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Aging Physiology And Pharmacology

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1. vision changes: elderly
P2-metab: Lorazepam - Trazepam - Oxazepam
Used to calculate renal fcn - clearance of Cr adjusted for age
Destrusor overactivity -> urge - BPH -> overflow - more urine output later in day - atrophic vaginitis - ^PVR: post-void residual -> overflow - v total bladder capacity -> overflow - v sphincter tone -> stress
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

2. delirium incidence
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

3. using long-acting opioids in elderly
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Figure out a good diet - social aspect - resources - dental/oral comfort
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Treat underlying disease/lack resources

4. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Screen for potentially embarrassing dx - patient/Dr trust
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
^morbidity + mortality - -frailest @ greatest risk

5. what mechanical loading helps to prevent pressure ulcers?
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
>60yo - low abuse risk - ^ monitoring possible

6. what nutritional interventions help underweight?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Doctors
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

7. functional incontinence tx
Hyperuricemia -> gout
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Environment modification: obstacles - mobility - -bladder fcn ok
No: chest pain - yes: fatigue - nausea - low functional status - SOB

8. incontinence complication
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
80% of hospital admission for syncope for >65yo

9. dementia tx
Stress: #1 - functional - urge - overflow
5% - underreported
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Isolated systolic HTN

10. frailty signs
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Make sure to discuss with patient - some states require reporting
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

11. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
ANF: Na+ retention - disinhib vasoconstriction
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

12. galantamine
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Cholinesterase inhib - use: dementia
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

13. what % of hospitalizations of elderly are due to ADR + noncompliance?
Cholinesterase inhib - use: dementia
Legal: Cruzan v Hamon
Environment modification: obstacles - mobility - -bladder fcn ok
28% - ADR: 17% - non-compliance 11%

14. antiarrhythmic + diuretic: interaction outcome
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
P2-metab: Lorazepam - Trazepam - Oxazepam
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Electrolyte imbalance - arrhythmia

15. What is the bone deterioration cascade?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Consider responsibilities - drivin
Bone loss -> osteopenia -> osteoporosis -> Fx
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

16. donepezil
Phenytoin
A-blockers - B-blockers - TCA
Cholinesterase inhib - use: dementia
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

17. lightheadedness
Catch-all of unspecified dizziness
Universal - progressive - partially encoded (genetic) - destructive -
Cachexia - PEM - FTT - obesity
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

18. physical neglect
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Isolated systolic HTN
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Electrical: change in HR - structural: aortic outflow obstruction

19. What is ISH?
Isolated systolic HTN
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Injury - neglect - physical/psychosocial - financial - violation of rights

20. How does ANF prevent syncope?
ANF: Na+ retention - disinhib vasoconstriction
Legal: Cruzan v Hamon
Threats/ terrorizing - isolation - denying food/privileges/liberty
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

21. What is START criteria?
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Used to calculate renal fcn - clearance of Cr adjusted for age

22. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

23. What is the best approach to malnutrition
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Treat underlying disease/lack resources
CNS suppression -> cholinesterase inhibitors
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

24. How does the aging heart compensate for lower HR to maintain unchanged CO?
NMDR antagonist - use: dementia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^SV (diastolic stroke volume)

25. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Receptors changes: # - sensitivity - counter-regulatory moa

26. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
30% preventable - of these - 40% serious - of these 40% preventable
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
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. surrogate decision making heirarchy

28. conservator
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Appointed by court if no substituted judgment -conservator of finance -conservator of person
A-blockers - B-blockers - TCA
P2-metab: Lorazepam - Trazepam - Oxazepam

29. What are the common causes of lightheadedness?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Voice - character - plot - context - time - reader
^BP -> a-HTN
IdioPx - psychiatric: depression - anxiety - somatoform

30. urge incontinence tx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
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
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

31. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
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
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

32. Syncope prognosis based on etio
Electrical: change in HR - structural: aortic outflow obstruction
Hypotension - ^K+
Worse for cardiac causes v noncardia
Environment modification: obstacles - mobility - -bladder fcn ok

33. what ADR are common in elderly patient?
Electrolyte imbalance - arrhythmia
Hypotension - ^K+
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

34. What are the rf for elderly abuse?
Threats/ terrorizing - isolation - denying food/privileges/liberty
High mortality - esp + Fx - very common in elderly
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

35. How does sliding scale glycemic control relate to elderly?
Phenytoin
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Parkinsonism -> l-DOPA
Serum Cr: used for Cr clearance equation

36. refusing intervention
Confusion - sedation - falls
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Legal: Cruzan v Hamon

37. How does aging affect Rx pharmacokinetic distribution?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Voice - character - plot - context - time - reader
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

38. delirium: mgmt
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Treat underlying disease/lack resources
Serum Cr: used for Cr clearance equation

39. What are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Parkinsonism -> l-DOPA
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

40. describe the % of ADR considered preventable - and of those serious
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Make sure to discuss with patient - some states require reporting
30% preventable - of these - 40% serious - of these 40% preventable
Electrolyte imbalance - arrhythmia

41. what normally prevents syncope?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Parkinsonism -> l-DOPA
3 reflexes: baroreceptor - renal nerve - ANF

42. falls epidemiology
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
P2-metabolite - phase 1 biotx much more affected than phase 2
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

43. osteoporosis etio
Worse for cardiac causes v noncardia
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

44. What are the 4 basic ethical principles?
Temporalis muscle wasting = temporal wasting
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
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
Respect for autonomy - nonmaleficence - beneficence - justice

45. What is the epidemiology of dizziness?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

46. Aging descriptors
Delayed absorption - like competitive inhib
Hyperuricemia -> gout
Begin @25-50% recommended dose - APAP may be dose-limiting
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

47. fall causes
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Respect for autonomy - nonmaleficence - beneficence - justice
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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

48. elderly abuse epidemiology
Make sure to discuss with patient - some states require reporting
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Treat underlying disease/lack resources
5% - underreported

49. ACE inhib + K+: interaction outcome
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
^K+

50. rivastigmine
^morbidity + mortality - -frailest @ greatest risk
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Cholinesterase inhib - use: dementia
Begin @25-50% recommended dose - APAP may be dose-limiting