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Aging Physiology And Pharmacology

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1. Aging features
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
^SV (diastolic stroke volume)
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Universal - progressive - partially encoded (genetic) - destructive -

2. What is the best approach to malnutrition
CVA: stroke - AMI: acute MI - HF
Treat underlying disease/lack resources
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Multisystemic vulnerability - -lowered reserves

3. What are the pharmacodynamic changes associated with aging?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Used to calculate renal fcn - clearance of Cr adjusted for age
Receptors changes: # - sensitivity - counter-regulatory moa

4. preventing malnutrition
Map of people - perceptions - etc - varies by perspective
Figure out a good diet - social aspect - resources - dental/oral comfort
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

5. How does aging affect pharmacokinetic protein binding?
Voice - character - plot - context - time - reader
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Confusion - sedation - falls
^K+

6. How does aging affect Rx renal elimination?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Pressure ulcer - fecal impaction - dehydration
28% - ADR: 17% - non-compliance 11%
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

7. delirium: mgmt
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
CNS suppression -> cholinesterase inhibitors
Beers criteria - medication appropriateness index (12 ?)
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

8. What are the 3 sentinel events for LT care?
P2-metabolite - phase 1 biotx much more affected than phase 2
80% of hospital admission for syncope for >65yo
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Pressure ulcer - fecal impaction - dehydration

9. narcotics may lead to what prescription cascade?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Constipation -> laxatives
80% of hospital admission for syncope for >65yo

10. 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
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Delayed absorption - like competitive inhib

11. What are the vascular changes of presyncope?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

12. What is the bone deterioration cascade?
5% - underreported
Temporalis muscle wasting = temporal wasting
Mechanical loading - skin care - avoid friction/shear
Bone loss -> osteopenia -> osteoporosis -> Fx

13. driving considerations
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Beers criteria - medication appropriateness index (12 ?)
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Make sure to discuss with patient - some states require reporting

14. How does renal nerve prevent syncope?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
30% preventable - of these - 40% serious - of these 40% preventable
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

15. malnutrition
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
CNS suppression -> cholinesterase inhibitors
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

16. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Make sure to discuss with patient - some states require reporting
CNS suppression -> cholinesterase inhibitors
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

17. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Parkinsonism -> l-DOPA
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

18. rivastigmine
Cholinesterase inhib - use: dementia
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
80% of hospital admission for syncope for >65yo
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

19. advanced directive/care plan

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20. refusing intervention
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Therapy - SSRI
Legal: Cruzan v Hamon

21. MI + atypical Sx
Hypotension - ^K+
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Mechanical loading - skin care - avoid friction/shear
No: chest pain - yes: fatigue - nausea - low functional status - SOB

22. How does aging affect pharmacokinetics?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Cachexia - PEM - FTT - obesity
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

23. what receptors decrease sensitivity with aging?
Therapy - SSRI
Cholinesterase inhib - use: dementia
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
5% - underreported

24. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Serum Cr: used for Cr clearance equation
Threats/ terrorizing - isolation - denying food/privileges/liberty

25. functional incontinence tx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Universal - progressive - partially encoded (genetic) - destructive -
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Environment modification: obstacles - mobility - -bladder fcn ok

26. pressure ulcer: staging
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Mechanical loading - skin care - avoid friction/shear
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
80% of hospital admission for syncope for >65yo

27. what Rx are commonly monifoted in elderly for ADR?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
A-blockers - B-blockers - TCA
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

28. what drugs can cause dizziness?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Cholinesterase inhib - use: dementia
A-blockers - B-blockers - TCA

29. How does aging affect GI absorption of Rx?
Universal - progressive - partially encoded (genetic) - destructive -
3 reflexes: baroreceptor - renal nerve - ANF
Cholinesterase inhib - use: dementia
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

30. What are the key points of safe prescription for elderly - lecture
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Diagnosis - risk/benefit analysis to choose Rx
Cachexia - PEM - FTT - obesity
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

31. how may hypertension compensate for aging?
28% - ADR: 17% - non-compliance 11%
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

32. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Hyperuricemia -> gout
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
^morbidity + mortality - -frailest @ greatest risk

33. describe the % of ADR considered preventable - and of those serious
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
30% preventable - of these - 40% serious - of these 40% preventable

34. fall causes
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Used to calculate renal fcn - clearance of Cr adjusted for age

35. malignancy + atypical Sx
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Breast cancer + 2o LBP
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

36. opioid tx in elderly
^SV (diastolic stroke volume)
Begin @25-50% recommended dose - APAP may be dose-limiting
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
3 reflexes: baroreceptor - renal nerve - ANF

37. How does aging affect Rx pharmacokinetic metabolism?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Breast cancer + 2o LBP

38. frailty raises vulnerability to...
Voice - character - plot - context - time - reader
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
#1 patient's last competent indication of wishes - substituted judgment - beneficence

39. How does baroreceptor reflex prevent syncope?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
^ANS tone -> ^periph vasoconstriction - ^HR
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Legal: Cruzan v Hamon

40. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
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
Used to calculate renal fcn - clearance of Cr adjusted for age
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

41. What is ISH?
^K+
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Isolated systolic HTN
Falls - delirium - malnutrition - P ulcers - opportunistic i2

42. which benzodiazepines are most appropriate for elderly?
Prescribing - monitoring - patient adherence
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
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
P2-metab: Lorazepam - Trazepam - Oxazepam

43. psychological abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
Serum Cr: used for Cr clearance equation
80% of hospital admission for syncope for >65yo
Diagnosis - risk/benefit analysis to choose Rx

44. lightheadedness
Catch-all of unspecified dizziness
Determined by Dr for a patient - -> used to determine competency
Hyperuricemia -> gout
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

45. Disequilibrium
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Legal: Cruzan v Hamon
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

46. 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
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
^SV (diastolic stroke volume)
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

47. What is the preferred depression treatment in elderly?
Therapy - SSRI
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Constipation -> laxatives
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

48. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Diagnosis - risk/benefit analysis to choose Rx
Cholinesterase inhib - use: dementia
Environment modification: obstacles - mobility - -bladder fcn ok

49. Cockcroft Gault equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
^K+
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

50. delirium: medical rf
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Isolated systolic HTN

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Aging Physiology And Pharmacology

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