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Aging Physiology And Pharmacology

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1. how is cachexia different from wasting?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
>9 Rx
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

2. frailty
^ANS tone -> ^periph vasoconstriction - ^HR
5% - underreported
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Multisystemic vulnerability - -lowered reserves

3. Alb-bound Rx
Phenytoin
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Cholinesterase inhib - use: dementia

4. urinary incontinence types
Cholinesterase inhib - use: dementia
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Stress: #1 - functional - urge - overflow
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

5. how can you determine whether Rx is appropriate to use in elderly patient?
Electrical: change in HR - structural: aortic outflow obstruction
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Beers criteria - medication appropriateness index (12 ?)
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

6. delirium incidence
Injury - neglect - physical/psychosocial - financial - violation of rights
Therapy - SSRI
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

7. What is the epidemiology of dizziness?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Diagnosis - risk/benefit analysis to choose Rx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

8. Approach to idioPx - recurrent syncope
Falls - delirium - malnutrition - P ulcers - opportunistic i2
P2-metabolite - phase 1 biotx much more affected than phase 2
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Consider responsibilities - drivin

9. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
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

10. red flags for further inquiry
Cachexia - PEM - FTT - obesity
Electrical: change in HR - structural: aortic outflow obstruction
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

11. nutrition syndromes
Hypotension - ^K+
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Cachexia - PEM - FTT - obesity
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

12. What is the preferred depression treatment in elderly?
Therapy - SSRI
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

13. What are the narrative elements of clinical ethics?
Voice - character - plot - context - time - reader
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
IdioPx - psychiatric: depression - anxiety - somatoform
Phenytoin

14. thyroid dx + atypical Sx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

15. narcotics may lead to what prescription cascade?
High mortality - esp + Fx - very common in elderly
^morbidity + mortality - -frailest @ greatest risk
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Constipation -> laxatives

16. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

17. What are common physical abuse Sx in elderly?
CVA: stroke - AMI: acute MI - HF
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Make sure to discuss with patient - some states require reporting
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

18. incontinence complication
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Doctors
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
>9 Rx

19. What is polypharmacy
Confusion - sedation - falls
Screen for potentially embarrassing dx - patient/Dr trust
>9 Rx
Universal - progressive - partially encoded (genetic) - destructive -

20. What are the common types of elder mistreatment?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
ANF: Na+ retention - disinhib vasoconstriction
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Multisystemic vulnerability - -lowered reserves

21. what normally prevents syncope?
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
3 reflexes: baroreceptor - renal nerve - ANF

22. delirium: medical rf
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Mechanical loading - skin care - avoid friction/shear

23. What are the vascular changes of presyncope?
A-blockers - B-blockers - TCA
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

24. ACE inhib + diuretic: interaction outcome
>60yo - low abuse risk - ^ monitoring possible
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Cholinesterase inhib - use: dementia
Hypotension - ^K+

25. pulm edema + atypical Sx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Insiduous onset
High mortality - esp + Fx - very common in elderly
Delayed absorption - like competitive inhib

26. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

27. what illnesses are underreported in elderly?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Phenytoin

28. rivastigmine
Cholinesterase inhib - use: dementia
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Legal: Cruzan v Hamon

29. How does sliding scale glycemic control relate to elderly?
Tx underlying etio - + Kegels - pessary - surgery
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

30. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Determined by Dr for a patient - -> used to determine competency

31. What are rf for osteoporosis?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Voice - character - plot - context - time - reader
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

32. advanced directive/care plan

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33. How to prevent pressure ulcers?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
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
Mechanical loading - skin care - avoid friction/shear
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

34. violation of rights
Consider responsibilities - drivin
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

35. how is the CAM used to diagnose delirium?
80% of hospital admission for syncope for >65yo
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+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Stress: #1 - functional - urge - overflow

36. describe the % of ADR considered preventable - and of those serious
Confusion - sedation - falls
30% preventable - of these - 40% serious - of these 40% preventable
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Hypothetical plan - serves as patient's last competent indicated wishes

37. frailty signs
Multisystemic vulnerability - -lowered reserves
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Stress: #1 - functional - urge - overflow

38. what ADR are common in elderly patient?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Injury - neglect - physical/psychosocial - financial - violation of rights

39. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

40. Syncope prognosis based on etio
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Worse for cardiac causes v noncardia
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

41. conservator
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Falls - delirium - malnutrition - P ulcers - opportunistic i2
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

42. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Multisystemic vulnerability - -lowered reserves

43. What are the key points of safe prescription for elderly - lecture
Insiduous onset
>60yo - low abuse risk - ^ monitoring possible
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Diagnosis - risk/benefit analysis to choose Rx

44. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
Prescribing - monitoring - patient adherence
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Confusion - sedation - falls

45. What are the hazards of elderly hospitalization?
Doctors
Delayed absorption - like competitive inhib
^morbidity + mortality - -frailest @ greatest risk
Cholinesterase inhib - use: dementia

46. What is abuse?
Injury - neglect - physical/psychosocial - financial - violation of rights
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

47. What are the rf for caregiver to abuse elderly?
Parkinsonism -> l-DOPA
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Falls - delirium - malnutrition - P ulcers - opportunistic i2

48. 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
Worse for cardiac causes v noncardia
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Breast cancer + 2o LBP

49. metoclopramide may lead to what prescription cascade?
^ANS tone -> ^periph vasoconstriction - ^HR
BMD (bone mineral density): T-score >2.5 std dev below normal 1
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Parkinsonism -> l-DOPA

50. How does baroreceptor reflex prevent syncope?
^ANS tone -> ^periph vasoconstriction - ^HR
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Temporalis muscle wasting = temporal wasting
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

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Aging Physiology And Pharmacology

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