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Aging Physiology And Pharmacology

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1. How does aging affect pharmacokinetics?
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
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Electrolyte imbalance - arrhythmia
80% of hospital admission for syncope for >65yo

2. galantamine
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
Serum Cr: used for Cr clearance equation
Cholinesterase inhib - use: dementia
Pressure ulcer - fecal impaction - dehydration

3. How does aging increase incontinence?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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
Hyperuricemia -> gout

4. elderly abuse epidemiology
5% - underreported
Map of people - perceptions - etc - varies by perspective
Doctors
High mortality - esp + Fx - very common in elderly

5. What are common medical causes of syncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
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
Electrical: change in HR - structural: aortic outflow obstruction
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

6. What is the epidemiology of dizziness?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
P2-metabolite - phase 1 biotx much more affected than phase 2

7. thyroid dx + atypical Sx
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

8. what illnesses are underreported in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Prescribing - monitoring - patient adherence
Insiduous onset
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

9. What are the common types of elder mistreatment?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Confusion - sedation - falls

10. falls epidemiology
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Receptors changes: # - sensitivity - counter-regulatory moa
Catch-all of unspecified dizziness
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

11. how can you determine whether Rx is appropriate to use in elderly patient?
Tx underlying etio - + Kegels - pessary - surgery
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Beers criteria - medication appropriateness index (12 ?)

12. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
>9 Rx
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

13. what normally prevents syncope?
80% of hospital admission for syncope for >65yo
3 reflexes: baroreceptor - renal nerve - ANF
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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

14. refusing intervention
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Legal: Cruzan v Hamon
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

15. What are rf for osteoporosis?
Therapy - SSRI
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

16. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Hypotension - ^K+

17. driving considerations
Figure out a good diet - social aspect - resources - dental/oral comfort
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
Confusion - sedation - falls
Make sure to discuss with patient - some states require reporting

18. 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
Bone loss -> osteopenia -> osteoporosis -> Fx
Worse for cardiac causes v noncardia
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

19. delirium: mgmt
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Multisystemic vulnerability - -lowered reserves
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

20. pulm edema + atypical Sx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
IdioPx - psychiatric: depression - anxiety - somatoform
Insiduous onset
Breast cancer + 2o LBP

21. psychological abuse
Confusion - sedation - falls
Threats/ terrorizing - isolation - denying food/privileges/liberty
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Beers criteria - medication appropriateness index (12 ?)

22. ACE inhib + K+: interaction outcome
Confusion - sedation - falls
^K+
Serum Cr: used for Cr clearance equation
Bone loss -> osteopenia -> osteoporosis -> Fx

23. Presyncope
Isolated systolic HTN
High mortality - esp + Fx - very common in elderly
1/2
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

24. physical neglect
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Beers criteria - medication appropriateness index (12 ?)

25. vision changes: elderly
Parkinsonism -> l-DOPA
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
P2-metabolite - phase 1 biotx much more affected than phase 2
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

26. tube feeding
Doctors
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Prescribing - monitoring - patient adherence

27. using long-acting opioids in elderly
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
^morbidity + mortality - -frailest @ greatest risk
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

28. fall sequelae
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Parkinsonism -> l-DOPA
^K+
#1 patient's last competent indication of wishes - substituted judgment - beneficence

29. donepezil
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cholinesterase inhib - use: dementia
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

30. overflow incontinence tx
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
Screen for potentially embarrassing dx - patient/Dr trust
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Cachexia - PEM - FTT - obesity

31. incontinence epidemiology
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Diagnosis - risk/benefit analysis to choose Rx

32. How does aging impact syncope-preventing reflexes
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Therapy - SSRI
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Pressure ulcer - fecal impaction - dehydration

33. Disequilibrium
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Map of people - perceptions - etc - varies by perspective
^morbidity + mortality - -frailest @ greatest risk

34. MI + atypical Sx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Make sure to discuss with patient - some states require reporting
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

35. delirium predisposing rf
Doctors
IdioPx - psychiatric: depression - anxiety - somatoform
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Receptors changes: # - sensitivity - counter-regulatory moa

36. memantine
Legal: Cruzan v Hamon
NMDR antagonist - use: dementia
Confusion - sedation - falls
BMD (bone mineral density): T-score >2.5 std dev below normal 1

37. What is a PE sign of cachexia?
80% of hospital admission for syncope for >65yo
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Temporalis muscle wasting = temporal wasting
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

38. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
Pressure ulcer - fecal impaction - dehydration
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

39. What is sCr?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
CVA: stroke - AMI: acute MI - HF
Serum Cr: used for Cr clearance equation
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

40. How does ANF prevent syncope?
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
ANF: Na+ retention - disinhib vasoconstriction
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Consider responsibilities - drivin

41. what professional is least likely to report abuse?
Multisystemic vulnerability - -lowered reserves
Doctors
Stress: #1 - functional - urge - overflow
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

42. What drugs can contribute to syncope?
^SV (diastolic stroke volume)
A-blockers - B-blockers - TCA
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

43. ADR rf
Mechanical loading - skin care - avoid friction/shear
^BP -> a-HTN
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

44. frailty
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Cholinesterase inhib - use: dementia
Multisystemic vulnerability - -lowered reserves
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

45. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
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
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

46. How does aging affect GI absorption rate of Rx?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Delayed absorption - like competitive inhib
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

47. What are the pharmacodynamic changes associated with aging?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Receptors changes: # - sensitivity - counter-regulatory moa
^K+
Hypotension - ^K+

48. How does aging affect Rx renal elimination?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

49. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
Begin @25-50% recommended dose - APAP may be dose-limiting
Therapy - SSRI
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

50. Beers criteria: what 10 Rx should elderly avoid or use + caution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
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
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

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