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Toronto Notes 2019
Landmark Geriatric Trials
Geriatric Medicine GM15
Table 11. Common Medications (continued)
Drug Name Brand Name
Sleeping Medications
Dosing Schedule
3.75 mg PO qhs (initially)
15 mg PO qhs
0.5 mg PO qhs (initially)
Immediate release 5 mg PO qhs (initially), or extended release 2 mg PO qhs
Indications
Insomnia
Short-term management of insomnia
Anxiety, insomnia
Insomnia
Contraindications
Known hypersensitivity, caution in myasthenia gravis, severe hepatic disease
Geriatrics: dose reduction (dose- related adverse events)
Known hypersensitivity, myasthenia gravis, sleep apnea Geriatrics: dose reduction recommended
Known hypersensitivity, myasthenia gravis, narrow-angle glaucoma
Geriatrics: dose reduction recommended
Known hypersensitivity, concurrent immunosuppressive treatment
Side Effects
Bitter taste, palpitations, vomiting, anorexia, sialorrhea, confusion, agitation, anxiety, tremor, sweating, cognitive impairment, falls
Drowsiness, dizziness, impaired coordination, hangover, lethargy, dependence, cognitive Impairment, falls
Dizziness, drowsiness, lethargy, dependence, cognitive impairment, falls
Hypothermia, sedation, somnolence, fatigue
Mechanism of Action
Short-acting hypnotic (no tolerance effects)
Benzodiazepine: generalized CNS depression mediated by GABA
Benzodiazepine: generalized CNS depression mediated by GABA
Mimics hormone produced by pineal gland, regulates sleep cycle
zopiclone
temazepam
lorazepam
melatonin
Imovane®
Restoril®
Ativan®
Several brands OTC
Note: Docusate has been shown to be ineffective for the prevention/treatment of constipation in the elderly
Landmark Geriatric Trials
Trial
Optimal management of urinary tract infections in older people
Delirium is a strong risk factor for dementia in the oldest-old: a population-based cohort study
Donepezil and Memantine for Moderate-to-Severe Alzheimer’s Disease
Hip protectors for fracture prevention HYVET
PROFET
Yale Delirium Prevention Trial
Reduction of inappropriate benzodiazepine prescriptions through patient education: the EMPOWER cluster randomized trial
Updated Beers Criteria for potentially inappropriate medication use in older adults
STOPP and START. Consensus validation
A multifactorial intervention to reduce the risk of falling among elderly people living in the community
Frailty in older adults: evidence for a phenotype
Tube feeding in patients with advanced dementia: A review of the evidence
Systolic Hypertension in the Elderly Program (SHEP): antihypertensive efficacy of chlorthalidone
Systolic Hypertension in Europe (Syst-Eur) trial
Reference
Clin Interv Aging 2011;6:173-180 Brain 2012;135(9): 2809-16 NEJM 2012;366:893-903
NEJM 2000;343:1506-1513 NEJM 2008;358:1887-1898 Lancet 1999;353:93-97
NEJM 1999;340:669-676
JAMA Intern Med 2014;174:890-
898
J Am Geriatr Soc 2015;63:2227-46
Int J Clin Pharmacol Ther
2008;46:72-83
N Engl J Med 1994;331:821-827
J Gerontol A Biol Sci Med Sci
56:M146-56
JAMA 1999;282:1365-1370
Am J Cardiol 1985;56:913-20 Lancet 1997;350:757-64
Results
UTIs are over diagnosed and over treated in older people. Asymptomatic bacteriuria is very common in later life and should not be screened for or treated
First population study to show that delirium is a strong risk factor for dementia and cognitive decline in elderly patients
Continued treatment with donepezil was associated with cognitive benefits over the course of 12 mo in patients with moderate or severe Alzheimer’s disease
The risk of hip fracture can be reduced in frail elderly adults by the use of an anatomically designed external hip protector
Antihypertensive treatment with indapamide (sustained release), with or without perindopril, in adults 80 yr or older is beneficial
Demonstrates that an interdisciplinary approach to elderly adults with a previous history of falls can significantly decrease the risk of further falls and limit functional impairment
A risk-factor intervention strategy can result in significant reductions in the number and duration of episodes of delirium in hospitalized older patients
Direct-to-consumer education describing the risks of benzodiazepine use and a stepwise tapering protocol effectively elicits shared decision making and discontinuation of medications that increase the risk of harm in older adults
A 13-member interdisciplinary panel of experts in geriatric care and pharmacotherapy updated the 2012 AGS Beers Criteria to be avoided or dose-adjusted in older adults
STOPP/START is a valid, reliable, and comprehensive screening tool that enables the prescribing physician to appraise an older patient’s prescription drugs in the context of his/her concurrent diagnoses
A multiple-risk-factor intervention(medication adjustment, behavioural instruction, exercise program) strategy resulted in a significant reduction in the risk of falling among elderly persons in the community
This study provides a potential standardized definition of frailty in community-dwelling older adults, where three or more of the following criteria are present: unintentional weight loss, exhaustion, weakness, slow walking speed, and low physical activity
There is no direct data to support tube feeding of demented patients with eating difficulties for any of the commonly cited indications. Survival has not been shown to be prolonged by tube feeding.
Chlorthalidone is effective for lowering blood pressure in elderly patients with systolic hypertension
Among elderly patients with isolated systolic hypertension, antihypertensive drug treatment starting with nitrendipine reduces the rate of cardiovascular complications. Treatment of 1000 patients for 5 years with this type of regimen may prevent 29 strokes or 53 major cardiovascular endpoints