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Aging Physiology And Pharmacology

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1. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

2. What are the rf for caregiver to abuse elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Legal: Cruzan v Hamon
Constipation -> laxatives

3. opioid tx in elderly
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Begin @25-50% recommended dose - APAP may be dose-limiting
P2-metab: Lorazepam - Trazepam - Oxazepam
Cachexia - PEM - FTT - obesity

4. What are the possible cardiac causes of presyncope?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Electrical: change in HR - structural: aortic outflow obstruction
Pressure ulcer - fecal impaction - dehydration

5. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

6. Alb-bound Rx
Phenytoin
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

7. Aging descriptors
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
^SV (diastolic stroke volume)
IdioPx - psychiatric: depression - anxiety - somatoform
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

8. How does baroreceptor reflex prevent syncope?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Injury - neglect - physical/psychosocial - financial - violation of rights
^ANS tone -> ^periph vasoconstriction - ^HR
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

9. red flags for further inquiry
Vd v plasma prot-binding: usually ^Vd - when prot-binding significant: changes in enzymes - changes in metab/elim - lab value interp (total v free) - ^t1/2
Electrical: change in HR - structural: aortic outflow obstruction
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
A-blockers - B-blockers - TCA

10. fall sequelae

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11. What is the natural history of syncope?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Therapy - SSRI
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

12. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
IdioPx - psychiatric: depression - anxiety - somatoform
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Electrolyte imbalance - arrhythmia

13. How does ANF prevent syncope?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Respect for autonomy - nonmaleficence - beneficence - justice
ANF: Na+ retention - disinhib vasoconstriction
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

14. What is the preferred depression treatment in elderly?
Therapy - SSRI
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
IdioPx - psychiatric: depression - anxiety - somatoform
Temporalis muscle wasting = temporal wasting

15. osteoporosis epidemiology
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
High mortality - esp + Fx - very common in elderly
Mechanical loading - skin care - avoid friction/shear
Screen for potentially embarrassing dx - patient/Dr trust

16. what ADR are common in elderly patient?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Multisystemic vulnerability - -lowered reserves
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

17. metoclopramide may lead to what prescription cascade?
Delayed absorption - like competitive inhib
Parkinsonism -> l-DOPA
P2-metabolite - phase 1 biotx much more affected than phase 2
Insiduous onset

18. MI + atypical Sx
Doctors
Legal: Cruzan v Hamon
No: chest pain - yes: fatigue - nausea - low functional status - SOB
30% preventable - of these - 40% serious - of these 40% preventable

19. ACE inhib + diuretic: interaction outcome
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Bone loss -> osteopenia -> osteoporosis -> Fx
Hypotension - ^K+

20. advanced directive/care plan

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21. cachexia
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

22. What is ISH?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Hypotension - ^K+
Isolated systolic HTN
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

23. Syncope prognosis based on etio
Hypothetical plan - serves as patient's last competent indicated wishes
Written doc - don't alter it - pertinent +/- - use patient/caregiver's own words - photos - report: concise - precise - likeliness of abuse: definite/accident/indeterminate - body map for forensic documentation
CNS suppression -> cholinesterase inhibitors
Worse for cardiac causes v noncardia

24. which benzodiazepines are most appropriate for elderly?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
P2-metab: Lorazepam - Trazepam - Oxazepam
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
#1 patient's last competent indication of wishes - substituted judgment - beneficence

25. how is syncope related to elderly admission to hospital?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
80% of hospital admission for syncope for >65yo
CNS suppression -> cholinesterase inhibitors
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

26. What is sCr?
Serum Cr: used for Cr clearance equation
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cholinesterase inhib - use: dementia

27. how is the CAM used to diagnose delirium?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
5% - underreported
No: fever - leukocytosis - yes: falls - appetite change - low functional status
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

28. galantamine
Cholinesterase inhib - use: dementia
Tx underlying etio - + Kegels - pessary - surgery
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Injury - neglect - physical/psychosocial - financial - violation of rights

29. malnutrition
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Voice - character - plot - context - time - reader
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

30. What are the 3 stages of ADRs?
Tx underlying etio - + Kegels - pessary - surgery
Breast cancer + 2o LBP
Prescribing - monitoring - patient adherence
Bone loss -> osteopenia -> osteoporosis -> Fx

31. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

32. What is polypharmacy
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
>9 Rx
Prescribing - monitoring - patient adherence
Insiduous onset

33. How to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
#1 patient's last competent indication of wishes - substituted judgment - beneficence
NMDR antagonist - use: dementia

34. delirium: Rx that contribute
High mortality - esp + Fx - very common in elderly
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
CVA: stroke - AMI: acute MI - HF
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

35. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Therapy - SSRI
Constipation -> laxatives
Treat underlying disease/lack resources

36. NSAID may lead to what prescription cascade?
Legal: Cruzan v Hamon
P2-metabolite - phase 1 biotx much more affected than phase 2
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
^BP -> a-HTN

37. what receptors decrease sensitivity with aging?
^ANS tone -> ^periph vasoconstriction - ^HR
Figure out a good diet - social aspect - resources - dental/oral comfort
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

38. What are the risks of uncontrolled ISH?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
CVA: stroke - AMI: acute MI - HF
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Mechanical loading - skin care - avoid friction/shear

39. How does aging affect pharmacokinetic Rx distribution?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Environment modification: obstacles - mobility - -bladder fcn ok
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

40. What are the 4 basic ethical principles?
Environment modification: obstacles - mobility - -bladder fcn ok
Determined by Dr for a patient - -> used to determine competency
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Respect for autonomy - nonmaleficence - beneficence - justice

41. incontinence epidemiology
PPI: PUD uncomplicated >8wk - aspirin wo CAD/CVA/PVD - duplicate Rx - loop diuretics LT: HTN; can use for ankle edema - LT NSAID use (>3mo): mild OA - falls: BZD - opiates - neuroepileptics - vasodilators: orthostatic patient risk
Pressure ulcer - fecal impaction - dehydration
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
F>M (until 80yo) - stress incontinence #1 - $26B/yr

42. delirium: tx approach
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Cholinesterase inhib - use: dementia
Environment modification: obstacles - mobility - -bladder fcn ok

43. what professional is least likely to report abuse?
Map of people - perceptions - etc - varies by perspective
Doctors
Constipation -> laxatives
Phenytoin

44. What is START criteria?
ANF: Na+ retention - disinhib vasoconstriction
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

45. What are rf for osteoporosis?
Treat underlying disease/lack resources
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Doctors
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

46. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
No: chest pain - yes: fatigue - nausea - low functional status - SOB
CVA: stroke - AMI: acute MI - HF
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

47. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
No: chest pain - yes: fatigue - nausea - low functional status - SOB
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
F>M (until 80yo) - stress incontinence #1 - $26B/yr

48. delirium: mgmt
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
^ANS tone -> ^periph vasoconstriction - ^HR
^BP -> a-HTN

49. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Universal - progressive - partially encoded (genetic) - destructive -

50. What is the epidemiology of dizziness?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Hypothetical plan - serves as patient's last competent indicated wishes
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Vd v plasma prot-binding: usually ^Vd - when prot-binding significant: changes in enzymes - changes in metab/elim - lab value interp (total v free) - ^t1/2