Epidemiology

• 15-30% prevalence dwelling in community and at least 50% of institutionalized older adults

• morbidity:cellulitis, pressure injuries, urinary tract infections,falls with fractures,sleep deprivation,

social withdrawal, depression,sexual dysfunction

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• not associated with increased mortality

• risk factors: impaired mobility, falls, medications, depression, TIA/stroke, dementia, CHI'

,obesity

Etiology

• physiologic changes with age:(e.g. decreased bladder capacity)

• genitourinary diseases (e.g.cystitis, urethritis, BPH)

• neurogenic (e.g. cauda equina syndrome,stroke, MS)

• iatrogenic:(e.g. prostate surgery)

• trauma: (e.g. pelvic trauma, traumatic spinal cord injury)

• drugs (e.g. alcohol, loop diuretics,sedative hypnotics, GABAergic agents)

• cognitive (e.g. dementia, depression)

• functional impairment (e.g. arthritis, poor vision)

Investigations

• laboratory tests: urinalysis and urine culture,serum creatinine, BUN

• imaging: post-void residual, renal ultrasound

• other: voiding diary, pad test

Management

• lifestyle modification:avoid excessive fluid intake and alcohol

• pharmacologic: (J-adrenergic agonists to reduce involuntary bladder contractions

• physiologic changes with age: pelvic muscle exercises, bladder training, biofeedback

• genitourinary diseases: treat underlying cause (empiric antimicrobial treatment for cystitis, a

blockers/5-a reductase inhibitors for BPH )

• functional impairment:incontinence pads,environmental modification, personal assistance

• cognitive:referral to incontinence program if needed

• safety assessment: assess bathroom distance,fall prevention strategies, need for a bedside commode,

liaise with occupational therapy if necessary

Malnutrition

Definition

• no uniformly accepted definition of malnutrition in older adults. One definition provided by the

2018 Global Leadership Initiative on Malnutrition requires a combination of one phenotypic and one

etiologic finding:

• phenotype

involuntary weight loss (community: >2% over 1 mo, >10 lbs over 6 mo,or >4% over 1 yr; nursing

home:>5% over 1 mo,>10% over 180 d)

loss of muscle mass

- low BM1

• etiology

• decreased food intake/absorption

inflammation

• chronic disease

• other definitions include:hypocholesterolemia (<4.1 mmol/L), hypoalbuminemia (community:

538 g/L;hospital:535g/L), insufficient energy intake, fluid accumulation (e.g. edema), loss of

subcutaneous fat, decreased hand-grip function

Etiology

• nutritional

• decreased assimilation:impaired transit,maldigestion,malabsorp

decreased intake:financial, psychiatric (depression), cognitive deficits, anorexia associated with

chronic disease, functional deficits (e.g.difficulty shopping, preparing meals, or feeding oneself

due to functional impairment),substance use

• stress: acute or chronic illness/infection, chronic inflammation, abdominal pain

• mechanical: dental problems, dysphagia

• age-related changes: appetite dysregulation,decreased thirst,decreased smell and taste

• mixed:increased energy demands (e.g. hyperthyroidism), abnormal metabolism, protein-losing

enteropathy

Clinical Features

• history

weight loss in 6 mo prior to examination

recent or chronic illness

constitutional symptoms (e.g. recent weight loss)

• dietary intake in relation to usual pattern

depression, Gl symptoms (e.g. anorexia, nausea, vomiting,diarrhea)

• functional disability: impaired ADLs and lADLs

• social factors: economic barriers, dental problems, and living situation (e.g. living alone)

• substance use (e.g.alcohol,smoking,IV or recreational drug use)

Etiology of Malnutrition in Older Adults

MEALS ON WHEELS

Medications

Emotional problems

Anorexia

Late-life paranoia

Swallowing disorders

Oral problems

Nosocomial infections

Wandering/dementia related activity

Hyperthyroid/hypercalcemiaf

hypoadrenalism

Enteric disorders

Eating problems

Low-salt/low-fat diet

Stones

tion

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GM12 Geriatric Medicine Toronto Notes 2023

•physical exam

• BMI <23.5 in males and <22.0 in females should raise concern

• muscle wasting, temporal wasting, presence of triceps skin fold

loss ofsubcutaneous fat

ankle orsacral edema, ascites

• assess cognition

Investigations

•CBC, electrolytes, Ca

^/albumin. Mg PO+J-,creatinine, LFTs (INR, bilirubin), vitamin B12,folate,

TSH, lipid profile

•if indicated by assessment, can consider urinalysis, ESR, CXR

Treatment

•direct treatment of underlying causes

•dietary modification: high calorie foods, oral nutritional supplementation: patient specific meal

replacement products (e.g.Ensure'

, Glucerna '

, Nepro'

), vitamins/minerals (e.g. vitamin Bit, calcium,

vitamin D, thiamine)

• referral:speech language pathologist, nutritionist

Presbycusis

• see

Presbyopia

• see Ophthalmology. OPS

Pressure Injuries

•see Plastic Surgery, Pressure Ulcers, PL18

Definition

•previously termed pressure ulcers, also termed decubitus ulcers

•any lesion caused by unrelieved pressure resulting in damage of underlying tissue; usually develops

over bony prominences

Risk Factors

•extrinsic:friction, pressure,shear force, moisture

•intrinsic: immobility, malnutrition, comorbidities (e.g. DM, PVD, vasculitis, immunodeficiency),

sensory loss

•geriatric: age-related skin changes, hedbound, cognitive impairment, chronic illness

Risk Assessment and Prevention of Pressure

Ulcers

Ann Intern Med 2015:162:359- 369

lire American College of Physicians(ACP)strongly

recommends advanced state mattressesor advanced

static overlays for patients who aie at an increased

risk oldevelopng pressure injuries,the ACPalso

recommends agamst using alterlutmgair mattresses

oi alternating air overlays.

Table 5. NPIAP Staging System for Pressure Injuries

Stage1 Localized area of nonblanchableerythema of intact skin (appearance may vary in darkly pigmented skin)

Changes in sensation, temperature, or firmness may precede visual changes

Colour changes do not include purple or maroon discolouration (may indicate deep tissue penetration injury)

Partial thicknessloss of skin with exposed dermis

Wound bed is viable, pink or red. moist,and may present as a serum-filled blister

Adipose and deeper tissue not visible

full thickness loss of skin; adipose tissue visible

Granulation tissue and epibole (rolled wound edges) often present

Full thicknessskin and tissue loss

Exposed or directly palpable fascia, muscle,tendon,ligament, cartilage, or bone

Epibole. undeimining. and/or tunneling often present

Full-thicknessskin and tissue loss;extent of tissue damage cannot be determined due to obstruction by

slough or eschar

Intact or noninlact skin with localized nonbtanchable maroon or purple discolouration, or epidermal

separation revealing dark wound bed or blood -filled blister

Pam and temperature changes may precede skin colour changes

Injury results(rom intense and/or prolonged pressure and shear forces at the bone-muscle interface

Stage 2

Stage 3

Stage 4

Jnstagcablc Pressure Injury

Deep Tissue Pressure Injury

Source: Edvberg LE. Black JM. Goldberg M.et al. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System:Revised Pressure

Injury Staging System.J Wound OstomyContlnonce Nurs 201G:43{6);585-597.

Complications

• noninfectious:amyloidosis, heterotopic bone formation, perineal urethral fistula, pseudoaneurvsm,

Marjolin ulcer, systemic complications of topical treatment, complications of oral/I V treatments

• infectious: bacteremia/sepsis, cellulitis, osteomyelitis,septic arthritis,sinus tracts, abscess,

endocarditis,meningitis

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Prevention

• pressure reduction

frequent repositioning (q2 h )

pressure-reducing devices (static,dynamic)

• maintaining nutrition, encouraging mobility,and managing incontinence

• use validated pressure injury risk assessment tools on admission for those identified to be at risk for

skin breakdown

Treatment

• optimize nutritionalstatus

• minimize pressure on wound

• analgesia

• all ulcers with necrosis warrant debridement (mechanical,enzymatic, and autolytic are non-urgent

forms of debridement, whereas sharp debridement is performed urgently due to risk of sepsis or

cellulitis)

• dressing application (exudate absorbing, barrier products to reduce friction)

• maintain moist wound environment to enable re-epithelialization

• treatment of wound infections (topical gentamicin,silver sulfadiazine, mupirocin)

• swab wounds not demonstrating clinical improvement for C&S; biopsy chronic wounds to rule out

malignancy

• referral to Wound Care or Plastic Surgery

• consider other treatment options:

negative pressure wound therapy/vacuum-assisted closure

• biological agents: application of fibroblast growth factor or platelet-derived growth factor to

wound

non-contact normothermic wound therapy

• electrotherapy

Driving Competency

Reporting Requirements

• physician-reporting to the Ministry of Transportation is mandatory in all provinces and territories

except in Quebec, Nova Scotia, and Alberta,where it is discretionary

• British Columbia, Ontario: must refer for re-test at >80 yr

• in the U.S., varies by state

Key Factors to Consider in Older

Drivers

SAFEDRIVE

Safety record

Attention (e.g. concentration lapses,

episodes of disorientation)

Family observations

Ethanol use

Drugs

Reaction time

Intellectual impairment

Vision/Visuospatial function

Executive functions (e g.planning.

decision-making, self-monitoring

behaviours)

farlatrkslWt.SIM-K

Conditions That May Impair Driving

Table 6. Conditions That Impair Driving

Patients v/ilh history ol impaired driving and those with a high probability of future impaired

driving should notdrive until further assessed

Alcohol dependence or alcohol use disorder:if suspected,should be advised not lo drive

Alcohol withdrawalseizure: must (1|receive favourable report Irom addictions counsellor post

treatment and|2) be in remission .md oi remained abstinent lor 12 mo

HTN:sustained BP >170/110 should be evalualed carefully

Hypotension:sustained BP <90/60:if syncopal, discontinue driving until syncope is treated and

preventable

Suspected asymplomalic CA0 or stable angina: no restrictions

StEMI. NSIEMI with significant IV damage, coronary artery bypasssurgery: no driving lor 1mo

following hospital discharge

NSIEMI with minor LV damage, unstable angina:no driving for 48 h if PCI or 7 d it no PCI performed

IIA:should not be allowed lo drive untila medical assessment is completed

Stroke:should not drive for alleasl1mo:may resume driving if functionally able:no clinically

significant motor, cognitive, perceptual,or vision deficits: no obviousrisk of sudden recurrence:

underlying cause appropriately treated:no post stroke seiture

Mlld/modcratc impairment: no restrictions

Moderate or severe impairment requiring supplemental oxygen: load test with supplemental

oxygen

Alcohol

Blood Pressure Abnormalities

Cognitive Tests and Determining Fitnessto Drive

in Dementia:ASystcmatic Review

JAm Genatr Soc 2016:M(9|:1904-191T

Purpose: lo ctamine Hie relationship between

cognitive tests and driving to determine vrtethei a

cognitive assessment can be implemented as a tool to

examine driver safety.

Methods:Systematic review of 28studes

investigating the relationship between cognitive

functiom - g and driving in individuals with dementia.

Results:Composite batteries comprising m. tiple

individual testsIrom different cognitive domains

consistently predicted driving performance lor

individualswith dementia. Scoies on individual tests

or tests of a single cognitive domain did not predxt

driver safety.

Conclusions:Khi le studies consistently found

composite batteries predicted driving performance,

these tests were not clinically usable asthey lacked

the ability to discriminate between sale and unsale

drivers. Heed development ola reliable,valid

composite battery that can correctly determine driver

safety in patients w th dementia.

Cardiovascular Disease

Cerebrovascular Conditions

C0PD

N.B.guidelines included refer specifically to private driving:please seeCMA guidelines for commercial driving

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Table 6. Conditions That Impair Driving

Cognitive Impairment/Dementia Moderate to severe dementia is a contraindication to driving, defined as the “inability to

independently perform 2 Dr more lADLs or any basic ADL"

Patients withmild dementia should be assessed;if indicated,refer to specialized driving testing

centre;if deemed fit to drive,re-evaluate patient every 6-12 mo

Poor performance on MMSE,clock drawing,or frails B suggests a need to investigate driving

ability further

MMSE score alone (whether normal or low) is insufficientto determine fitness to drive

Diet controlled or oral hypoglycemic agents: norestrictions in absence of diabetes complications

that may impair ability to drive (e.g.retinopathy,nephropathy,neuropathy,cardiovascular,or

cerebrovascular disease)

Insulin use:may drive if no complications (as above) and no severe hypoglycemic episode in the

last 6 mo

Be aware ol:analgesics,anticholinergics, anticonvulsants,antidepressants,antipsychotics,

opiates,sedatives,stimulants

Degree of impairment varies: patients should be warned of the medication/withdrawal effect on

driving

Eflect of impaired hearing on ability to drive safely is controversial

Acute labyrinthitis,positional vertigo with horizontal head movement,recurrent vertigo: advise

not to drive until condition resolves

Diabetes

Drugs

Hearing Loss

Physician's role is to report etiology,prognosis,and extent of disability (pain,range of motion,

coordination,muscle strength)

Outpatient, conscious sedation:nodriving lor 24 h

Outpatient, general anesthesia:no driving for >24 h

First, single,unprovoked:nodliving for 3 mo until complete neurologic assessment.EES.Cl head

Epilepsy:can drive it seizure-free lor 6 mo. on medication that docs not impair ability to drive,and

physician has insight into patient compliance (Ontario guideline)

If patient is believed to be at risk due to a symptomatic sleep disorder but refuses investigation

with a sleep study or refuses appropriate treatment,the patient should notdrive

Visual acuity: contraindicated to drive if

'

20/50 with both eyes examined simultaneously

Visual field: contraindicated to drive if <120'along horizontal meridian and15'continuous above

and below fixation with both eyes examined simultaneously

Musculoskeletal Disorders

Postoperative

Seizures

Sleep Disorders

Visual Impairment

N B. guidelines included rclcr specillcully to privatedriving:please seeCMA guidelines lor commercial dilvlng

Hazards of Hospitalization

Table 7. Recommendations for Sequelae of Hospitalization in Older Patients

Sequelae Recommendations

No dietary restrictions (except diabetes and salt restriction If applicable),

assistance,dentures if necessary,siltingin a chair to eat

Medication review,icmove environmental barriers,discontinue use of catheter

Routine screening

Medication review

Orientation,visuatand hearing aids, volume repletion,noise reduction,early

mobilization,medication review,remove restraints

Low-resistance mattress,daily inspection,repositioning every 2 h.nutrition

Early mobilization,removeunnecessary IV lines,catheters, NG tubes

Appropriate footwear,assistive devices,early mobilization,remove restraints,

medication review

Early recognition and repletion (ideally oral rehydralion,if possible),access to

water

Early mobilization

Malnutrition

Urinary Incontinence

Depression

Adverse DrugEvent

Confusion/Delirium

Pressure Injuries

Infection

Falls

HypotensionfDehydration

Diminished Aerobic Capacity/Loss ol Muscle Strength/

Contractures

Decreased Respiratory Function

Functional Decline

Incentive spirometry, physiotherapy

Structured exercise,progressive resistance training,walking programs

Bell SP.Vasilevskis EE.Sarat AA.et al.Geriatric Syndromes inHospitalized Oldet Adults Discharged toSkilled Nursing Facilities.J Am Geriatr Soc

2016;64(4):?15-722.

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Healthcare Institutions

Table 8. Classification of Healthcare Services and Institutions

Institution/Service Description

Home and Community Support Services At home support services ottered to patients living at home

independently or under the care ol family members. These include

professional healthcare services, personal care and support (ADI

assistance), homemaking (IADL assistance), community support

services (c.g. transportation, meal delivery, day programs, caregiver

relief,security checks)

Healthcare services ottered in an institution lo oplimite patients'

function. Independence,and gualily ol life

Divided into short ('60-90 d/yr) and long (indefinite)stay

Seniors who live independently and manage their own care, but prefer

lo live near other older adults; usually has accessibility features:rent is

ad|usted based on income

Residents are fairly independentand require minimalsupport with AOLs

and lADLs; often privately owned

Residents require minimal lo moderate assistance vrith daily activities

while living independently; often rental units in an apartment; may

offer physiotherapy and rehabilitation services

Around the clock nursing care and on- call physician coverage; often

offers occupational therapy, physiotherapy, respiratory therapy,and

rehabilitation services;may be used short-term for caregiver respite

or forsupportive patient care to regain strength and confidence after

leaving the hospital

Free-standing facility or designated floor in a hospital or nursing home

(or care of terminally ill patients and their families;focus is on quality of

life and often requires prognosiss3 mo

Rehabilitation

Residential

a) Older adults Affordable Housing

b) Retirement Home

c) Supportive Housing

d) Long-term Care/Skilled Nursing facility

e) Hospice

• names of community healthcare institutions, types of facilities, and services offered vary between

geographical locations

• factors to consider when referring to community services and institutions: level and type of support

required, income/socioeconomic status,social supports and/or degree of social isolation, other social

determinants of health creating potential harriers to care

Geriatric Pharmacology

Pharmacokinetics

Table 9. Age-Associated Pharmacokinetics

Parameter Age Effect Implications

Increased gastric pH. decreased splanchnic bipod flow. Comorbidities, drug- drug, and drug-lood interactions are

Gl absorptive surface and dermal vascularity, delayed mote likely lo aflect absorption

gastric emptying. However, appropriate absorption

of most oral drugsisseen in healthy older-aged

patients:reduced absorption may be related to patient

comorbidilies

Absorption

(lesssignificant)

Distribution Increased total body tat

Increased al- glycoprotein

Decreased lean body mass and total body water

Decreased albumin

Lipophilic drugs have a larger volume ol distribution

Increased binding of basic drugs

Decreased volume of distribution of hydrophilic drugs

Decreased binding of acidic drugs

Decreased hepatic mass and hepatic blood flow;impaired Lower doses may be therapeutic

phase I reactions(oxidative system)

Decreased renal blood flow, glomerular filtration rate. Lower doses may be therapeutic

tubularsecretion

Overall reduction in renal function by 30-50%

Metabolism

(lesssignificant)

Elimination

Pharmacodynamics

Drug Sensitivity

• changes in pharmacokinetics as well as intrinsic sensitivity lead to altered drug responses

• increased sensitivity to warfarin,sedatives, antipsychotics, anticholinergics, digoxin, and narcotics

• decreased sensitivity to (3-blockers and ^

-adrenergic stimulants, though may have increased

sensitivity

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Decreased Homeostasis

• poorer compensatory mechanisms leading to more adverse reactions (e.g. bleeding with NSAlDs/

anticoagulants, altered mental status with anticholinergic/sympathomimetic/anti

-Parkinsonian

drugs)

Polypharmacy

ft Definition

• prescription, administration,or use of more medications than are clinically indicated

Epidemiology

• in Canada, >60% of older adults reported using >5 medications

• hospitalized older adults are given an average of 10 medications during admission

New medications:Start Low, Go Slow!

Avoid starting 2 drugs at the same time.

Risk Factors for Polypharmacy

• patient-level risk factors: age,female sex, cognitive impairment, frailty, mental health conditions,

multiple chronic conditions, lack of primary care physician, residing in LTC, multiple pharmacies

• systems-level risk factors: multiple prescribers, poor documentation systems, automated refill

systems,lack ofsystematic medication review

Risk Factors for Non-Compliance

• greater number of medications (compliance with 1 medication is 80%, but drops to 25% with £6

medications)

• increased dosing frequency, complicated container design, financial constraints, and cognitive

impairment

Adverse Drug Reactions (ADRs)

• any noxious or unintended response to a drug that occurs at doses used for prophylaxis or therapy

• risk factors in older adults

intrinsic: comorbidities(>5), age >85,low BM1,age-related changes in pharmacokinetics and

pharmacodynamics,CrCl <50 mL/min

extrinsic: number of medications (>9 medications,>12 doses/d), multiple prescribers, unreliable

drug history, prior ADR

• prescribing cascade: process whereby an ADR is misinterpreted as a new medical condition, and a

subsequent drug is prescribed to treat the initial drug-induced event. Providersshould ask themselves:

isthe new drug being prescribed to address an adverse event from a previously prescribed drug

therapy?

• is the initial drug therapy really needed, especially if leading to a drug cascade?

do the benefits of the initial drug therapy outweigh the harms?

Adverse drug reactions In older adults

may present as delirium, falls,fractures,

urinary incontinence/retention, orfecal

incontinence/impaction.

Preventing Polypharmacy

• consider drug:safer side effect profiles, convenient dosing schedules, convenient route, efficacy

• consider patient: other medications, clinical indications, medical comorbidities

• consider patient

-drug interaction risk factors for ADRs

• review drug list regularly to eliminate medications with no clinical indication or with evidence of

toxicity

• avoid treating an ADR with another medication

Principlesfor Prescribing in Older

Adults

CARED

Caution/Compliance

Age (adjust dosage for age)

Review regimen regularly

Educate

Discontinue unnecessary medications

Geriatric Peals.PMadelpMa FA Dans Company.1999 Inappropriate Prescribing in Older Adults

Epidemiology

• the estimated prevalence of potentially inappropriate prescribing ranges from 12-40%

Inappropriate prescribing in older persons:A

systematic reviewof medications availablein

d ifferenl criteria

Arcli Gerontol Geriatr 2017:68:55-61

Purpose: Comprehensive review ol all potentially

inappropriate medicationsfor older persons, included

! : trla of the last decade.

Results: Iron 118 ankles, 14 criteria were

minded in l he boil analysis, including a total ol

J28 med iation classes among all analyted criteria.

Dratepam was included In all 14criteria, followed by

amitriptyline in 13criteria and donepin In 12criteria.

Seniodiaiepmes. antihistamines, and antipsyclrolics

wrerethe moot common drugs reported as potenlially

inappropriate for older adults, among final criteria.

Cone lesion:Seniodiaiepmes, HSAIDs.

antihistamines,and antipsycholics were the most

common drugsreported as potentially inappropriate

for older persons.

Beers Criteria

• a list of medications to avoid in adults >65 yr due to safety concerns

• 2019 update lists drugs that are inappropriate in most older adults, those that should typically be

avoided with certain conditions, drugs to use with caution, drug-drug interactions, and drug dose

adjustment based on kidney function

• examples include long-acting benzodiazepines,strong anticholinergics, high-dose sedatives

• older adults are often under-treated (ACEI.ASA, p-blockers, thrombolytic*

, oral anticoagulants)

STOPP/START Criteria

• another screening tool for potentially inappropriate prescribing in older adults

• STOPP:Screening Tool of Older Persons Prescriptions

• systems-based list of medications contraindicated in adults £65 yr in the context of their

diagnoses

• START: ScreeningTool to Alert physicians to Right T reatment

systems-based list of medications indicated in adults >65 yr in the context of their diagnoses

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Common Medications

Table 10. Common Medications

Drug Name Brand Name Dosing Schedule Indications Contraindications Side Effects Mechanism of Action

Cognitive Enhancers

donepezil AricepG 5-10 mg PO once Known hypersensitivity,caution

inuntreated obstructive airway

disease,cardiac conduction

abnormalities,active PUD or occult Gl (uncommon),heart block

bleed,seizuredisorder,syncope NYD (uncommon)

