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Aging Physiology And Pharmacology

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1. what ADR are common in elderly patient?
Parkinsonism -> l-DOPA
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

2. what nutritional interventions help underweight?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Cachexia - PEM - FTT - obesity

3. How does aging affect pharmacokinetic protein binding?
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
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

4. How does an 80yo renal fcn compare to that of a 20yo?
Multisystemic vulnerability - -lowered reserves
1/2
Begin @25-50% recommended dose - APAP may be dose-limiting
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

5. delirium: Rx that contribute
Hypothetical plan - serves as patient's last competent indicated wishes
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
80% of hospital admission for syncope for >65yo

6. What is sCr?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Serum Cr: used for Cr clearance equation
High mortality - esp + Fx - very common in elderly

7. documenting elderly abuse

8. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Legal: Cruzan v Hamon
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

9. fall sequelae

10. What are the rf for elderly abuse?
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
Vertigo - presyncope - disequilibrium - lightheadedness
P2-metab: Lorazepam - Trazepam - Oxazepam

11. How does ANF prevent syncope?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Confusion - sedation - falls
Cholinesterase inhib - use: dementia
ANF: Na+ retention - disinhib vasoconstriction

12. stress incontinence tx
Tx underlying etio - + Kegels - pessary - surgery
A-blockers - B-blockers - TCA
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

13. preventing malnutrition
Phenytoin
Figure out a good diet - social aspect - resources - dental/oral comfort
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

14. what normally prevents syncope?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
3 reflexes: baroreceptor - renal nerve - ANF
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

15. how is cachexia different from wasting?
^SV (diastolic stroke volume)
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
80% of hospital admission for syncope for >65yo

16. surrogate decision making heirarchy

17. incontinence epidemiology
Determined by Dr for a patient - -> used to determine competency
#1 patient's last competent indication of wishes - substituted judgment - beneficence
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

18. thyroid dx + atypical Sx
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Cholinesterase inhib - use: dementia
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

19. metoclopramide may lead to what prescription cascade?
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
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
Parkinsonism -> l-DOPA
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

20. driving considerations
Make sure to discuss with patient - some states require reporting
BMD (bone mineral density): T-score >2.5 std dev below normal 1
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

21. frailty
Multisystemic vulnerability - -lowered reserves
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
1/2
^morbidity + mortality - -frailest @ greatest risk

22. fall causes
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Threats/ terrorizing - isolation - denying food/privileges/liberty

23. delirium: tx approach
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

24. What is the natural history of syncope?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Used to calculate renal fcn - clearance of Cr adjusted for age
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

25. What is a PE sign of cachexia?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
A-blockers - B-blockers - TCA
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
Temporalis muscle wasting = temporal wasting

26. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
^K+

27. conservator
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Parkinsonism -> l-DOPA

28. How does aging affect Rx pharmacokinetic metabolism?
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
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Breast cancer + 2o LBP

29. How does sliding scale glycemic control relate to elderly?
28% - ADR: 17% - non-compliance 11%
^ANS tone -> ^periph vasoconstriction - ^HR
Cholinesterase inhib - use: dementia
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

30. what % of hospitalizations of elderly are due to ADR + noncompliance?
Cholinesterase inhib - use: dementia
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
5% - underreported
28% - ADR: 17% - non-compliance 11%

31. What drugs can contribute to syncope?
CNS suppression -> cholinesterase inhibitors
A-blockers - B-blockers - TCA
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
5% - underreported

32. What are the narrative elements of clinical ethics?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Voice - character - plot - context - time - reader
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

33. how is the CAM used to diagnose delirium?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Determined by Dr for a patient - -> used to determine competency
^BP -> a-HTN

34. Beers criteria
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
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

35. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Parkinsonism -> l-DOPA
Beers criteria - medication appropriateness index (12 ?)
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

36. What are common medical causes of syncope?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
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

37. malnutrition
Electrical: change in HR - structural: aortic outflow obstruction
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

38. who is a good candidate for opioid tx?
P2-metabolite - phase 1 biotx much more affected than phase 2
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
>60yo - low abuse risk - ^ monitoring possible
28% - ADR: 17% - non-compliance 11%

39. refusing intervention
Legal: Cruzan v Hamon
Cholinesterase inhib - use: dementia
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Constipation -> laxatives

40. rivastigmine
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Cholinesterase inhib - use: dementia
28% - ADR: 17% - non-compliance 11%
Delayed absorption - like competitive inhib

41. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Mechanical loading - skin care - avoid friction/shear
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Vertigo - presyncope - disequilibrium - lightheadedness

42. delirium: medical rf
Pressure ulcer - fecal impaction - dehydration
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Serum Cr: used for Cr clearance equation
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

43. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
Map of people - perceptions - etc - varies by perspective
Multisystemic vulnerability - -lowered reserves
NMDR antagonist - use: dementia

44. How does aging affect Rx renal elimination?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Constipation -> laxatives
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

45. tube feeding
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

46. How does aging impact syncope-preventing reflexes
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
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

47. pressure ulcer: staging
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

48. opioid tx in elderly
Hyperuricemia -> gout
Legal: Cruzan v Hamon
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Begin @25-50% recommended dose - APAP may be dose-limiting

49. What are the possible cardiac causes of presyncope?
Electrical: change in HR - structural: aortic outflow obstruction
Threats/ terrorizing - isolation - denying food/privileges/liberty
No: fever - leukocytosis - yes: falls - appetite change - low functional status
5% - underreported

50. anticholinergic drugs may lead to what prescription cascade?
Bone loss -> osteopenia -> osteoporosis -> Fx
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
F>M (until 80yo) - stress incontinence #1 - $26B/yr
CNS suppression -> cholinesterase inhibitors