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Aging Physiology And Pharmacology

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1. What are common scenarios of untreated indications in elderly?
Diagnosis - risk/benefit analysis to choose Rx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

2. i2 + atypical Sx
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
No: fever - leukocytosis - yes: falls - appetite change - low functional status

3. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Hyperuricemia -> gout
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

4. How does ANF prevent syncope?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Treat underlying disease/lack resources
ANF: Na+ retention - disinhib vasoconstriction

5. antiarrhythmic + diuretic: interaction outcome
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Make sure to discuss with patient - some states require reporting
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Electrolyte imbalance - arrhythmia

6. How does the aging heart compensate for lower HR to maintain unchanged CO?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Cholinesterase inhib - use: dementia
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)

7. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
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
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

8. What is the Cockcroft Gault equation?
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
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

9. delirium incidence
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
ANF: Na+ retention - disinhib vasoconstriction

10. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Figure out a good diet - social aspect - resources - dental/oral comfort
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
P2-metabolite - phase 1 biotx much more affected than phase 2
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

11. What is the STOPP criteria?
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
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Cholinesterase inhib - use: dementia
Cholinesterase inhib - use: dementia

12. How does an 80yo renal fcn compare to that of a 20yo?
1/2
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Parkinsonism -> l-DOPA
Vertigo - presyncope - disequilibrium - lightheadedness

13. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
CVA: stroke - AMI: acute MI - HF
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

14. depression + atypical Sx
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
^SV (diastolic stroke volume)

15. What are common medical causes of syncope?
Mechanical loading - skin care - avoid friction/shear
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

16. what ADR are common in elderly patient?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
#1 patient's last competent indication of wishes - substituted judgment - beneficence

17. How does aging increase incontinence?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
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
Threats/ terrorizing - isolation - denying food/privileges/liberty

18. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

19. what mechanical loading helps to prevent pressure ulcers?
CVA: stroke - AMI: acute MI - HF
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

20. Presyncope
^BP -> a-HTN
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

21. which benzodiazepines are most appropriate for elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
^morbidity + mortality - -frailest @ greatest risk
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

22. what receptors decrease sensitivity with aging?
Legal: Cruzan v Hamon
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Cachexia - PEM - FTT - obesity
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

23. How does sliding scale glycemic control relate to elderly?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

24. what nutritional interventions help underweight?
>9 Rx
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Hypotension - ^K+
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

25. red flags for further inquiry
Treat underlying disease/lack resources
^ANS tone -> ^periph vasoconstriction - ^HR
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
CNS suppression -> cholinesterase inhibitors

26. incontinence epidemiology
3 reflexes: baroreceptor - renal nerve - ANF
F>M (until 80yo) - stress incontinence #1 - $26B/yr
30% preventable - of these - 40% serious - of these 40% preventable
Electrical: change in HR - structural: aortic outflow obstruction

27. What are the possible cardiac causes of presyncope?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Electrical: change in HR - structural: aortic outflow obstruction
>9 Rx

28. what professional is least likely to report abuse?
Doctors
80% of hospital admission for syncope for >65yo
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Serum Cr: used for Cr clearance equation

29. How does aging affect pharmacokinetic protein binding?
Multisystemic vulnerability - -lowered reserves
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Electrolyte imbalance - arrhythmia

30. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Legal: Cruzan v Hamon
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

31. What are the key points of safe prescription for elderly - lecture
High mortality - esp + Fx - very common in elderly
Diagnosis - risk/benefit analysis to choose Rx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Multisystemic vulnerability - -lowered reserves

32. How does aging affect GI absorption rate of Rx?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Mechanical loading - skin care - avoid friction/shear
Delayed absorption - like competitive inhib
Doctors

33. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
28% - ADR: 17% - non-compliance 11%
>60yo - low abuse risk - ^ monitoring possible
Threats/ terrorizing - isolation - denying food/privileges/liberty

34. Alb-bound Rx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Phenytoin
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
IdioPx - psychiatric: depression - anxiety - somatoform

35. Why is abuse underreported?
Begin @25-50% recommended dose - APAP may be dose-limiting
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Consider responsibilities - drivin
Isolated systolic HTN

36. What is ISH?
Screen for potentially embarrassing dx - patient/Dr trust
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Isolated systolic HTN

37. delirium diagnosis
>60yo - low abuse risk - ^ monitoring possible
Determined by Dr for a patient - -> used to determine competency
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

38. Cockcroft Gault equation
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Voice - character - plot - context - time - reader

39. PEM
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
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

40. urge incontinence tx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
^K+

41. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Serum Cr: used for Cr clearance equation
Hypotension - ^K+

42. stress incontinence tx
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Used to calculate renal fcn - clearance of Cr adjusted for age
Tx underlying etio - + Kegels - pessary - surgery
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

43. How does aging affect pharmacokinetic Rx distribution?
Electrical: change in HR - structural: aortic outflow obstruction
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

44. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Multisystemic vulnerability - -lowered reserves
Legal: Cruzan v Hamon
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

45. using long-acting opioids in elderly
30% preventable - of these - 40% serious - of these 40% preventable
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Therapy - SSRI

46. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Receptors changes: # - sensitivity - counter-regulatory moa
Voice - character - plot - context - time - reader

47. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Prescribing - monitoring - patient adherence

48. What are the common types of elder mistreatment?
Respect for autonomy - nonmaleficence - beneficence - justice
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
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

49. ADR rf
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
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

50. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
IdioPx - psychiatric: depression - anxiety - somatoform
Treat underlying disease/lack resources
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin