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Aging Physiology And Pharmacology

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1. metoclopramide may lead to what prescription cascade?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Consider responsibilities - drivin
Respect for autonomy - nonmaleficence - beneficence - justice
Parkinsonism -> l-DOPA

2. ADR rf
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

3. How does an 80yo renal fcn compare to that of a 20yo?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Pressure ulcer - fecal impaction - dehydration
1/2
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

4. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Threats/ terrorizing - isolation - denying food/privileges/liberty
Hyperuricemia -> gout

5. Alb-bound Rx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Phenytoin
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

6. What are the 4 forms of dizziness?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
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
Vertigo - presyncope - disequilibrium - lightheadedness

7. How does the aging heart compensate for lower HR to maintain unchanged CO?
Threats/ terrorizing - isolation - denying food/privileges/liberty
^SV (diastolic stroke volume)
Insiduous onset
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

8. How does aging impact syncope-preventing reflexes
Breast cancer + 2o LBP
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Parkinsonism -> l-DOPA

9. What is START criteria?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
80% of hospital admission for syncope for >65yo
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Phenytoin

10. Why is abuse underreported?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
5% - underreported
Pressure ulcer - fecal impaction - dehydration

11. How does aging affect pharmacokinetics?
Confusion - sedation - falls
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

12. What is a PE sign of cachexia?
Cachexia - PEM - FTT - obesity
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Temporalis muscle wasting = temporal wasting
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

13. What is the natural history of syncope?
Vertigo - presyncope - disequilibrium - lightheadedness
Hyperuricemia -> gout
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

14. restrain requirements
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Map of people - perceptions - etc - varies by perspective
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

15. fall causes
30% preventable - of these - 40% serious - of these 40% preventable
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Tx underlying etio - + Kegels - pessary - surgery

16. What are the common types of elder mistreatment?
CVA: stroke - AMI: acute MI - HF
Breast cancer + 2o LBP
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

17. red flags for further inquiry
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
P2-metab: Lorazepam - Trazepam - Oxazepam
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

18. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
5% - underreported

19. documenting elderly abuse
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
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
IdioPx - psychiatric: depression - anxiety - somatoform
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

20. How does aging affect Rx pharmacokinetic distribution?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Environment modification: obstacles - mobility - -bladder fcn ok
Parkinsonism -> l-DOPA
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

21. Cockcroft Gault equation
Environment modification: obstacles - mobility - -bladder fcn ok
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

22. dementia tx
Voice - character - plot - context - time - reader
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

23. incontinence complication
Worse for cardiac causes v noncardia
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

24. ACE inhib + K+: interaction outcome
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
^K+
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

25. delirium diagnosis
High mortality - esp + Fx - very common in elderly
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Voice - character - plot - context - time - reader
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

26. What are the vascular changes of presyncope?
Worse for cardiac causes v noncardia
Phenytoin
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

27. incontinence epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
>9 Rx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Electrolyte imbalance - arrhythmia

28. cachexia
Hyperuricemia -> gout
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Confusion - sedation - falls

29. opioid tx in elderly
Confusion - sedation - falls
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Beers criteria - medication appropriateness index (12 ?)
Begin @25-50% recommended dose - APAP may be dose-limiting

30. How does aging increase incontinence?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
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

31. frailty raises vulnerability to...
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

32. nutrition syndromes
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Cachexia - PEM - FTT - obesity

33. What are the narrative elements of clinical ethics?
Confusion - sedation - falls
Voice - character - plot - context - time - reader
Tx underlying etio - + Kegels - pessary - surgery
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

34. How does ANF prevent syncope?
Universal - progressive - partially encoded (genetic) - destructive -
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
CVA: stroke - AMI: acute MI - HF
ANF: Na+ retention - disinhib vasoconstriction

35. What are the common causes of lightheadedness?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Voice - character - plot - context - time - reader
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
IdioPx - psychiatric: depression - anxiety - somatoform

36. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
30% preventable - of these - 40% serious - of these 40% preventable
Hypothetical plan - serves as patient's last competent indicated wishes

37. surrogate decision making heirarchy
Consider responsibilities - drivin
28% - ADR: 17% - non-compliance 11%
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
#1 patient's last competent indication of wishes - substituted judgment - beneficence

38. What is the epidemiology of dizziness?
Bone loss -> osteopenia -> osteoporosis -> Fx
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Begin @25-50% recommended dose - APAP may be dose-limiting

39. What are the risks of uncontrolled ISH?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Mechanical loading - skin care - avoid friction/shear
CVA: stroke - AMI: acute MI - HF
P2-metabolite - phase 1 biotx much more affected than phase 2

40. Beers criteria: what 10 Rx should elderly avoid or use + caution?
30% preventable - of these - 40% serious - of these 40% preventable
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

41. What are the key points of safe prescription for elderly - lecture
Diagnosis - risk/benefit analysis to choose Rx
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Delayed absorption - like competitive inhib
Universal - progressive - partially encoded (genetic) - destructive -

42. Disequilibrium
Insiduous onset
Beers criteria - medication appropriateness index (12 ?)
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

43. What is capacity?
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Determined by Dr for a patient - -> used to determine competency
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Phenytoin

44. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Begin @25-50% recommended dose - APAP may be dose-limiting
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Cholinesterase inhib - use: dementia

45. how may hypertension compensate for aging?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Vertigo - presyncope - disequilibrium - lightheadedness

46. what illnesses are underreported in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Tx underlying etio - + Kegels - pessary - surgery

47. What is the Cockcroft Gault equation?
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Bone loss -> osteopenia -> osteoporosis -> Fx
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Used to calculate renal fcn - clearance of Cr adjusted for age

48. lipid-soluble Rx
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
80% of hospital admission for syncope for >65yo
CVA: stroke - AMI: acute MI - HF
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

49. What is the best approach to malnutrition
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Treat underlying disease/lack resources
Diagnosis - risk/benefit analysis to choose Rx
Hypothetical plan - serves as patient's last competent indicated wishes

50. How does sliding scale glycemic control relate to elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Isolated systolic HTN
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

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