would be a great potential side benefit with using Bupropion - Correct Answer It is beneficial for smoking cesstaion. What are the benefits with Mirtazipine - Correct Answer IT is both beneficial for insomnia, and its beneficial for those with low body weight Yeah is that last one really normally really a benefit in modern america - Correct Answer In theory yes, but most of the time always important to remember that Mirtazipine is one that is really associated with substantial weight gain What is monitoring that you do with the anit psy rugs - Correct Answer All the metabolic stuff like Body weight, BMI, blood pressure

What are some of the physiological changes in the elderly that can alter drug absorption

• Correct Answer There is a decrease in drug absorption, due to decrease in the rate of gastric emptying There is an increase in fat tissues, which for lipid soluble drugs can increase their Vd There is a decrease in total body water, and decrease in volume of distribution Why does the increase in adipose tissue matter - Correct Answer most psychotrophic dugs are fat soluble, so lipophillic conction will increase the half life of lipophillic drugs such as benzo's, diazepam, clonzapam. diazepam - Correct Answer Why is decreasing amount of body water an issue - Correct Answer it decreases the margin of safety iin water soluble drugs such as lithium The elderly also hve a deccrease in the amount of plasma proteins - Correct Answer Increase concentration of unbound drugs, many are pharmacologically active such as anti seizure medications and TCA's In the elderly there is a decrease in hepatic blood flow what issue does this cause - Correct Answer If means there is less metabolism in the liver, which means drugs cleared by CYP, or activated by cyp's sell either have a longer half life, or be less effect What are the drugs that we just covered that decreased renal filtration would be a potential issue - Correct Answer venlafaxine, duloxetine, paliperidone, lithium, memantine, rivastigmine Fluxetine and Paraoxetine are potent inhibitors of - Correct Answer 2D duloxetine is a mild inhibitor or - Correct Answer 2D Bupropion inhibitor of - Correct Answer 2D Fluoxetine metabolite - Correct Answer 3A CYP2D6 substrates - Correct Answer What are your major cardiovascular consideration with the elderly - Correct Answer Increased QTC prolongation QT prolongation drug in this lecture - Correct Answer Citalopram In elderly the max dose for Citalopram, due to QT prolongation issues is - Correct Answer 20mg/day

Why do SSRI increase bleeding risk - Correct Answer Serotonin is one of the tools to get platelets to aggregate, when an SSRI is being used What do the SSRI do to the stomach that can be an issue in the elderly - Correct Answer SSRI can increase gastric acid sereation and this can lead to increased ulceration What is the great thing about ECT - Correct Answer ECT, induction of seizure with electrical stimulus, work quickly, and the response is seen in the next couple of weeks Does usually require 6-12 treatments administerd every 3 weeks With the Beer's criteria which drugs do you want to aoid to help avoid falls - Correct Answer -Avoid the Z drugs in possible, could try alternatives such as melatonin, melatonin agonist, or doxepin -Avoid the benzodiazipines with long half lives such as diazaapam -Avoid the benzo's with active metabolites (diazepam chlodiazeposide -Good alternative are lorazapam, oxazepam, and temazepam What is a benzo with a long half life - Correct Answer Diazapam Which are some good benzo's because they do not have active metabolites - Correct Answer LOT Lorazepam Oxazepam Temazepam Begun the epilepsy and seizure management slides - Correct Answer Who is more likley to get epilepsy in the US, the young or the elderly - Correct Answer Older adults, 1.5%, compared to 0.5% in the youth What are the peak ages of intial onset - Correct Answer 0- 5- early puberty and in older adults In epilepsy in older adults are aura more or less frequent - Correct Answer Aura is less frequent, or it is non specific such as dizzziness In epilepsy with seizures what of post ictal confusion - Correct Answer It can be prolonged

what is an issue with diagnosing seizures in the elderly - Correct Answer epilepsy may present with altered mental status, confusion or memory issues What other diagnosis could epilepsy in the elderly be confused with - Correct Answer seizures could me misdiagnosed as TIA or dementia What if you dont treat the first incidence of epilepsy - Correct Answer The recurrence rate is higher then it is in younget adults after the first seizure is untreated What are the consequences of not diagnosis a seizure in the elderly - Correct Answer - Loss of independence and self‐esteem -Falls and fractures secondary to seizures •Increases risk 2 -6 fold What are the predisposng conditions for epilepsy (all ages) - Correct Answer •Idiopathic (70%) •Genetics •Head trauma •Brain tumors •Cerebrovascular disease •Infection •Alcohol and drug withdrawal What two conditions other the idiopathic cause an increase in epilepsy in older adults - Correct Answer -Stroke (vascular)39‐45% -Degenerative (i.e. Alzheimer's) 12% _____% of newly diagnosed seizures in older adults are due to stoke - Correct Answer 1/ Are focal or general seizures more common after a stroke - Correct Answer -Focal (60%)> Generalized (25%) What sub type of focal seizures is more common after a stroke - Correct Answer - Focal seizures are commonly simple motor seizures (75%) that sometimes secondarily generalize (25%) Why is the diagnosis of stroke after seizures difficult - Correct Answer Transient ischemic attack (TIA) can lead to simple focal seizures. Length of event is differential features. Simple focal seizures (few minutes). TIAs (longer, usually hours) What is the definition of an early seizure in a stroke - Correct Answer -By definition within 7 days of stroke when do most of them occur - Correct Answer majority of them occur with 48hr Do you start treatment - Correct Answer -Some neurologist start ASDs after first seizure while others wait until at least after the second seizure

Wht are the risk of late post stroke seizure - Correct Answer -2 -6 % during first year after stroke -1 ‐2% thereafter ->17‐fold increase in the relative risk of seizures compared with the same population of the same age without stroke. Is that a cumulative 1-2% risk increase - Correct Answer yup When to use ASD post stroke epilespsy - Correct Answer If the patient has a stroke, with no seizure - Correct Answer No evidence that prophylaxis with ASD is effective With Stroke patient has early acute seizure - Correct Answer Consider metabolic and other causes, risk of recurrent seizures, adverse effects of ASD, drug interactions What if a=patient has early acute + recurrect seizure - Correct Answer start ASD What if patient has a late seizure with no acute seizure - Correct Answer Consider risk of recurrent seizures, adverse effects of ASDs, drug interactions and patient preference what if patient has a late and recurrent seizure - Correct Answer start ASD If after a stroke it is a first seizure after a stroke what is the decision to treat require - Correct Answer •Rule out and treat underlying cause if possible •Abnormal EEG? •History of previous cerebral insult (stroke, TBI) •Treat if seizures reoccur •If first seizure is a generalized tonic‐clonic (GTC) seizure with no known etiology a decision is usually made to start ASD treatment Which drugs treat focal +- 2 degree - Correct Answer Phenytoin Carbamazepine Oxcarbazepine Gabapentin Pregablin Lacosamide Vigabatrin do any of the above drugs treat generalized seizures - Correct Answer NO Which list of drug treat both Primary generalized and focal aeizures - Correct Answer Valoprate Lamotrigine Topirimate

Zonisimide Levetiractam Rufinamide Generalized, secondary or both, Valpooate - Correct Answer Both Generalized, secondary or both, carbamazepine - Correct Answer focal Generalized, secondary or both, Gabapentin - Correct Answer focal Generalized, secondary or both, Topitmate - Correct Answer both Generalized, secondary or both Levetiracetam - Correct Answer both Generalized, secondary or both, locasamide - Correct Answer focal Generalized, secondary or both, Lamotrigine - Correct Answer both Generalized, secondary or both, Phenytoin - Correct Answer focal Generalized, secondary or both, Zonisamide - Correct Answer both In a medically stable or medically ill man or women what are the top two drugs - Correct Answer Lamotrigine Levetiracetam IF those two fail what is the first line replacement - Correct Answer Lacosamide What is a consideration when choosing drugs in the elderly - Correct Answer Older adults with focal seizures were shown to have significiiantly more cognitive dysfunction then healthy aged match controls There is also ASD SE that are different to seperate then post stroke effects - Correct Answer cognitive effects tremor sedation ataxia What is one of the main reasons that Lamotrigine and Levetiracetam are on the top of the prescribers lists - Correct Answer they had the highest adherence rates Which drugs had lower adherence rates - Correct Answer Phenobarbital, valproate, and gabapentin What is the other reason they were at the top of the prescribers list - Correct Answer They each also had the highest rates of seizure free

