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Aging Physiology And Pharmacology

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1. metoclopramide may lead to what prescription cascade?
IdioPx - psychiatric: depression - anxiety - somatoform
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Parkinsonism -> l-DOPA
Begin @25-50% recommended dose - APAP may be dose-limiting

2. lightheadedness
Catch-all of unspecified dizziness
Phenytoin
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Threats/ terrorizing - isolation - denying food/privileges/liberty

3. What is sCr?
Diagnosis - risk/benefit analysis to choose Rx
Serum Cr: used for Cr clearance equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
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. conservator
Prescribing - monitoring - patient adherence
Constipation -> laxatives
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Phenytoin

5. i2 + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Stress: #1 - functional - urge - overflow

6. what mechanical loading helps to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

7. delirium predisposing rf
Figure out a good diet - social aspect - resources - dental/oral comfort
Make sure to discuss with patient - some states require reporting
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

8. acute abdomen + atypical Sx
^BP -> a-HTN
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

9. How does sliding scale glycemic control relate to elderly?
Electrical: change in HR - structural: aortic outflow obstruction
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

10. What is the STOPP criteria?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
^SV (diastolic stroke volume)
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
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

11. preventing malnutrition
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
Cholinesterase inhib - use: dementia
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Figure out a good diet - social aspect - resources - dental/oral comfort

12. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Figure out a good diet - social aspect - resources - dental/oral comfort
A-blockers - B-blockers - TCA

13. How does aging affect Rx pharmacokinetic metabolism?
Stress: #1 - functional - urge - overflow
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

14. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
>60yo - low abuse risk - ^ monitoring possible
NMDR antagonist - use: dementia
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

15. What is a PE sign of cachexia?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Temporalis muscle wasting = temporal wasting
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

16. refusing intervention
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Legal: Cruzan v Hamon
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Confusion - sedation - falls

17. frailty signs
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
High mortality - esp + Fx - very common in elderly

18. malignancy + atypical Sx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
^SV (diastolic stroke volume)
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
Breast cancer + 2o LBP

19. Aging features
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Universal - progressive - partially encoded (genetic) - destructive -
Temporalis muscle wasting = temporal wasting

20. delirium diagnosis
Map of people - perceptions - etc - varies by perspective
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

21. donepezil
80% of hospital admission for syncope for >65yo
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Cholinesterase inhib - use: dementia
Mechanical loading - skin care - avoid friction/shear

22. Why is abuse underreported?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Figure out a good diet - social aspect - resources - dental/oral comfort
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

23. how is syncope related to elderly admission to hospital?
IdioPx - psychiatric: depression - anxiety - somatoform
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Universal - progressive - partially encoded (genetic) - destructive -
80% of hospital admission for syncope for >65yo

24. ADR rf
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
ANF: Na+ retention - disinhib vasoconstriction
Map of people - perceptions - etc - varies by perspective

25. What are rf for osteoporosis?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
BMD (bone mineral density): T-score >2.5 std dev below normal 1
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

26. MRP: medication related problems
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

27. What are the narrative elements of clinical ethics?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Voice - character - plot - context - time - reader
>9 Rx

28. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Multisystemic vulnerability - -lowered reserves

29. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Vertigo - presyncope - disequilibrium - lightheadedness
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

30. NSAID may lead to what prescription cascade?
^BP -> a-HTN
Catch-all of unspecified dizziness
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Insiduous onset

31. What are the 3 stages of ADRs?
>9 Rx
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Prescribing - monitoring - patient adherence
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

32. urge incontinence tx
CVA: stroke - AMI: acute MI - HF
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Tx underlying etio - + Kegels - pessary - surgery

33. How does aging affect GI absorption of Rx?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Used to calculate renal fcn - clearance of Cr adjusted for age
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
P2-metabolite - phase 1 biotx much more affected than phase 2

34. What are the possible cardiac causes of presyncope?
Worse for cardiac causes v noncardia
Electrolyte imbalance - arrhythmia
Figure out a good diet - social aspect - resources - dental/oral comfort
Electrical: change in HR - structural: aortic outflow obstruction

35. Cockcroft Gault equation
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
NMDR antagonist - use: dementia
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

36. osteoporosis epidemiology
Receptors changes: # - sensitivity - counter-regulatory moa
High mortality - esp + Fx - very common in elderly
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

37. how can you determine whether Rx is appropriate to use in elderly patient?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Mechanical loading - skin care - avoid friction/shear
Beers criteria - medication appropriateness index (12 ?)
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

38. what drugs can cause dizziness?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Screen for potentially embarrassing dx - patient/Dr trust
3 reflexes: baroreceptor - renal nerve - ANF

39. what % of hospitalizations of elderly are due to ADR + noncompliance?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Vertigo - presyncope - disequilibrium - lightheadedness
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
28% - ADR: 17% - non-compliance 11%

40. 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
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Bone loss -> osteopenia -> osteoporosis -> Fx

41. What is polypharmacy
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
>9 Rx
Insiduous onset

42. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
NMDR antagonist - use: dementia
High mortality - esp + Fx - very common in elderly

43. what Rx are commonly monifoted in elderly for ADR?
80% of hospital admission for syncope for >65yo
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Stress: #1 - functional - urge - overflow
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

44. What are the 3 sentinel events for LT care?
80% of hospital admission for syncope for >65yo
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Phenytoin
Pressure ulcer - fecal impaction - dehydration

45. delirium: mgmt
CVA: stroke - AMI: acute MI - HF
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

46. Disequilibrium
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
^BP -> a-HTN
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Treat underlying disease/lack resources

47. rivastigmine
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Treat underlying disease/lack resources
^morbidity + mortality - -frailest @ greatest risk
Cholinesterase inhib - use: dementia

48. osteoporosis
Isolated systolic HTN
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
3 reflexes: baroreceptor - renal nerve - ANF

49. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
80% of hospital admission for syncope for >65yo
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Insiduous onset

50. documenting elderly abuse

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