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Aging Physiology And Pharmacology

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1. restrain requirements
Therapy - SSRI
30% preventable - of these - 40% serious - of these 40% preventable
Treat underlying disease/lack resources
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

2. What are the 3 sentinel events for LT care?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Phenytoin
Pressure ulcer - fecal impaction - dehydration
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

3. How does renal nerve prevent syncope?
Beers criteria - medication appropriateness index (12 ?)
Treat underlying disease/lack resources
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Constipation -> laxatives

4. functional incontinence tx
Mechanical loading - skin care - avoid friction/shear
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
Environment modification: obstacles - mobility - -bladder fcn ok
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

5. donepezil
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Cholinesterase inhib - use: dementia
Appointed by court if no substituted judgment -conservator of finance -conservator of person

6. What are common scenarios of untreated indications in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

7. How does aging affect pharmacokinetic Rx distribution?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
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
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

8. pressure ulcer: staging
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Stress: #1 - functional - urge - overflow
Pressure ulcer - fecal impaction - dehydration

9. What is START criteria?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
NMDR antagonist - use: dementia
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Hypotension - ^K+

10. What are common physical abuse Sx in elderly?
Universal - progressive - partially encoded (genetic) - destructive -
Make sure to discuss with patient - some states require reporting
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

11. NSAID may lead to what prescription cascade?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
^BP -> a-HTN
^SV (diastolic stroke volume)
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

12. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
Temporalis muscle wasting = temporal wasting
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

13. What are the key points of safe prescription for elderly - lecture
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
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Diagnosis - risk/benefit analysis to choose Rx

14. Aging features
Hypotension - ^K+
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Universal - progressive - partially encoded (genetic) - destructive -
^K+

15. incontinence complication
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Doctors
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

16. violation of rights
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

17. fall causes
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Pressure ulcer - fecal impaction - dehydration
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

18. What are the vascular changes of presyncope?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Mechanical loading - skin care - avoid friction/shear
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

19. What are common medical causes of syncope?
Hypotension - ^K+
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
IdioPx - psychiatric: depression - anxiety - somatoform
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

20. What are the possible cardiac causes of presyncope?
Electrical: change in HR - structural: aortic outflow obstruction
A-blockers - B-blockers - TCA
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Cholinesterase inhib - use: dementia

21. how is syncope related to elderly admission to hospital?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Environment modification: obstacles - mobility - -bladder fcn ok
#1 patient's last competent indication of wishes - substituted judgment - beneficence
80% of hospital admission for syncope for >65yo

22. describe the % of ADR considered preventable - and of those serious
Isolated systolic HTN
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
30% preventable - of these - 40% serious - of these 40% preventable
Consider responsibilities - drivin

23. What is the STOPP criteria?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
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

24. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

25. anticholinergic drugs may lead to what prescription cascade?
Injury - neglect - physical/psychosocial - financial - violation of rights
CNS suppression -> cholinesterase inhibitors
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

26. How does baroreceptor reflex prevent syncope?
Map of people - perceptions - etc - varies by perspective
Vertigo - presyncope - disequilibrium - lightheadedness
^ANS tone -> ^periph vasoconstriction - ^HR
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

27. What is the bone deterioration cascade?
Make sure to discuss with patient - some states require reporting
Hyperuricemia -> gout
Bone loss -> osteopenia -> osteoporosis -> Fx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

28. when selecting an P1-metabolite or P2-metabolite safer in elderly?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
P2-metabolite - phase 1 biotx much more affected than phase 2
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
BMD (bone mineral density): T-score >2.5 std dev below normal 1

29. what receptors increase sensitivity with aging?
ANF: Na+ retention - disinhib vasoconstriction
Diagnosis - risk/benefit analysis to choose Rx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Insiduous onset

30. How does aging affect pharmacokinetic protein binding?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Consider responsibilities - drivin

31. Disequilibrium
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Map of people - perceptions - etc - varies by perspective
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

32. Presyncope
NMDR antagonist - use: dementia
Pressure ulcer - fecal impaction - dehydration
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
5% - underreported

33. using long-acting opioids in elderly
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
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
3 reflexes: baroreceptor - renal nerve - ANF
Diagnosis - risk/benefit analysis to choose Rx

34. vision changes: elderly
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

35. What are the 3 stages of ADRs?
Worse for cardiac causes v noncardia
Multisystemic vulnerability - -lowered reserves
Prescribing - monitoring - patient adherence
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

36. How to prevent pressure ulcers?
Figure out a good diet - social aspect - resources - dental/oral comfort
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Mechanical loading - skin care - avoid friction/shear
Parkinsonism -> l-DOPA

37. What are the common causes of lightheadedness?
Breast cancer + 2o LBP
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
^ANS tone -> ^periph vasoconstriction - ^HR
IdioPx - psychiatric: depression - anxiety - somatoform

38. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Determined by Dr for a patient - -> used to determine competency
High mortality - esp + Fx - very common in elderly
5% - underreported

39. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Hyperuricemia -> gout
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

40. 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
80% of hospital admission for syncope for >65yo
^morbidity + mortality - -frailest @ greatest risk
Doctors

41. ACE inhib + K+: interaction outcome
Determined by Dr for a patient - -> used to determine competency
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Doctors
^K+

42. vertigo
Figure out a good diet - social aspect - resources - dental/oral comfort
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Delayed absorption - like competitive inhib
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

43. how is cachexia different from wasting?
28% - ADR: 17% - non-compliance 11%
5% - underreported
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

44. How does aging affect GI absorption rate of Rx?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Delayed absorption - like competitive inhib
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

45. frailty raises vulnerability to...
ANF: Na+ retention - disinhib vasoconstriction
Cholinesterase inhib - use: dementia
CVA: stroke - AMI: acute MI - HF
Falls - delirium - malnutrition - P ulcers - opportunistic i2

46. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
A-blockers - B-blockers - TCA

47. What are the pharmacodynamic changes associated with aging?
Environment modification: obstacles - mobility - -bladder fcn ok
Receptors changes: # - sensitivity - counter-regulatory moa
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
F>M (until 80yo) - stress incontinence #1 - $26B/yr

48. urinary incontinence types
Universal - progressive - partially encoded (genetic) - destructive -
Stress: #1 - functional - urge - overflow
Injury - neglect - physical/psychosocial - financial - violation of rights
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

49. what Rx are commonly monifoted in elderly for ADR?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Consider responsibilities - drivin

50. which benzodiazepines are most appropriate for elderly?
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
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Multisystemic vulnerability - -lowered reserves
P2-metab: Lorazepam - Trazepam - Oxazepam