Carbamazepine main adverse eent - Correct Answer drowsiness Gabapentin main adverse events - Correct Answer Cognitive, diziness, drowsiness Levetiracetam main adverse events - Correct Answer drowsiness, psychiatric Lamotrigine - Correct Answer inbalance Oxcarbazepine - Correct Answer dizziness, and drowsiness Topirmate main SE - Correct Answer cognitive, drowsiness valproate min adverse event - Correct Answer tremor Zonisimide main adverse event - Correct Answer cognitive WHich ASD are known to be broad spectrum inducer of CYP enzymes - Correct Answer Carbamazepine, Phenytoin, Phenobarbital What do they induce - Correct Answer CYP1A2, CYP2C, CYP3A, UGTs What do Topirmate and Oxcarbazepine induce - Correct Answer 3A Which ASD are the selective UGT inducers - Correct Answer Lamotrigine Oxcarbazepine Which ASD is known as a broad spectrum inhibitor - Correct Answer Valproate Valproate inhibit's - Correct Answer UGTs, CYP2C9, Epoxide hydrolase Which two drugs are selective CYP2C19 enzyme inhibitor - Correct Answer Topiramate Oxcarbazepine What are the fab 5 of ASD and drug interaction. (They neither induce nor inhibit) - Correct Answer Gabapentin Levetiracetam Pregabalin Zonisamide Lacosamide Why is all of these drug interactions so important - Correct Answer cause its the elderly and most will have other conditions, with lts of other drugs Which are the statins with 3A4 metabolism - Correct Answer Lovastatin

Simvastatin Fluvastatin Atorvastatin What when older women take ASD - Correct Answer there is a two fold higher risk of bone fracture There is also the obvious risk of falls if a person has an epileptic fit DOes anyone know why ASD are associated with decreased bone density - Correct Answer -Generalized seizures -Duration of epilepsy -Polytherapy -Patients receiving enzyme inducing ASDs (phenobarbital, carbamazepine, phenytoin, primidone) had increased risk compared to those receiving valproic acid, lamotrigine, clonazepam, gabapentin, topiramate and ethosuximide. so which types of ASD had the highest risk - Correct Answer enzyme inducing ASDs What are the enzyme inducing ASD - Correct Answer phenobarbital, carbamazepine, phenytoin, primidone Which are the non-enzyme inducing ASD - Correct Answer valproic acid, lamotrigine, clonazepam, gabapentin, topiramate ethosuximide Which CYP's decrease in the elderly - Correct Answer All of them What is the one clearence mechanism that is with you to the very end - Correct Answer UGT As you age what happens to you albuminin - Correct Answer it decreases why is this important - Correct Answer it can alter how you measures drugs and their impact Decreased protein binding only effects _______ _________ drugs that are monitored using ____________ - Correct Answer Highly protein bound Plasma concentrations This could result in __________ underestimated ________ concentrations with decreased albumin - Correct Answer total concentration

