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Aging Physiology And Pharmacology

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1. anticholinergic drugs may lead to what prescription cascade?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
CNS suppression -> cholinesterase inhibitors
#1 patient's last competent indication of wishes - substituted judgment - beneficence
^BP -> a-HTN

2. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
No: fever - leukocytosis - yes: falls - appetite change - low functional status

3. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
NMDR antagonist - use: dementia
Electrolyte imbalance - arrhythmia

4. delirium: Rx that contribute
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
IdioPx - psychiatric: depression - anxiety - somatoform
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

5. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
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
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

6. What are the vascular changes of presyncope?
Worse for cardiac causes v noncardia
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

7. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
Delayed absorption - like competitive inhib
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

8. using long-acting opioids in elderly
Universal - progressive - partially encoded (genetic) - destructive -
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Hyperuricemia -> gout

9. Why is abuse underreported?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
30% preventable - of these - 40% serious - of these 40% preventable
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

10. What are the possible cardiac causes of presyncope?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Prescribing - monitoring - patient adherence
Electrical: change in HR - structural: aortic outflow obstruction
Serum Cr: used for Cr clearance equation

11. How does baroreceptor reflex prevent syncope?
^ANS tone -> ^periph vasoconstriction - ^HR
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

12. How does aging affect GI absorption rate of Rx?
^ANS tone -> ^periph vasoconstriction - ^HR
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Delayed absorption - like competitive inhib

13. Presyncope
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Reduce exposure to PIM: pot inapprop med - category 1: avoid in elderly regardless of dx - category 2: pot inapprop dept on dx - category 3: used with caution
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Beers criteria - medication appropriateness index (12 ?)

14. osteoporosis etio
Vertigo - presyncope - disequilibrium - lightheadedness
Multisystemic vulnerability - -lowered reserves
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

15. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Diagnosis - risk/benefit analysis to choose Rx
ANF: Na+ retention - disinhib vasoconstriction
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

16. what mechanical loading helps to prevent pressure ulcers?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
NMDR antagonist - use: dementia
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
1/2

17. what Rx are commonly monifoted in elderly for ADR?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Electrical: change in HR - structural: aortic outflow obstruction
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

18. What are the hazards of elderly hospitalization?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
^morbidity + mortality - -frailest @ greatest risk
Parkinsonism -> l-DOPA
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

19. pressure ulcer: staging
Insiduous onset
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Catch-all of unspecified dizziness
NMDR antagonist - use: dementia

20. narcotics may lead to what prescription cascade?
Constipation -> laxatives
Cholinesterase inhib - use: dementia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

21. rivastigmine
Used to calculate renal fcn - clearance of Cr adjusted for age
Worse for cardiac causes v noncardia
Cholinesterase inhib - use: dementia
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

22. What is a PE sign of cachexia?
Temporalis muscle wasting = temporal wasting
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Threats/ terrorizing - isolation - denying food/privileges/liberty
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

23. incontinence epidemiology
Prescribing - monitoring - patient adherence
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

24. urge incontinence tx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

25. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
Hypothetical plan - serves as patient's last competent indicated wishes
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

26. driving considerations
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Make sure to discuss with patient - some states require reporting
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

27. Aging principles
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Cachexia - PEM - FTT - obesity
Environment modification: obstacles - mobility - -bladder fcn ok
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

28. LBW equation
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
80% of hospital admission for syncope for >65yo

29. What is the bone deterioration cascade?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Cachexia - PEM - FTT - obesity
Cholinesterase inhib - use: dementia
Bone loss -> osteopenia -> osteoporosis -> Fx

30. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
^ANS tone -> ^periph vasoconstriction - ^HR
Legal: Cruzan v Hamon

31. what receptors increase sensitivity with aging?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

32. restrain requirements
28% - ADR: 17% - non-compliance 11%
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
30% preventable - of these - 40% serious - of these 40% preventable
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

33. What are common medical causes of syncope?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Threats/ terrorizing - isolation - denying food/privileges/liberty
30% preventable - of these - 40% serious - of these 40% preventable
80% of hospital admission for syncope for >65yo

34. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
Reduce exposure to PIM: pot inapprop med - category 1: avoid in elderly regardless of dx - category 2: pot inapprop dept on dx - category 3: used with caution
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

35. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Temporalis muscle wasting = temporal wasting
#1 patient's last competent indication of wishes - substituted judgment - beneficence
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

36. psychological abuse
Cholinesterase inhib - use: dementia
Pressure ulcer - fecal impaction - dehydration
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Threats/ terrorizing - isolation - denying food/privileges/liberty

37. What are the 3 sentinel events for LT care?
>9 Rx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Pressure ulcer - fecal impaction - dehydration
#1 patient's last competent indication of wishes - substituted judgment - beneficence

38. clues of neglect
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Begin @25-50% recommended dose - APAP may be dose-limiting
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

39. delirium: medical rf
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Temporalis muscle wasting = temporal wasting
Delayed absorption - like competitive inhib

40. What drugs can contribute to syncope?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
A-blockers - B-blockers - TCA
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

41. what professional is least likely to report abuse?
^K+
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Doctors
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

42. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
Used to calculate renal fcn - clearance of Cr adjusted for age
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

43. what normally prevents syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Falls - delirium - malnutrition - P ulcers - opportunistic i2
3 reflexes: baroreceptor - renal nerve - ANF
#1 patient's last competent indication of wishes - substituted judgment - beneficence

44. How does aging impact syncope-preventing reflexes
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Pressure ulcer - fecal impaction - dehydration

45. osteoporosis
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Therapy - SSRI
Determined by Dr for a patient - -> used to determine competency
BMD (bone mineral density): T-score >2.5 std dev below normal 1

46. What is ISH?
Isolated systolic HTN
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Insiduous onset
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

47. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

48. how can you determine whether Rx is appropriate to use in elderly patient?
Beers criteria - medication appropriateness index (12 ?)
Tx underlying etio - + Kegels - pessary - surgery
Stress: #1 - functional - urge - overflow
Hyperuricemia -> gout

49. fall sequelae

50. delirium predisposing rf
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Threats/ terrorizing - isolation - denying food/privileges/liberty
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)