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Aging Physiology And Pharmacology

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1. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
P2-metabolite - phase 1 biotx much more affected than phase 2
3 reflexes: baroreceptor - renal nerve - ANF
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

2. How does aging affect Rx renal elimination?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

3. ACE inhib + diuretic: interaction outcome
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Hypotension - ^K+

4. substituted judgment
3 reflexes: baroreceptor - renal nerve - ANF
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

5. Aging descriptors
Insiduous onset
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

6. vision changes: elderly
Isolated systolic HTN
Consider responsibilities - drivin
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

7. describe the % of ADR considered preventable - and of those serious
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
30% preventable - of these - 40% serious - of these 40% preventable
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

8. pulm edema + atypical Sx
Screen for potentially embarrassing dx - patient/Dr trust
Insiduous onset
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

9. What are common scenarios of untreated indications in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

10. how can you determine whether Rx is appropriate to use in elderly patient?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Beers criteria - medication appropriateness index (12 ?)
Map of people - perceptions - etc - varies by perspective
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

11. What is abuse?
Respect for autonomy - nonmaleficence - beneficence - justice
Temporalis muscle wasting = temporal wasting
Injury - neglect - physical/psychosocial - financial - violation of rights
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

12. What are the common causes of lightheadedness?
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
IdioPx - psychiatric: depression - anxiety - somatoform
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

13. what nutritional interventions help underweight?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

14. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Isolated systolic HTN
Temporalis muscle wasting = temporal wasting
Used to calculate renal fcn - clearance of Cr adjusted for age

15. How does renal nerve prevent syncope?
>9 Rx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

16. who is a good candidate for opioid tx?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
>60yo - low abuse risk - ^ monitoring possible
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

17. What is the STOPP criteria?
30% preventable - of these - 40% serious - of these 40% preventable
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
Used to calculate renal fcn - clearance of Cr adjusted for age
^BP -> a-HTN

18. delirium predisposing rf
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
A-blockers - B-blockers - TCA
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Treat underlying disease/lack resources

19. documenting elderly abuse

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20. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
3 reflexes: baroreceptor - renal nerve - ANF
Confusion - sedation - falls
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

21. How does aging affect pharmacokinetic Rx distribution?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Map of people - perceptions - etc - varies by perspective
Confusion - sedation - falls
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

22. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Injury - neglect - physical/psychosocial - financial - violation of rights
CVA: stroke - AMI: acute MI - HF
Tx underlying etio - + Kegels - pessary - surgery

23. overflow incontinence tx
>9 Rx
ANF: Na+ retention - disinhib vasoconstriction
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

24. incontinence epidemiology
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Universal - progressive - partially encoded (genetic) - destructive -
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

25. clues of neglect
Cholinesterase inhib - use: dementia
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
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

26. elderly abuse epidemiology
5% - underreported
Parkinsonism -> l-DOPA
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
High mortality - esp + Fx - very common in elderly

27. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
Parkinsonism -> l-DOPA
1/2
Screen for potentially embarrassing dx - patient/Dr trust

28. donepezil
Cholinesterase inhib - use: dementia
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
ANF: Na+ retention - disinhib vasoconstriction
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

29. what ADR are common in elderly patient?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

30. Why is abuse underreported?
Breast cancer + 2o LBP
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

31. How does aging affect pharmacokinetic protein binding?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
3 reflexes: baroreceptor - renal nerve - ANF
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

32. What are the rf for caregiver to abuse elderly?
^BP -> a-HTN
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

33. How does aging increase incontinence?
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
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Environment modification: obstacles - mobility - -bladder fcn ok
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

34. delirium diagnosis
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Phenytoin
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

35. cachexia
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Mechanical loading - skin care - avoid friction/shear
IdioPx - psychiatric: depression - anxiety - somatoform

36. What is the preferred depression treatment in elderly?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Therapy - SSRI
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

37. fall causes
30% preventable - of these - 40% serious - of these 40% preventable
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Delayed absorption - like competitive inhib
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

38. delirium: Rx that contribute
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Cholinesterase inhib - use: dementia
Begin @25-50% recommended dose - APAP may be dose-limiting

39. What is a PE sign of cachexia?
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Temporalis muscle wasting = temporal wasting
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

40. acute abdomen + atypical Sx
Beers criteria - medication appropriateness index (12 ?)
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

41. red flags for further inquiry
^K+
Therapy - SSRI
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

42. stress incontinence tx
3 reflexes: baroreceptor - renal nerve - ANF
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Tx underlying etio - + Kegels - pessary - surgery

43. How does aging affect pharmacokinetics?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Respect for autonomy - nonmaleficence - beneficence - justice
Cholinesterase inhib - use: dementia
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

44. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Vertigo - presyncope - disequilibrium - lightheadedness
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

45. What drugs can contribute to syncope?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
A-blockers - B-blockers - TCA
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

46. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

47. galantamine
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
^ANS tone -> ^periph vasoconstriction - ^HR
Cholinesterase inhib - use: dementia
Falls - delirium - malnutrition - P ulcers - opportunistic i2

48. How to prevent pressure ulcers?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Isolated systolic HTN
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Mechanical loading - skin care - avoid friction/shear

49. Presyncope
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

50. What are the 3 sentinel events for LT care?
^SV (diastolic stroke volume)
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Pressure ulcer - fecal impaction - dehydration

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Aging Physiology And Pharmacology

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