Opioids
What are the roles of parenteral opioids?
Morphine - most widely used, can be given IV
Meperdine - less potent, shorter acting
Hydromorphone - 1-2 mg IM every 2-3 hrs
Methadone - 10mg IM or oral every 4-6 hrs longer acting
What are the physiologic consequences of uncontrolled pain?
Cardiovascular - tachycardia hypertension increased cardiac workload, pulmonary - hypoxia hypercarbia atelectasis decreased cough, GI - Decreased gastric emptying nausea/vomiting ileus, Renal - urinary retention, endocrine - increased adreneric activity catabolic state sodium/water retention, immunologic - impairment slowed would healing , MSK - splinting contractures decreased mobility, hematologic - increased coagulation, neurological - anxiety fear anger fatigue delirium
Role of oral analgesiscs? Name em!
Effective adter pain severity decreases, asprin often avoided, acetaminophen + codeine / propoxyphene, hydrocodone + acetaminophen, Oxycodone + asprin, oxycodone + acetaminophen
What are some pharmacodynamic changes with aging?
Geriatric patients are more sensitive to drugs, aging leads to fewer receptors, homeostatic responses are diminished, average blood pressure increases with age, orthastatic hypotension also increases with age, posprodial blood glucose increases by 1 mg/dl each year above 50
ANTI-HTN Drugs! spill it.
Hypertension should be treated in the elderly, aggressive management can help reduce dementia, thiazides are usual initial choice, Calcium channel blockers are effective, betablockers less often used than CCBs except in chronic HF patients, ACE-I less useful HF or DM is present, Vasodilators are rarely used, monitor regularly for orthostatic hypotension.
I can be given orally and IM, i dont cause respiratory depression, there's no known complications with NSAID, make sure you dont dose me more than 120 mg/day, what am I?
Ketorolac
this goes from strong parenteral opioids, enteral opioid to non-opioid analgesic as pain decreases
WFSA analgesic ladder
Going directly into the ___ space, ___ opioids produce intense prolonged segmental analgesia, with less respiratory depression sympathetic motor or sensory disturbances, slightly delayed onset of action but longer pain relief, superior to IV and IM opioids, patients are more alert better GI functions, pruritus nausea urinary retention and respiratory depression
Continuous Epidural Analgesia
What precautions we need to take while prescribing sedatives-hypnotics in the elderly
BZDs, BRBs half life increases 50-150% between ages 30 and 70, BZD with active intermediate metabolites to be avoided, decline in renal function and liver disease can contribute to long t1/2, volume distribution may increase for some drugs, loraxepam, oxazepam and temazepam may be less affected by these changes, PD sensitivity to sedative-hypnotics may also vary in elderly
Name a few practical considerations in geriatrics
Patient as participant, deliberate nonadherence, take a careful drug history, lack of saliva, arthritis, labels should be large and color coded, impaired hearing
Strong?
Weak?
Not Recommended?
Fentanyl, Hydromorphone methadone morphine oxycodone oxymorphone
Codeine Hydrocodone Tramadol
Meperidine
What are some factors that affect postoperative pain?
Introthoracic intra-abdominal and orthopedic procedures; duration of operation degree of operative trauma type of incision intraoperative retroaction; gentle tissue handling expedient operations good muscle relaxation; gentle tissue handling expedient operations good muscle relaxation; nature of procedure influence pain; same procedure different amounts of pain; physical emotional and cultural characteristics
Intercoastal block, say what?
Used to decrease pain following thoracic and abdominal operations, block does not include the visceral afferent nerve fibers, however the block eliminations muscle spasm helps restore respiratory function, no risk of hypotension, analgesia for 3 -12 hrs, risk of pneumathorax, repeated injections, catheter in the intercoastal space/pleura, bupivacaine
What precautions we do we need to take while prescribing opioid analgesics in the elderly
Elderly patients are more sensitive to the respiratory effects of analgesics, choose opioids only for acute pain conditions, studies show underutilization of opioids in elderly
Are these common reasons for drug adverse reactions in the elderly? Prescription errors and patient errors compound the problems example cimatidine, average number of prescriptions between 6 and 8, 50% of patients in long term facilities will have ADRs
Yes
Patients needs, frequent reassurance, genuine concern, frank discussions of progress any complications are helpful, preoperative drug and substance abuse, patient care team
This is how you determine the starting doses of oral ____; convert the patients daily opioid dose into oral morphine equivalents, reduce the calculated daily oral ____ dose by 33-50%, divide the resulting reduced daily dose by 3, and prescribe this dose of oral __ every 8 hrs.
Methadone
___ administration of a combination of local anesthetics, infiltration following induction of IV anesthesia prior to skin incision
Direct infiltration
WHare are some age related changes in antipsychotic pharmacotherapy
Antipsychotic dosage should not be increase in elderly, no evidence these have any beneficial effects in Alzheimer's dementia, anti-muscarinic effects of phenathiazines might worsen memory impairment and intellectual dysfunction, Efficacy in agitated and combative patients is mostly due to sedative effect, Haloperidol causes less sedation but more likely to cause EPS toxicity, Chlorapramazine induces orthostatic hypotension, atypical antipsychotics are not much superior to typical antipsychotics, Olanzapine is better than 2nd gen antipsychotics in elderly terms of efficacy
Anti-inflammatory drug stufffff
Asprin, newer NSAIDS, COX2 selective NSAIDS are not any safer, renal function monitoring may be needed, Long term high dose corticosteroids can lead to osteoporosis
Opioids are the main stay, there's a direct effect on these receptors, the IM route result in wide plasma concentration, and I've been given too small and infrequent doses, what am I?
Parenteral Opioids
name some non opioid analgesics
Acetoaminophen, ibuprofen, ketorolac, naproxen, celecoxib
What are some major pharmacokinetic changes in elderly? And elaborate on them.
Absorption, distribution, metabolism, elimination
are there any age related changes in antidepressant pharmacotherapy
Ophthalmic drugs
Management of glaucoma does not differ, age-related macular degeneration (AMD), Advanced AMD treated with neovascular AMD.