COURSE TITLE: Pharmacologic Management of the Geriatric Patient: Oral Health Care Considerations

COURSE TITLE: Pharmacologic Management of the Geriatric Patient: Oral Health Care Considerations

COURSE INSTRUCTOR: Ann Eshenaur Spolarich, RDH, PhD

COURSE CREDITS: 3 CEUs

COURSE DATE: April 28, 2017

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COURSE DESCRIPTION: The purpose of this course is to review characteristics and disease trends among the aging population, and oral disease risks associated with medications and common systemic diseases. Most patients take multiple medications, many of which have oral complications and drug interactions of significance to dentistry. Medication therapies, oral drug and disease complications, drug interactions and dental practice management considerations will be discussed. Recommendations for treatment modifications and oral hygiene self-care programs will be provided.

LEARNING OBJECTIVES:

Upon completion of this continuing education program, course participants will be able to:

1. Describe common oral disorders observed in the elderly population, including xerostomia, taste and smell disorders, orofacial muscular disorders, and lichenoid drug reactions.

2. Discuss changes in pharmacokinetics associated with normal aging.

3. Describe the Beers Criteria for potentially inappropriate medication use in older adults.

4. Identify drugs that are associated with an increased risk for falling.

5. Identify drugs that are associated with risk for alteration of the QT interval.

6. Discuss considerations with antibiotics, benzodiazepines, sedatives and opiate use in older adults.

7. Discuss indications and adverse events associated with drugs used for dementia and Parkinson’s disease.

8. Discuss potential uses and risks associated with antipsychotic medications in older adults.

9. Describe different classes of blood altering medications with indications for use.

*These course materials may not be duplicated without the written consent of the course instructor.

I. Pharmacokinetics of Normal Aging

·  Decreased absorption due to increased stomach acidity (*why elderly use antacids)

·  Decreased liver function; more drug unchanged (more “active” drug)

·  Decreased lean body mass

·  Increased body fat (drug storage)

·  Decreased total body water (drug more concentrated in blood)

·  Decreased plasma proteins (more unbound “active” drug)

·  Less binding capacity (decreased plasma proteins), less metabolism (decreased liver function) and decreased renal function allow for normal doses of drug to act at overdose levels in the geriatric patient

·  Give lower dose

·  Liver diseases = in most cases, drug metabolism is reduced due to diminished function of the cytochrome P-450 system; dosing must be reduced

·  Renal diseases = results in renal impairment of drug excretion; dosing must be modified on the basis of renal clearance values of the drug

II. Benzodiazepines

·  Commonly abused

·  Prescribers rarely understand addictive quality of these meds with related complications in elderly patients

·  Patients receive prescriptions from multiple providers

·  Patients develop “benzo-abstinence syndrome” due to unavailability of drug or during hospitalization for other medical problem

Indications for BDZs

·  Chronic anxiety

o  Should assess for depression

o  Prescribe antidepressants with slow discontinuation of BDZs

·  Depression

·  Sleep disturbance

o  Chronic insomnia significant problem in elderly

o  Rarely improves with long-term use of BDZs

o  Nightly use of BDZs lose effectiveness after 3-6 mos (tolerance)

o  Requires steadily increasing doses to initiate sleep

·  Long-term use produces significant physical dependence or addiction

Complications of BDZs

·  Exacerbates chronic medical problems

o  COPD, GERD

·  Increases length of stay and morbidity in hospitalized patients

·  Higher rates of MVA and falls

·  Significant additive effect with other sedative hypnotic drugs (opiates, alcohol)

·  Prolonged half-life predisposes to easy intoxication

·  Withdrawal syndrome occurs after stopping (similar to alcohol withdrawal)

·  Withdrawal often happens following admission to hospital for other medical reason (e.g. surgery)

·  Treatment for BDZ abuse:

o  Detoxification and withdrawal

o  Appropriate therapy for psychiatric problems

o  Long-term addiction treatment (e.g. AA, NA)

·  If less than 2 years of life remaining, remain on BDZs but monitor dosages

·  Most have very long half-lives

·  Most are metabolized to active compounds

·  Repeated dosing results in accumulation of drug in the body

·  triazolam (Halcion) – shortest half-life of oral meds

o  fast onset of action

o  *no kinetic data reported with multiple titration doses (used for oral conscious sedation)

§  “unlabeled” use

o  elderly experience greater sedation and increased psychomotor impairment

§  much higher risk for oversedation

III. *Beers Criteria

·  3 lists of medications that pose potential risks outweighing potential benefits for people 65 and older

