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Aging Physiology And Pharmacology

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1. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

2. What is the epidemiology of dizziness?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

3. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Determined by Dr for a patient - -> used to determine competency

4. ACE inhib + diuretic: interaction outcome
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Hypotension - ^K+
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Begin @25-50% recommended dose - APAP may be dose-limiting

5. pressure ulcer: staging
CNS suppression -> cholinesterase inhibitors
Parkinsonism -> l-DOPA
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
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

6. delirium predisposing rf
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
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
>60yo - low abuse risk - ^ monitoring possible
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

7. frailty
A-blockers - B-blockers - TCA
Multisystemic vulnerability - -lowered reserves
Make sure to discuss with patient - some states require reporting
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

8. 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
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
>9 Rx

9. How does aging affect Rx pharmacokinetic metabolism?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Hypothetical plan - serves as patient's last competent indicated wishes
Mechanical loading - skin care - avoid friction/shear
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

10. What are the narrative elements of clinical ethics?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Multisystemic vulnerability - -lowered reserves
Voice - character - plot - context - time - reader
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

11. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Isolated systolic HTN
Serum Cr: used for Cr clearance equation
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

12. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
P2-metabolite - phase 1 biotx much more affected than phase 2
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

13. describe the % of ADR considered preventable - and of those serious
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
30% preventable - of these - 40% serious - of these 40% preventable
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

14. how may hypertension compensate for aging?
Receptors changes: # - sensitivity - counter-regulatory moa
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Prescribing - monitoring - patient adherence
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

15. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

16. conservator
>60yo - low abuse risk - ^ monitoring possible
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Appointed by court if no substituted judgment -conservator of finance -conservator of person
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

17. What is a PE sign of cachexia?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Temporalis muscle wasting = temporal wasting
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Prescribing - monitoring - patient adherence

18. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Mechanical loading - skin care - avoid friction/shear
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

19. delirium incidence
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
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

20. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Used to calculate renal fcn - clearance of Cr adjusted for age
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

21. How does baroreceptor reflex prevent syncope?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Mechanical loading - skin care - avoid friction/shear
^ANS tone -> ^periph vasoconstriction - ^HR
Cholinesterase inhib - use: dementia

22. Presyncope
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Beers criteria - medication appropriateness index (12 ?)
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Worse for cardiac causes v noncardia

23. BZD + antipsychotic: interaction outcome
>60yo - low abuse risk - ^ monitoring possible
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Catch-all of unspecified dizziness
Confusion - sedation - falls

24. NSAID may lead to what prescription cascade?
P2-metabolite - phase 1 biotx much more affected than phase 2
^BP -> a-HTN
Respect for autonomy - nonmaleficence - beneficence - justice
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

25. How does aging affect Rx renal elimination?
ANF: Na+ retention - disinhib vasoconstriction
Consider responsibilities - drivin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

26. red flags for further inquiry
Threats/ terrorizing - isolation - denying food/privileges/liberty
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

27. How does aging affect pharmacokinetics?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Hyperuricemia -> gout

28. delirium: tx approach
Cachexia - PEM - FTT - obesity
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

29. 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
Hypotension - ^K+
^BP -> a-HTN
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

30. MRP: medication related problems
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
NMDR antagonist - use: dementia
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

31. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
NMDR antagonist - use: dementia
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

32. What are the rf for caregiver to abuse elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
A-blockers - B-blockers - TCA
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Delayed absorption - like competitive inhib

33. What is the best approach to malnutrition
Treat underlying disease/lack resources
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Appointed by court if no substituted judgment -conservator of finance -conservator of person

34. Approach to idioPx - recurrent syncope
Receptors changes: # - sensitivity - counter-regulatory moa
Consider responsibilities - drivin
Used to calculate renal fcn - clearance of Cr adjusted for age
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

35. thiazide diuretic may lead to what prescription cascade?
Insiduous onset
Receptors changes: # - sensitivity - counter-regulatory moa
Consider responsibilities - drivin
Hyperuricemia -> gout

36. Syncope prognosis based on etio
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Worse for cardiac causes v noncardia
Vertigo - presyncope - disequilibrium - lightheadedness
Threats/ terrorizing - isolation - denying food/privileges/liberty

37. What are rf for osteoporosis?
Hypothetical plan - serves as patient's last competent indicated wishes
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

38. What are the 4 basic ethical principles?
3 reflexes: baroreceptor - renal nerve - ANF
Respect for autonomy - nonmaleficence - beneficence - justice
Cachexia - PEM - FTT - obesity
Breast cancer + 2o LBP

39. rivastigmine
Cholinesterase inhib - use: dementia
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
>9 Rx
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

40. What are the vascular changes of presyncope?
CNS suppression -> cholinesterase inhibitors
>9 Rx
Cholinesterase inhib - use: dementia
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

41. What is the preferred depression treatment in elderly?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Therapy - SSRI
Hypotension - ^K+
Cholinesterase inhib - use: dementia

42. What are the hazards of elderly hospitalization?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
^morbidity + mortality - -frailest @ greatest risk
Cholinesterase inhib - use: dementia
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

43. substituted judgment
Falls - delirium - malnutrition - P ulcers - opportunistic i2
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Cachexia - PEM - FTT - obesity

44. osteoporosis
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

45. What are the key points of safe prescription for elderly - lecture
Diagnosis - risk/benefit analysis to choose Rx
3 reflexes: baroreceptor - renal nerve - ANF
^BP -> a-HTN
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

46. what Rx are commonly monifoted in elderly for ADR?
Parkinsonism -> l-DOPA
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
CVA: stroke - AMI: acute MI - HF
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

47. surrogate decision making heirarchy

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48. dementia tx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

49. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
IdioPx - psychiatric: depression - anxiety - somatoform
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

50. What is START criteria?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Confusion - sedation - falls