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Aging Physiology And Pharmacology

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1. documenting elderly abuse

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2. What are the 4 forms of dizziness?
High mortality - esp + Fx - very common in elderly
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Receptors changes: # - sensitivity - counter-regulatory moa
Vertigo - presyncope - disequilibrium - lightheadedness

3. What is the best approach to malnutrition
Treat underlying disease/lack resources
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Prescribing - monitoring - patient adherence
Falls - delirium - malnutrition - P ulcers - opportunistic i2

4. What are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

5. What is the STOPP criteria?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
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
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

6. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
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
Parkinsonism -> l-DOPA
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

7. Cockcroft Gault equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Diagnosis - risk/benefit analysis to choose Rx
Beers criteria - medication appropriateness index (12 ?)

8. ADR rf
Worse for cardiac causes v noncardia
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Beers criteria - medication appropriateness index (12 ?)
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

9. What are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
Isolated systolic HTN
Determined by Dr for a patient - -> used to determine competency
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

10. MRP: medication related problems
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Hypotension - ^K+
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

11. malignancy + atypical Sx
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Doctors
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Breast cancer + 2o LBP

12. What are the hazards of elderly hospitalization?
^morbidity + mortality - -frailest @ greatest risk
3 reflexes: baroreceptor - renal nerve - ANF
Insiduous onset
1/2

13. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
>60yo - low abuse risk - ^ monitoring possible
Serum Cr: used for Cr clearance equation

14. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

15. What drugs can contribute to syncope?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
A-blockers - B-blockers - TCA

16. What are the 3 stages of ADRs?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Prescribing - monitoring - patient adherence
Confusion - sedation - falls
F>M (until 80yo) - stress incontinence #1 - $26B/yr

17. frailty
Bone loss -> osteopenia -> osteoporosis -> Fx
Voice - character - plot - context - time - reader
Multisystemic vulnerability - -lowered reserves
^BP -> a-HTN

18. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
5% - underreported
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

19. How does aging affect GI absorption of Rx?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Make sure to discuss with patient - some states require reporting
No: chest pain - yes: fatigue - nausea - low functional status - SOB

20. tube feeding
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
ANF: Na+ retention - disinhib vasoconstriction
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

21. What is the Cockcroft Gault equation?
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
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Used to calculate renal fcn - clearance of Cr adjusted for age
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

22. urinary incontinence types
Confusion - sedation - falls
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
CVA: stroke - AMI: acute MI - HF
Stress: #1 - functional - urge - overflow

23. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Delayed absorption - like competitive inhib
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
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

24. stress incontinence tx
Screen for potentially embarrassing dx - patient/Dr trust
Doctors
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Tx underlying etio - + Kegels - pessary - surgery

25. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

26. frailty signs
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Phenytoin
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

27. cachexia
^BP -> a-HTN
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
IdioPx - psychiatric: depression - anxiety - somatoform
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

28. dementia tx
Hyperuricemia -> gout
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

29. How does aging affect Rx renal elimination?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Treat underlying disease/lack resources

30. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
Begin @25-50% recommended dose - APAP may be dose-limiting
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Consider responsibilities - drivin

31. delirium: medical rf
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

32. What are the pharmacodynamic changes associated with aging?
Legal: Cruzan v Hamon
Receptors changes: # - sensitivity - counter-regulatory moa
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

33. antiarrhythmic + diuretic: interaction outcome
Prescribing - monitoring - patient adherence
Electrolyte imbalance - arrhythmia
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
^BP -> a-HTN

34. Aging principles
3 reflexes: baroreceptor - renal nerve - ANF
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
^BP -> a-HTN
Cholinesterase inhib - use: dementia

35. what nutritional interventions help underweight?
Serum Cr: used for Cr clearance equation
Confusion - sedation - falls
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Electrical: change in HR - structural: aortic outflow obstruction

36. how is cachexia different from wasting?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Constipation -> laxatives
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

37. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Injury - neglect - physical/psychosocial - financial - violation of rights
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

38. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Hypothetical plan - serves as patient's last competent indicated wishes
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

39. What are the possible cardiac causes of presyncope?
Electrical: change in HR - structural: aortic outflow obstruction
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
5% - underreported

40. What is the bone deterioration cascade?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Bone loss -> osteopenia -> osteoporosis -> Fx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

41. How to prevent pressure ulcers?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Map of people - perceptions - etc - varies by perspective
Mechanical loading - skin care - avoid friction/shear
Confusion - sedation - falls

42. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Therapy - SSRI

43. rivastigmine
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Cholinesterase inhib - use: dementia
P2-metab: Lorazepam - Trazepam - Oxazepam
5% - underreported

44. what drugs can cause dizziness?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
^SV (diastolic stroke volume)
Insiduous onset
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

45. vertigo
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Confusion - sedation - falls
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

46. BZD + antipsychotic: interaction outcome
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Electrolyte imbalance - arrhythmia
Confusion - sedation - falls
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

47. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Cachexia - PEM - FTT - obesity
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

48. Disequilibrium
Prescribing - monitoring - patient adherence
Serum Cr: used for Cr clearance equation
CNS suppression -> cholinesterase inhibitors
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

49. What are the common types of elder mistreatment?
Catch-all of unspecified dizziness
Make sure to discuss with patient - some states require reporting
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

50. What are the common causes of lightheadedness?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Therapy - SSRI
IdioPx - psychiatric: depression - anxiety - somatoform
Respect for autonomy - nonmaleficence - beneficence - justice