unbound (active) concentration Which two ASD have protein binding that exceeds 90% - Correct Answer Phenytoin Valproate Phenytoin is primarily used for - Correct Answer focal seizures The normal issue with phenytoin is that it is a broad _________ includigng _______, ______, ______, ________ - Correct Answer inducer CYP1A2, CYP2C, CYP3A, UGTs Phenytoin is metabolized by - Correct Answer CYP2C9 (major) and CYP2C19 (minor) Why is aging and phenytoin notoriously for playing bad together - Correct Answer - Decreased protein binding -Maximum rate of metabolism (Vmax) declines with age What is the intitial dosing of phenytoin - Correct Answer 200 mg/day What happens in hypoalbuminemia - Correct Answer The tests for phenytoin concentrations run on the assumption of 90% protein bound s you age there is less protein, and also less metabolism of phenytoin by th CYP, so phenytoin levels can build up substantially What are the phenytoin SE associated with CNS - Correct Answer ataxia, confusion, coordination problems, cognitive impairment, dizziness, headache, lethargy, nystagmus, sedation, visual blurring How common are rash's and phenytoin - Correct Answer -2‐5% mild maculopapular eruptions -Can be early sign of hepatotoxicity What is the serious rash based SE associated with phenytoin - Correct Answer SJS what is the genome halotype associated with SJ/TEN - Correct Answer HLA-B 1502 What tooth based disease is assoiciated with Phenytoin - Correct Answer Gingival hyperplasia How can we reduce the risk of Gingival hyperplasia with patients on Phenytoin - Correct Answer Supplement Folic Acid Supplementation with folic acid 0.5 mg/d was shown to decrease the development of gingival overgrowth by 67% in children ages 6‐15y. Phenytoin 60's counseling - Correct Answer •May cause drowsiness, unsteady gait, visual blurring especially during first part of treatment.

•If persist or reappear may need dosage adjustment •Discuss potential for gum hypertrophy and recommend good oral hygiene •If skin rash appears, contact prescriber immediately. •Importance of compliance Valproate can be used for both - Correct Answer generalized and focal seizures most common adverse event associated with Valproate - Correct Answer tremor Valproate is a broad spectrum ___________ of _______, _______, _______ - Correct Answer inhibitor UGT, 2C9, Epoxide Hydrolase Valproate is _____% protein bound - Correct Answer 93% Valproate is metabolized by _______, ______, ______, and is highly protein bound to ______ - Correct Answer B‐oxidation, UGT, CYPs Albumin As you age there is -decrease protein binding ______ % of the free fraction -Decreased drug metabolizing capacity _____ decrease in unbound clearance - Correct Answer 44% 40% in older adults reduce the initial starting dose by ____% - Correct Answer 40% most common concentration related Side effect in Valproate is - Correct Answer Tremor 60's counseling point for Valproate - Correct Answer •May cause drowsiness and upset stomach‐especially during the first part of treatment •If persist or reappear, dosage adjustment may be needed •Take with food •Report to prescriber: -Abdominal pain, confusion, fatigue, dark urine, light stools (children )

•May cause increased appetite and weight gain. Suggest monitoring calorie intake and consulting with prescriber Carbamazepine is used for - Correct Answer focal seizures Most common adverse event with Carbamazepine is - Correct Answer Drowiness Carbamazepine is a broad spectrum __________, and it effects ____,______,______,______ - Correct Answer inducer CYP1A2, CYP2C, CYP3A, UGTs Carbamazepine is ____% protein bound - Correct Answer 75% Carbmazepine is metabolized by - Correct Answer CYP3A4 (major), Cyp1A2 and CYP2C8 (minor) Drugs that inhibit CYP _____ will cause clinically significant interaction with carbamazepine - Correct Answer 3A4 Decreased albumin will alter Carbamazepine levels because - Correct Answer •Both carbamazepine and its active metabolite, carbamazepine epoxide are 68‐85% bound to albumin and A1‐acid glycoprotein When it comes to clearence with carbamazepine, at what age ______ due you assume a decrease in clearence - Correct Answer 70 years old What are the neurosensory effects of carbamazepine - Correct Answer •diplopia, drowsiness, dizziness, blurred vision, paresthesias, ataxia, nystagmus, headache Carbamazepine anticholinergic side effects are - Correct Answer -urinary retention, dry mouth, etc can carbamazepine alter your lipid levels - Correct Answer -Increased total cholesterol, LD lipoprotein, and LD/HDL ratio What is carbamazepine dising in healthy adults - Correct Answer 200 mg BID, increase every 3‐5 days until receive daily doses of 800‐1200 mg/day In older adults what is the starting dose - Correct Answer 100 mg BID and monitor plasma concentrations What genome test do you do with Carbamazepine - Correct Answer HLA-B 15:02