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Aging Physiology And Pharmacology

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1. functional incontinence tx
IdioPx - psychiatric: depression - anxiety - somatoform
Cholinesterase inhib - use: dementia
Environment modification: obstacles - mobility - -bladder fcn ok
Delayed absorption - like competitive inhib

2. LBW equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Respect for autonomy - nonmaleficence - beneficence - justice
Consider responsibilities - drivin
NMDR antagonist - use: dementia

3. How does aging affect pharmacokinetics?
^ANS tone -> ^periph vasoconstriction - ^HR
Voice - character - plot - context - time - reader
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Hypothetical plan - serves as patient's last competent indicated wishes

4. how is syncope related to elderly admission to hospital?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
28% - ADR: 17% - non-compliance 11%
CNS suppression -> cholinesterase inhibitors
80% of hospital admission for syncope for >65yo

5. what mechanical loading helps to prevent pressure ulcers?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

6. BZD + antidepressant: interaction outcome
30% preventable - of these - 40% serious - of these 40% preventable
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Confusion - sedation - falls

7. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Consider responsibilities - drivin
Falls - delirium - malnutrition - P ulcers - opportunistic i2
>60yo - low abuse risk - ^ monitoring possible

8. surrogate decision making heirarchy

9. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Stress: #1 - functional - urge - overflow
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Voice - character - plot - context - time - reader

10. overflow incontinence tx
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

11. Aging principles
Universal - progressive - partially encoded (genetic) - destructive -
Consider responsibilities - drivin
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

12. elderly abuse epidemiology
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
5% - underreported
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

13. delirium: Rx that contribute
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

14. MI + atypical Sx
Cachexia - PEM - FTT - obesity
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Isolated systolic HTN
ANF: Na+ retention - disinhib vasoconstriction

15. How does aging affect Rx pharmacokinetic metabolism?
Consider responsibilities - drivin
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Electrolyte imbalance - arrhythmia
Temporalis muscle wasting = temporal wasting

16. ADR rf
Figure out a good diet - social aspect - resources - dental/oral comfort
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Confusion - sedation - falls

17. metoclopramide may lead to what prescription cascade?
^K+
Cholinesterase inhib - use: dementia
Parkinsonism -> l-DOPA
Used to calculate renal fcn - clearance of Cr adjusted for age

18. What is a PE sign of cachexia?
ANF: Na+ retention - disinhib vasoconstriction
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Temporalis muscle wasting = temporal wasting
80% of hospital admission for syncope for >65yo

19. What are the pharmacodynamic changes associated with aging?
Worse for cardiac causes v noncardia
Receptors changes: # - sensitivity - counter-regulatory moa
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

20. How does aging affect Rx pharmacokinetic distribution?
Screen for potentially embarrassing dx - patient/Dr trust
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
Stress: #1 - functional - urge - overflow
Bone loss -> osteopenia -> osteoporosis -> Fx

21. What are the key points of safe prescription for elderly - lecture
Cholinesterase inhib - use: dementia
Diagnosis - risk/benefit analysis to choose Rx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Confusion - sedation - falls

22. opioid tx in elderly
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Begin @25-50% recommended dose - APAP may be dose-limiting
3 reflexes: baroreceptor - renal nerve - ANF
CNS suppression -> cholinesterase inhibitors

23. what Rx are commonly monifoted in elderly for ADR?
Serum Cr: used for Cr clearance equation
Insiduous onset
Hypotension - ^K+
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

24. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

25. How does aging affect pharmacokinetic protein binding?
Electrolyte imbalance - arrhythmia
Consider responsibilities - drivin
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

26. Syncope prognosis based on etio
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
>9 Rx
Worse for cardiac causes v noncardia

27. What is the preferred depression treatment in elderly?
Therapy - SSRI
Worse for cardiac causes v noncardia
NMDR antagonist - use: dementia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

28. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Begin @25-50% recommended dose - APAP may be dose-limiting
Therapy - SSRI
Respect for autonomy - nonmaleficence - beneficence - justice

29. delirium: medical rf
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
A-blockers - B-blockers - TCA

30. What is capacity?
P2-metab: Lorazepam - Trazepam - Oxazepam
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Determined by Dr for a patient - -> used to determine competency
Receptors changes: # - sensitivity - counter-regulatory moa

31. ACE inhib + K+: interaction outcome
High mortality - esp + Fx - very common in elderly
^K+
^SV (diastolic stroke volume)
Serum Cr: used for Cr clearance equation

32. What are the vascular changes of presyncope?
Cholinesterase inhib - use: dementia
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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Screen for potentially embarrassing dx - patient/Dr trust

33. Cockcroft Gault equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Hypothetical plan - serves as patient's last competent indicated wishes
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
80% of hospital admission for syncope for >65yo

34. Aging features
Electrolyte imbalance - arrhythmia
Universal - progressive - partially encoded (genetic) - destructive -
F>M (until 80yo) - stress incontinence #1 - $26B/yr
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

35. What is ISH?
Therapy - SSRI
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
ANF: Na+ retention - disinhib vasoconstriction
Isolated systolic HTN

36. What is abuse?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Injury - neglect - physical/psychosocial - financial - violation of rights
5% - underreported

37. How does baroreceptor reflex prevent syncope?
CNS suppression -> cholinesterase inhibitors
^ANS tone -> ^periph vasoconstriction - ^HR
3 reflexes: baroreceptor - renal nerve - ANF
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

38. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Injury - neglect - physical/psychosocial - financial - violation of rights
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

39. psychological abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
>60yo - low abuse risk - ^ monitoring possible
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

40. What is the epidemiology of dizziness?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
^BP -> a-HTN

41. urge incontinence tx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
BMD (bone mineral density): T-score >2.5 std dev below normal 1

42. what professional is least likely to report abuse?
Delayed absorption - like competitive inhib
Doctors
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Vertigo - presyncope - disequilibrium - lightheadedness

43. What is the natural history of syncope?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Electrolyte imbalance - arrhythmia
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

44. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Hyperuricemia -> gout
^K+
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

45. thiazide diuretic may lead to what prescription cascade?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Hyperuricemia -> gout
Beers criteria - medication appropriateness index (12 ?)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

46. frailty raises vulnerability to...
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Falls - delirium - malnutrition - P ulcers - opportunistic i2
>60yo - low abuse risk - ^ monitoring possible
Appointed by court if no substituted judgment -conservator of finance -conservator of person

47. incontinence complication
Therapy - SSRI
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Receptors changes: # - sensitivity - counter-regulatory moa
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

48. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Pressure ulcer - fecal impaction - dehydration
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

49. fall causes
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

50. what receptors increase sensitivity with aging?
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
^K+
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar