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Aging Physiology And Pharmacology

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1. elderly abuse epidemiology
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
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
5% - underreported

2. what can enhance reporting in elderly?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Delayed absorption - like competitive inhib
Screen for potentially embarrassing dx - patient/Dr trust

3. red flags for further inquiry
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

4. i2 + atypical Sx
>60yo - low abuse risk - ^ monitoring possible
Hyperuricemia -> gout
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Injury - neglect - physical/psychosocial - financial - violation of rights

5. Syncope prognosis based on etio
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Worse for cardiac causes v noncardia
Cholinesterase inhib - use: dementia

6. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
BMD (bone mineral density): T-score >2.5 std dev below normal 1

7. what Rx are commonly monifoted in elderly for ADR?
Voice - character - plot - context - time - reader
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

8. physical neglect
Therapy - SSRI
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

9. osteoporosis epidemiology
Hyperuricemia -> gout
High mortality - esp + Fx - very common in elderly
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Electrical: change in HR - structural: aortic outflow obstruction

10. thyroid dx + atypical Sx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
CVA: stroke - AMI: acute MI - HF
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Insiduous onset

11. conservator
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Isolated systolic HTN
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

12. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
30% preventable - of these - 40% serious - of these 40% preventable
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

13. frailty raises vulnerability to...
Confusion - sedation - falls
Falls - delirium - malnutrition - P ulcers - opportunistic i2
P2-metab: Lorazepam - Trazepam - Oxazepam
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

14. Beers criteria: what 10 Rx should elderly avoid or use + caution?
CVA: stroke - AMI: acute MI - HF
Hypothetical plan - serves as patient's last competent indicated wishes
Beers criteria - medication appropriateness index (12 ?)
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

15. How does aging affect Rx pharmacokinetic distribution?
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
Confusion - sedation - falls
IdioPx - psychiatric: depression - anxiety - somatoform
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

16. Why is abuse underreported?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Begin @25-50% recommended dose - APAP may be dose-limiting
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Insiduous onset

17. What are rf for osteoporosis?
Figure out a good diet - social aspect - resources - dental/oral comfort
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Breast cancer + 2o LBP
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

18. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Tx underlying etio - + Kegels - pessary - surgery
^morbidity + mortality - -frailest @ greatest risk
P2-metabolite - phase 1 biotx much more affected than phase 2
Universal - progressive - partially encoded (genetic) - destructive -

19. What are the 3 sentinel events for LT care?
A-blockers - B-blockers - TCA
Pressure ulcer - fecal impaction - dehydration
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

20. What is START criteria?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
30% preventable - of these - 40% serious - of these 40% preventable
P2-metabolite - phase 1 biotx much more affected than phase 2

21. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
28% - ADR: 17% - non-compliance 11%
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

22. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
A-blockers - B-blockers - TCA
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

23. substituted judgment
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Parkinsonism -> l-DOPA
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

24. urinary incontinence types
A-blockers - B-blockers - TCA
Doctors
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
Stress: #1 - functional - urge - overflow

25. what receptors decrease sensitivity with aging?
Used to calculate renal fcn - clearance of Cr adjusted for age
Respect for autonomy - nonmaleficence - beneficence - justice
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

26. ACE inhib + diuretic: interaction outcome
Diagnosis - risk/benefit analysis to choose Rx
Hypotension - ^K+
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

27. What is ISH?
Cholinesterase inhib - use: dementia
Isolated systolic HTN
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Hyperuricemia -> gout

28. donepezil
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Delayed absorption - like competitive inhib
Cholinesterase inhib - use: dementia
Falls - delirium - malnutrition - P ulcers - opportunistic i2

29. 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
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Prescribing - monitoring - patient adherence
>9 Rx

30. How does aging affect Rx renal elimination?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

31. What are the narrative elements of clinical ethics?
Used to calculate renal fcn - clearance of Cr adjusted for age
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Cachexia - PEM - FTT - obesity
Voice - character - plot - context - time - reader

32. Cockcroft Gault equation
Temporalis muscle wasting = temporal wasting
Prescribing - monitoring - patient adherence
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

33. thiazide diuretic may lead to what prescription cascade?
Hyperuricemia -> gout
Mechanical loading - skin care - avoid friction/shear
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Parkinsonism -> l-DOPA

34. delirium diagnosis
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

35. delirium: tx approach
Voice - character - plot - context - time - reader
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
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

36. Aging principles
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Breast cancer + 2o LBP
Used to calculate renal fcn - clearance of Cr adjusted for age

37. preventing malnutrition
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Figure out a good diet - social aspect - resources - dental/oral comfort
^BP -> a-HTN
Falls - delirium - malnutrition - P ulcers - opportunistic i2

38. What are the common types of elder mistreatment?
28% - ADR: 17% - non-compliance 11%
Isolated systolic HTN
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

39. MI + atypical Sx
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Vertigo - presyncope - disequilibrium - lightheadedness
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Doctors

40. vertigo
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
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
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

41. What are the rf for elderly abuse?
28% - ADR: 17% - non-compliance 11%
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
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

42. what drugs can cause dizziness?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
^BP -> a-HTN
Confusion - sedation - falls

43. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Legal: Cruzan v Hamon
Pressure ulcer - fecal impaction - dehydration
A-blockers - B-blockers - TCA

44. Aging descriptors
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

45. using long-acting opioids in elderly
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
^SV (diastolic stroke volume)

46. delirium: Rx that contribute
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

47. What are the hazards of elderly hospitalization?
^morbidity + mortality - -frailest @ greatest risk
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
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
Vertigo - presyncope - disequilibrium - lightheadedness

48. How does aging affect GI absorption rate of Rx?
28% - ADR: 17% - non-compliance 11%
Delayed absorption - like competitive inhib
^K+
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

49. falls epidemiology
Electrical: change in HR - structural: aortic outflow obstruction
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

50. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

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Aging Physiology And Pharmacology

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