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Aging Physiology And Pharmacology

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1. How does aging affect pharmacokinetic Rx distribution?
Therapy - SSRI
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

2. which benzodiazepines are most appropriate for elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
Screen for potentially embarrassing dx - patient/Dr trust
Catch-all of unspecified dizziness
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

3. How does baroreceptor reflex prevent syncope?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Beers criteria - medication appropriateness index (12 ?)
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
^ANS tone -> ^periph vasoconstriction - ^HR

4. fall sequelae

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5. BZD + antidepressant: interaction outcome
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Confusion - sedation - falls
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

6. vertigo
Hyperuricemia -> gout
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

7. antiarrhythmic + diuretic: interaction outcome
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
High mortality - esp + Fx - very common in elderly
Electrolyte imbalance - arrhythmia
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

8. BZD + antipsychotic: interaction outcome
Treat underlying disease/lack resources
Temporalis muscle wasting = temporal wasting
Confusion - sedation - falls
Universal - progressive - partially encoded (genetic) - destructive -

9. urge incontinence tx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

10. ACE inhib + K+: interaction outcome
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
^K+
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

11. incontinence complication
Determined by Dr for a patient - -> used to determine competency
High mortality - esp + Fx - very common in elderly
CVA: stroke - AMI: acute MI - HF
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

12. What is sCr?
3 reflexes: baroreceptor - renal nerve - ANF
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Temporalis muscle wasting = temporal wasting
Serum Cr: used for Cr clearance equation

13. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
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
Electrolyte imbalance - arrhythmia
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

14. MRP: medication related problems
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
A-blockers - B-blockers - TCA
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

15. falls epidemiology
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

16. delirium: tx approach
>60yo - low abuse risk - ^ monitoring possible
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Electrical: change in HR - structural: aortic outflow obstruction
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

17. delirium predisposing rf
Cholinesterase inhib - use: dementia
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

18. PEM
>60yo - low abuse risk - ^ monitoring possible
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Phenytoin
Insiduous onset

19. refusing intervention
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Legal: Cruzan v Hamon
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Appointed by court if no substituted judgment -conservator of finance -conservator of person

20. lightheadedness
Catch-all of unspecified dizziness
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
IdioPx - psychiatric: depression - anxiety - somatoform

21. ADR rf
Make sure to discuss with patient - some states require reporting
Delayed absorption - like competitive inhib
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

22. what Rx are commonly monifoted in elderly for ADR?
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
Insiduous onset
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

23. overflow incontinence tx
A-blockers - B-blockers - TCA
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
CVA: stroke - AMI: acute MI - HF

24. What is the Cockcroft Gault equation?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
NMDR antagonist - use: dementia
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Used to calculate renal fcn - clearance of Cr adjusted for age

25. pulm edema + atypical Sx
Tx underlying etio - + Kegels - pessary - surgery
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Insiduous onset
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

26. thiazide diuretic may lead to what prescription cascade?
Tx underlying etio - + Kegels - pessary - surgery
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Hyperuricemia -> gout
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

27. what ADR are common in elderly patient?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Screen for potentially embarrassing dx - patient/Dr trust
30% preventable - of these - 40% serious - of these 40% preventable

28. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Treat underlying disease/lack resources

29. surrogate decision making heirarchy

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30. How does renal nerve prevent syncope?
Parkinsonism -> l-DOPA
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

31. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

32. how is the CAM used to diagnose delirium?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
CNS suppression -> cholinesterase inhibitors
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Environment modification: obstacles - mobility - -bladder fcn ok

33. What is the best approach to malnutrition
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Treat underlying disease/lack resources
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Insiduous onset

34. what receptors increase sensitivity with aging?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Parkinsonism -> l-DOPA
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

35. vision changes: elderly
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
^K+

36. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
^SV (diastolic stroke volume)
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Cholinesterase inhib - use: dementia

37. What is the STOPP criteria?
Respect for autonomy - nonmaleficence - beneficence - justice
#1 patient's last competent indication of wishes - substituted judgment - beneficence
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
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

38. Aging features
Consider responsibilities - drivin
Universal - progressive - partially encoded (genetic) - destructive -
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

39. metoclopramide may lead to what prescription cascade?
Constipation -> laxatives
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Parkinsonism -> l-DOPA
Beers criteria - medication appropriateness index (12 ?)

40. conservator
Worse for cardiac causes v noncardia
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Hypotension - ^K+
Appointed by court if no substituted judgment -conservator of finance -conservator of person

41. donepezil
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
^K+
Cholinesterase inhib - use: dementia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

42. stress incontinence tx
NMDR antagonist - use: dementia
Tx underlying etio - + Kegels - pessary - surgery
Legal: Cruzan v Hamon
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

43. How does aging affect GI absorption of Rx?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
^SV (diastolic stroke volume)
Insiduous onset

44. Alb-bound Rx
A-blockers - B-blockers - TCA
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Phenytoin

45. Beers criteria
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
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
Parkinsonism -> l-DOPA
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

46. what professional is least likely to report abuse?
Doctors
Screen for potentially embarrassing dx - patient/Dr trust
No: chest pain - yes: fatigue - nausea - low functional status - SOB
5% - underreported

47. What are common physical abuse Sx in elderly?
Cholinesterase inhib - use: dementia
Hyperuricemia -> gout
IdioPx - psychiatric: depression - anxiety - somatoform
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

48. driving considerations
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Make sure to discuss with patient - some states require reporting

49. what normally prevents syncope?
Cholinesterase inhib - use: dementia
3 reflexes: baroreceptor - renal nerve - ANF
1/2
Vertigo - presyncope - disequilibrium - lightheadedness

50. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
>9 Rx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport