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Aging Physiology And Pharmacology

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1. What are the key points of safe prescription for elderly - lecture
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Diagnosis - risk/benefit analysis to choose Rx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

2. narcotics may lead to what prescription cascade?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Constipation -> laxatives
A-blockers - B-blockers - TCA
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

3. What are the risks of uncontrolled ISH?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
CVA: stroke - AMI: acute MI - HF
A-blockers - B-blockers - TCA

4. How does aging impact syncope-preventing reflexes
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Determined by Dr for a patient - -> used to determine competency
Appointed by court if no substituted judgment -conservator of finance -conservator of person

5. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Electrolyte imbalance - arrhythmia
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

6. Presyncope
^BP -> a-HTN
Therapy - SSRI
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

7. psychological abuse
^K+
Used to calculate renal fcn - clearance of Cr adjusted for age
Threats/ terrorizing - isolation - denying food/privileges/liberty
Confusion - sedation - falls

8. Syncope prognosis based on etio
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Worse for cardiac causes v noncardia
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

9. MRP: medication related problems
Doctors
Hypothetical plan - serves as patient's last competent indicated wishes
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

10. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
^SV (diastolic stroke volume)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

11. 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
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

12. delirium: tx approach
Electrical: change in HR - structural: aortic outflow obstruction
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

13. Aging principles
Delayed absorption - like competitive inhib
P2-metab: Lorazepam - Trazepam - Oxazepam
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
3 reflexes: baroreceptor - renal nerve - ANF

14. 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
Electrolyte imbalance - arrhythmia
Vertigo - presyncope - disequilibrium - lightheadedness
Cholinesterase inhib - use: dementia

15. How does aging affect pharmacokinetic Rx distribution?
Breast cancer + 2o LBP
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
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
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

16. delirium predisposing rf
Hypothetical plan - serves as patient's last competent indicated wishes
Worse for cardiac causes v noncardia
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

17. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Stress: #1 - functional - urge - overflow

18. incontinence complication
CNS suppression -> cholinesterase inhibitors
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Worse for cardiac causes v noncardia
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

19. Why is abuse underreported?
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
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Treat underlying disease/lack resources
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

20. ADR rf
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

21. What are common scenarios of untreated indications 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
Determined by Dr for a patient - -> used to determine competency
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

22. What are the vascular changes of presyncope?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

23. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Make sure to discuss with patient - some states require reporting
^SV (diastolic stroke volume)
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

24. How does aging affect Rx pharmacokinetic metabolism?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Pressure ulcer - fecal impaction - dehydration
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Constipation -> laxatives

25. vision changes: elderly
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

26. elderly abuse epidemiology
5% - underreported
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
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
3 reflexes: baroreceptor - renal nerve - ANF

27. refusing intervention
Hyperuricemia -> gout
Treat underlying disease/lack resources
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Legal: Cruzan v Hamon

28. driving considerations
>60yo - low abuse risk - ^ monitoring possible
Make sure to discuss with patient - some states require reporting
Begin @25-50% recommended dose - APAP may be dose-limiting
Consider responsibilities - drivin

29. metoclopramide may lead to what prescription cascade?
Make sure to discuss with patient - some states require reporting
Parkinsonism -> l-DOPA
Tx underlying etio - + Kegels - pessary - surgery
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

30. urinary incontinence types
Stress: #1 - functional - urge - overflow
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
CVA: stroke - AMI: acute MI - HF
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

31. LBW equation
1/2
30% preventable - of these - 40% serious - of these 40% preventable
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

32. What are common medical causes of syncope?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
#1 patient's last competent indication of wishes - substituted judgment - beneficence
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
Voice - character - plot - context - time - reader

33. How does aging affect Rx renal elimination?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Figure out a good diet - social aspect - resources - dental/oral comfort
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

34. dementia tx
Legal: Cruzan v Hamon
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

35. What are the pharmacodynamic changes associated with aging?
Temporalis muscle wasting = temporal wasting
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Receptors changes: # - sensitivity - counter-regulatory moa
^K+

36. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

37. incontinence epidemiology
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
30% preventable - of these - 40% serious - of these 40% preventable
F>M (until 80yo) - stress incontinence #1 - $26B/yr

38. pressure ulcer: staging
Parkinsonism -> l-DOPA
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Electrical: change in HR - structural: aortic outflow obstruction
Worse for cardiac causes v noncardia

39. What is abuse?
Injury - neglect - physical/psychosocial - financial - violation of rights
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Phenytoin
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

40. How does an 80yo renal fcn compare to that of a 20yo?
Consider responsibilities - drivin
P2-metabolite - phase 1 biotx much more affected than phase 2
1/2
Worse for cardiac causes v noncardia

41. What is the preferred depression treatment in elderly?
Catch-all of unspecified dizziness
Delayed absorption - like competitive inhib
Therapy - SSRI
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

42. using long-acting opioids in elderly
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Mechanical loading - skin care - avoid friction/shear
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

43. rule of doable effect
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
^BP -> a-HTN
Legal: Cruzan v Hamon
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

44. What is the natural history of syncope?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Bone loss -> osteopenia -> osteoporosis -> Fx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

45. What are the possible cardiac causes of presyncope?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Electrical: change in HR - structural: aortic outflow obstruction
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Figure out a good diet - social aspect - resources - dental/oral comfort

46. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Phenytoin
Cachexia - PEM - FTT - obesity

47. what ADR are common in elderly patient?
NMDR antagonist - use: dementia
P2-metab: Lorazepam - Trazepam - Oxazepam
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

48. preventing malnutrition
5% - underreported
Figure out a good diet - social aspect - resources - dental/oral comfort
Determined by Dr for a patient - -> used to determine competency
Cholinesterase inhib - use: dementia

49. How does baroreceptor reflex prevent syncope?
Legal: Cruzan v Hamon
Make sure to discuss with patient - some states require reporting
^ANS tone -> ^periph vasoconstriction - ^HR
CVA: stroke - AMI: acute MI - HF

50. delirium: mgmt
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
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
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor