BCGP cheat sheet

Physiologic aging reduces renal blood flow ~1% per year after age 30, lowering creatinine clearance even when serum creatinine appears normal.

Sarcopenia and reduced total body water increase the volume of distribution for water-soluble drugs and decrease it for lipophilic drugs.

Homeostenosis: diminished reserve capacity means older adults tolerate physiologic stress (illness, dehydration, surgery) poorly.

Atypical disease presentation is the norm: delirium, falls, incontinence, and weight loss may replace classic symptoms.

Frailty phenotype (Fried): unintentional weight loss, exhaustion, weakness, slow gait, low activity - three or more criteria define frailty.

Comprehensive geriatric assessment domains: function (ADLs/IADLs), cognition, mood, nutrition, continence, falls, social support, medications.

Life expectancy should guide screening and tight glycemic or lipid targets; time-to-benefit often exceeds remaining life expectancy.

Normal aging changes: decreased baroreflex sensitivity, reduced mucociliary clearance, presbyopia/presbycusis, impaired glucose tolerance.

Cockcroft-Gault: CrCl = [(140 − age) × weight kg] ÷ (72 × SCr), multiplied by 0.85 for females.

Absorption changes are usually modest; reduced gastric emptying and splanchnic blood flow alter rate more than extent.

Phase I hepatic metabolism (CYP450 oxidation) declines more than phase II conjugation, so oxidation-dependent drugs accumulate.

Anticholinergic burden, orthostasis, sedation, and QT prolongation are cumulative across drug classes.

Pharmacodynamic sensitivity increases for benzodiazepines, opioids, anticoagulants, and anticholinergics at lower plasma concentrations.

Half-life prolongation raises steady-state time to 4–5 half-lives, delaying both benefit and adverse-effect resolution.

Serum albumin decline raises free fraction of highly protein-bound acidic drugs (e.g., warfarin, phenytoin) transiently.

First-pass metabolism reduction increases oral bioavailability of high-extraction drugs such as propranolol and verapamil.

Hypertension goal for community-dwelling older adults is generally <130/80 mmHg when tolerated; avoid systolic <120 in frail patients.

Guideline-directed therapy for HFrEF: ARNI/ACEi/ARB, evidence-based beta-blocker, MRA, and SGLT2 inhibitor.

CHA2DS2-VASc ≥2 in men or ≥3 in women supports anticoagulation for nonvalvular atrial fibrillation.

Rate control targets for AF are lenient (<110 bpm at rest) unless symptoms or cardiomyopathy persist.

Statins for secondary prevention have no upper age limit; primary prevention requires individualized risk-benefit discussion.

Loop diuretics treat congestion; monitor orthostasis, renal function, and electrolytes rather than weight alone.

Beta-blockers are first-line for stable angina and post-MI; avoid abrupt withdrawal due to rebound ischemia.

Digoxin has a narrow window; target levels <0.9–1.0 ng/mL in HF and reduce dose with declining renal function.

Delirium is acute, fluctuating, and inattentive; dementia is chronic and progressive - both can coexist.

Anticholinergic and sedative drugs are leading reversible causes of delirium; first step is medication review.

Beers Criteria generally advise avoiding benzodiazepines and long-acting sulfonylureas; non-drug therapy is first-line for insomnia.

SSRIs are preferred antidepressants in older adults; start at half the adult dose (e.g., sertraline 25 mg) and titrate slowly.

Hyponatremia and SIADH are SSRI risks; check sodium 2–4 weeks after initiation or dose change.

Acetylcholinesterase inhibitors treat mild-moderate Alzheimer disease; monitor for bradycardia, GI upset, and weight loss.

Memantine (NMDA antagonist) is used for moderate-severe Alzheimer disease, often with a cholinesterase inhibitor.

Antipsychotics in dementia carry a boxed warning for increased mortality and cerebrovascular events; use lowest dose, shortest duration.

ADA loosens A1c targets in older adults: <7.0–7.5% if healthy, <8.0% if complex, <8.5% if very complex or limited life expectancy.

Metformin requires dose adjustment when eGFR <45 and discontinuation at eGFR <30; hold before iodinated contrast if eGFR <30.

Sulfonylureas (especially glyburide) cause prolonged hypoglycemia in older adults and are generally avoided.

Insulin secretagogues and insulin increase hypoglycemia risk; SGLT2 inhibitors and GLP-1 agonists carry lower risk.

Levothyroxine should be started low (12.5–25 mcg) in older adults with cardiac disease and titrated by TSH every 6–8 weeks.

Hypothyroidism presents atypically: cognitive decline, depression, constipation, or heart failure rather than classic myxedema.

SGLT2 inhibitors reduce HF hospitalization and CKD progression independent of glucose lowering; monitor volume status.

Hyperthyroidism in older adults may present as atrial fibrillation or unexplained weight loss (apathetic thyrotoxicosis).

Acetaminophen up to 3 g/day is first-line for osteoarthritis pain; lower the ceiling if hepatic risk or alcohol use.

Topical NSAIDs are preferred over oral NSAIDs for localized knee or hand osteoarthritis in older adults.

Oral NSAIDs increase GI bleeding, AKI, and heart failure risk; avoid in CKD stage 4–5 and with anticoagulants.

Opioid initiation in opioid-naive older adults: start at 25–50% of the usual adult dose and titrate slowly.

Bowel regimen (stimulant plus osmotic laxative) is required with chronic opioid therapy unless contraindicated.

Bisphosphonates require adequate calcium/vitamin D and renal function assessment; hold if CrCl <30–35 mL/min depending on agent.

Glucocorticoid use >3 months warrants bone protection assessment and consideration of calcium, vitamin D, and antiresorptive therapy.

Falls risk rises with sedating analgesics, muscle relaxants, and anticholinergics; deprescribe nonessential agents.

Age-related GFR decline means CKD is common; use eGFR and CrCl for dosing, and avoid nephrotoxins such as NSAIDs and aminoglycosides.

ACEi/ARB and SGLT2 inhibitors slow CKD progression; monitor potassium and creatinine within 1–2 weeks of initiation.

Proton pump inhibitors are appropriate short-term but long-term use is linked to C. difficile, fractures, hypomagnesemia, and B12 deficiency.

Constipation management: fiber and fluids first, then osmotic laxative (polyethylene glycol); avoid stimulant dependence in frail patients.

Urinary incontinence types: stress (pelvic floor), urge (antimuscarinics or beta-3 agonists), overflow (relieve obstruction).

Antimuscarinics for overactive bladder worsen cognition and constipation; consider beta-3 agonists in cognitively impaired patients.

Benign prostatic hyperplasia: alpha-blockers act within days; 5-alpha-reductase inhibitors act over months and lower PSA by ~50%.

Fecal impaction and overflow diarrhea are common in older adults and often misdiagnosed as infectious diarrhea.

COPD maintenance: LAMA/LABA for most symptomatic patients; add inhaled corticosteroid for frequent exacerbations or eosinophilia.

Inhaled therapy requires teach-back on technique; spacer use improves delivery and reduces oropharyngeal deposition.

Pneumonia in older adults may present without fever or cough - confusion or functional decline may be the only sign.

Vaccination: annual influenza, pneumococcal (PCV20 or PCV21), COVID-19, RSV (age ≥75 or 60–74 with risk), and shingles.

Urinary tract infection diagnosis requires urinary symptoms; asymptomatic bacteriuria should not be treated except in pregnancy or before urologic procedures.

Antibiotic stewardship: avoid fluoroquinolones when alternatives exist due to tendon rupture, QT, and C. difficile risk.

Tuberculosis in older adults often presents atypically; latent TB screening is required before biologics or TNF inhibitors.

Community-acquired pneumonia severity (CURB-65) guides site of care: confusion, urea, respiratory rate, blood pressure, age ≥65.

Beers Criteria identify potentially inappropriate medications for adults ≥65; they are decision support, not absolute prohibitions.

STOPP/START criteria flag both inappropriate medications (STOPP) and omitted indicated therapies (START).

Anticholinergic burden scales (e.g., ACB) sum scores; higher burden correlates with cognitive decline and falls.

Prescribing cascade: an adverse drug effect is treated with a new drug (e.g., amlodipine edema treated with a diuretic).

Deprescribing steps: identify candidates, verify indication, prioritize, taper, monitor, and document.

Taper, do not stop abruptly: benzodiazepines, opioids, beta-blockers, antidepressants, corticosteroids, and PPIs require tapering.

Medication reconciliation at every transition reduces discrepancies; obtain the best possible medication history including OTC and supplements.

High-alert medications in older adults: insulin, anticoagulants, opioids, and methotrexate - require dose verification and monitoring.

Beers Criteria and STOPP/START are applied at admission, discharge, and annual comprehensive medication review.

Screening tools: Mini-Cog for cognition, PHQ-2 for depression, Timed Up and Go for mobility, and Morse or Hendrich for falls.

Orthostatic vital signs: measure after 1 and 3 minutes of standing; a drop ≥20 mmHg systolic or ≥10 mmHg diastolic is positive.

Teach-back confirms patient understanding of new medications; low health literacy predicts readmission.

Transition bundle: discharge medication reconciliation, follow-up within 7 days, and clear written instructions reduce readmissions.

Anticoagulation monitoring: INR for warfarin, renal function for DOACs, and adherence assessment at each visit.

HbA1c reflects 2–3 months of glycemia; in anemia or CKD it may be unreliable, so use CGM or SMBG.

Pain assessment in cognitively impaired patients uses behavioral scales (PAINAD) rather than self-report alone.

Beers Criteria are consensus-based, not federal mandates; documentation of clinical rationale is required when used off-label.

CMS requires medication review for nursing home residents and gradual dose reduction attempts for antipsychotics.

OBRA regulations limit PRN antipsychotics and require documented indication, target behavior, and periodic review.

FDA boxed warnings (e.g., antipsychotics in dementia) require informed consent and documentation of risk-benefit discussion.

Informed consent requires capacity, disclosure, understanding, voluntariness, and authorization.

HIPAA permits disclosure for treatment, payment, and operations; minimum necessary standard applies.

Pharmacist scope of practice varies by state; collaborative practice agreements expand authority for dose adjustment and deprescribing.

Ethical principles: autonomy, beneficence, nonmaleficence, and justice guide decisions about potentially inappropriate medications.