Known hypersensitivity,caution

inuntreatedobstructive airway

disease,cardiac conduction

abnormalities,active PUD or occult Gl block (rare),seizure (rare),

bleed, seizuredisorder,syncope NYD delirium (rate)

Known hypersensitivity,severe

hepatic disease,caution m untreated dizziness,anorezia.insomnia,

obstructive auway disease,cardiac weight loss,delirium,heart

conduction abnormalities,active PUD block (rare)

or occultGl bleed,seizure disorder,

syncope NYD

Known hypersensitivity,conditions Dizziness,headache,

that alkalinizeurine,caution inrenal hypertension,constipation.

confusion,hallucinations

N/V,diarrhea,anoreiia. Reversible inhibition of

acetylcholinesterase

Moderate to severe

daily dementia of Alzheimer's insomnia,fatigue,muscle

type cramps, syncope,bradycardia

galantamine RemmyP 8-12 mg PO BID HIV.diarrhea,anorexia,

weight loss,headache,

dizziness, syncope,heart

Reversible inhibition of

acetylcholinesterase

Mild to moderate

dementia of Alzheimer's

type

rhrastigniine Exelon'

1.5 mg POBID

(starting) up to 6-12

mg POBID

Acetylcholinesterase inhibition

(reversible but very slow)

Mild to moderate

dementia olAlzheimer's

N/V.diarrhea,headache.

type

memantine Ebixa" Hemenda'

5mg PO once daily Mild tomoderate

(Can)/|U.S.) (starting) up to10mg dementia of Alzheimer's

POBID

NMDA-receptor antagonist

type failure,seizures

Laxatives

All-Bran1

1cup PO once daily Constipation

Constipation,

hypercholesterolemia

Bloating,flatus

Bloating,flatus

Bulk-forming laxative

Bulk-forming laxative

bran

Metamucil1

3.4 gPO once daily

Prodiem' Plain® totID

psyllium N.'

V.abdominal pain,obstruction

if another medication is taken

within 2 h

Patients on low galactose diets,

abdominal pam.NY

Chronulac' 15-30 ccPO once Constipation,hepatic

Cephulac - daily'BID and 5-10 encephalopathy, bowel

Krislalose 1 (U.S.) mlPOBID for 2-4wk evacuation following

Acilac;

:Apo- for bowel evacuation barium exam

Lactulose s; after barium

Laxilose'

;PMSLactulose'(Can)

lax-A-Day ®,

RestoraLAX

Pegalax -

(Can)

Gavilax ®,

Healthylax -' (U.S.)

SenokoG /Ex-lax"

2-4 tablets P0 once Constipation

daily or 10-15 ml

syrup once dahy BID.

Dosing should be the

smallest required to

pass soft stool

Flatus, cramps,nausea,

diarrhea

lactulose Osmotic laiatrve

PEG 3350

(polyethylene

glycol)

17 gPO once daily (

-1 Constipation,bowel prep Known/suspected bowel obstruction. Abdominal cramps,bloating

heaping tablespoon) (different dosing schedule) known hypersensitivity,renal

impairment

Osmotic laxative

of the stomach,diarrhea,

dissolved in1cup flatulence,nausea

(250ml) of beverage

Known/suspected bowel obstruction Abdominal cramps.N/V. Stimulant laxative

or abnormal constriction,atonic

bowel.IBD.abdominal pain NYD.

rectal bleeding NYD.severe

dehydration

senna

diarrhea,urine and/or fecal

discolouration

Dulcolax ® 5-15 mgP0 (10

mg PR)

Constipation Acute Gl diseases (e.g.appendicitis. Abdominal cramps,pain,

diarrhea),ileus,obstruction,

abdominal pain.HY.severe

dehydration,and ulcerative proctitis

and.or anal fissures if PR

bisacodyl Stimulant laxative

diarrhea,dehydration,

dizziness,N/V

Parkinsonian Agents - see Neurology,table 26.N57

Note Docusate has been shown to be ineffective for theprevention treatment of constipation in older adults

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