·  Medications that are potentially inappropriate because:

o  pose high risks of adverse effects

o  limited effectiveness in older patients

o  alternatives are available

·  Medications that are potentially inappropriate for those with certain diseases or disorders:

o  drugs may exacerbate health problems

·  Medications to be used with caution:

o  more risks than benefits

o  may be the best choice for a particular individual if administered with caution

o  medications need to be tailored to the unique needs of each patient

·  Benzodiazepines are to be avoided for treatment of:

o  Insomnia

o  Agitation

o  Delirium

·  Flumazenil = BDZ antagonist = “blocker” drug

·  Will not block CNS effects from alcohol, barbiturates, general anesthetics or opiates

·  May not reliably reverse respiratory depression/hypoventilation

o  Establish airway

o  Provide ventilation

·  BDZ reversal may cause seizures = be prepared to manage

IV. Opiates in Older Adults

·  Not all pain responds to same medications

·  When should treatment be intensified?

·  Unresolved pain or continued complaints of pain despite escalating doses of prescription opioids:

o  Disease progression

o  Self-medication of co-morbid psychiatric and/or physical complaints

o  Diversion

o  Pseudo-addiction = providing analgesia stops behaviors

·  Altered CYP450 enzymes

·  Reluctance to report adequate pain relief

o  Fear that care will be reduced

o  Fear that clinician will stop searching for underlying cause of pain

o  Misconceptions or misunderstanding regarding opioid treatment

*Avoid concurrent use of opiates and benzodiazepines whenever possible

Alternative Interventions to Pain Management

·  Musculoskeletal pain = acetaminophen or NSAIDS

·  Neuropathic pain = tricyclic antdepressants or anti-epileptics; topical anesthetics for localized neuropathic pain

o  Sympathectomy = weak evidence

·  Neuralgia = local anesthetics + steroids; botulinum toxin

·  Joint pain = steroids, hyaluronic acid

·  Cognitive behavioral therapy

·  Physical activity

·  Assistive devices

·  Transcutaneous electrical nerve stimulation (Tens units)

·  Massage

Should we use opiates in older adults?

·  Frequent occurrence of both cancer and non-cancer persistent pain

o  opioid analgesics are appropriate for moderate to severe persistent pain

·  Challenges: factors involved in making appropriate choices, monitoring the beneficial effects of pain relief and managing side-effects

·  Goals of using opioids = improved function and quality of life

Opiates and End of Life Care

·  Pain management in the elderly is undertreated

·  Challenges with pain management:

o  co-morbidities

o  polypharmacy

o  cognitive dysfunction

·  In the geriatric population, the assessment of pain requires measurement of:

o  pain intensity

o  delineation of opioid responsiveness

o  clarification of the impact of pain on patient’s

§  psychological

§  social

§  spiritual

§  existential domains

V. Drugs and Falls

·  Many drugs increase risk for falling

o  Antihypertensives (orthostatic hypotension)

o  Antidepressants

o  Sedative hypnotics

o  Antipsychotics

o  Benzodiazepines

o  Opiates

o  NSAIDS

o  *Alcohol

·  Risk assessment and prevention

VI. Drugs that Alter the QT Interval

·  Drugs that prolong the QT interval:

o  Fluoroquinolone antibiotics

§  moxifloxacin (Avelox)

§  ciprofloxacin (Cipro)

§  levofloxacin (Levaquin)

o  Macrolide antibiotics

§  azithromycin (Zithromax)

§  clarithromycin (Biaxin)

o  Azole antifungals

§  fluconazole (Diflucan)

§  ketoconazole

§  itraconazole (Sporanox)

o  Epinephrine

Lexicomp® Database 2013; Mosholder AD, Mathew J, Alexander JJ, Smith H, Nambiar S. Cardiovascular risks with azithromycin and other antibacterial drugs. N Engl J Med. 2013 May 2;368(18):1665-8.

VII. Considerations with Antibiotics

Clarithromycin/Azithromycin

·  Caution in liver disease = hepatotoxic

o  Can lead to hepatitic failure, death

·  Discontinue immediately if symptoms of hepatitis:

o  Malaise, nausea, vomiting, abdominal colic, fever

·  Alters QT interval of the heart = caution with vasoconstrictor

o  Elderly at greater risk

o  Avoid if uncorrected hyperkalemia or hypomagnesemia

o  Avoid if bradycardia

o  Avoid if taking Class I or Class III antiarrhythmics

o  Contraindicated in patients with ventricular arrhythmias (including torsade de pontes)

Pseudomembranous Colitis

·  Greatest number of antibiotic-associated cases of C diff diarrhea are from cephalosporins

·  Also clindamycin

o  *may occur with many antibiotics

VIII. MAJOR TRANQUILIZERS/ANTIPSYCHOTICS

A. Pharmacology and Use

-Older term: neuroleptic drugs

-A chemically diverse but pharmacologically similar class of drugs used to treat a variety of conditions

-Used in the treatment of:

-Psychotic disorders – Schizophrenia, paranoia

-Acute delirium and dementia

-Manic episodes during induction of lithium

-Movement disorders – Huntington’ disease, Tourette’s syndrome, ballismus

-Intractable hiccups

-Severe nausea and vomiting

-Individual drugs bind to a variety of receptors and act as antagonists:

-dopaminergic, alpha1 and alpha2 adrenergic, serotonergic (5-HT), muscarinic,

H1 histamine, sigma opioid

-Blockade of dopaminergic transmission in various areas of brain is thought to be responsible for their major effects

-Antipsychotic action = blockage in prefrontal cortex and limbic areas

-Extrapyramidal side effects = blockade in basal ganglia

-Antiemetic effects = blockade in chemoreceptor trigger zone of the medulla

-All antipsychotics have high therapeutic index

-Not addictive

B. Side Effects

-Extrapyramidal side effects:

Parkinsonism – akinesia (difficulties in initiating movement), tremor, rigidity

Caused by blockade of D2 receptors in basal ganglia

-Akathisia = restless legs syndrome; Caused by D2 receptor blockage in basal ganglia

-Dystonia – sustained muscular contraction

-Tardive Dyskinesia – abnormal movements, particularly of face and tongue, but may also be of trunk and limbs

-Noticeable after at least 6 months of chronic treatment

- begins with spastic, thrusting tongue movement, body restlessness, changes in HR & respiration

*Most extrapyramidal side effects are treatable with anticholinergic drugs

Sedation and autonomic side effects are caused by blockade of histamine, cholinergic and adrenergic receptors

-orthostatic hypotension

-blurred vision

-dry mouth

-nasal congestion

-constipation

-urinary retention

C. Drug Interactions of Significance to Dentistry

-Antipsychotics potentiate the actions of

-sedatives

-analgesics

-antihistamines

-Antipsychotics potentiate the respiratory depression caused by opioids

-Antacids = decrease absorption of antipsychotics

-Anticonvulsants = decrease plasma levels of antipsychotics

-Antipsychotics may alter efficacy of antihypertensive medications

*monitor vital signs

EPS = extrapyramidal effects

Why are Cholinesterase Inhibitors typically used?

·  Indirect-Acting Cholinergic Drugs

·  Also known as “cholinesterase inhibitors”

·  These drugs stop the breakdown of acetylcholine (via cholinesterase), which allows for the concentration of acetylcholine to build up = acetylcholine remains active and stimulates the PANS

·  These drugs produce PANS stimulation

·  Dementia with Alzheimer’s disease

·  Investigational for mild to moderate dementia with Parkinson’s disease

·  Examples:

o  donepezil (Aricept)

o  rivastigmine (Exelon)

o  galantamine (Razadyne)

Side Effects of Direct-Acting and Indirect-Acting Cholinergic Drugs

·  nausea, vomiting, diarrhea (by increasing GI activity)

·  salivation, sweating (increased gland secretions)

·  bronchoconstriction

·  constricted pupils

·  Paralysis at high doses (effect at neuromuscular junction)

·  CNS = confusion

Anticholinergic Drugs for Parkinson’s Disease

·  benztropine (Cogentin)

·  trihexyhenidyl (not in U.S.; Canadian drug)

Anticholinergic Drugs (Parasympatholytics)

·  Prevent the action of acetylcholine at the postganglionic PANS nerve endings

·  “blocker” drugs or antagonists

·  Block the receptor site for acetylcholine

·  Do not prevent release of ACH

·  Acetylcholine cannot act on receptors in smooth muscle, glands or the heart

·  Also called antimuscarinic drugs (block muscarinic receptors but not nicotinic receptors)

Pharmacologic Effects of Anticholinergic Drugs

·  Reduce PANS activity

o  Skin = decrease sweating

o  GI = decrease salivation, decreased gut motility

o  Urinary tract = urine retention

o  Respiratory = bronchodilation

o  CNS = decreased concentration/memory; sedation; possible hallucinations and coma

Adverse Reactions to Anticholinergic Drugs

·  Frequently are extensions of their pharmacologic effects

·  Xerostomia

·  Blurred vision, photophobia

·  Tachycardia

·  Fever

·  Urinary and GI stasis

·  Hyperpyrexia (elevated temperature)

·  Hot, dry flushed skin (lack of sweating)

·  Toxicity = CNS excitation = delirium, hallucinations, convulsions, respiratory depression

IX. ORAL HEALTH CONSIDERATIONS FOR NEUROPSYCHIATRIC CONDITIONS

- most neuropsychiatric medications cause xerostomia

-watch for opportunistic infections

-loss of protective effects: viral, fungal, bacterial infections

-traumatic aphthous ulcers

- lack of interest in performing daily self-care

- increased demineralization, caries and gingival disease