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Aging Physiology And Pharmacology

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1. What are common scenarios of untreated indications in elderly?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

2. opioid tx in elderly
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Begin @25-50% recommended dose - APAP may be dose-limiting
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

3. conservator
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Beers criteria - medication appropriateness index (12 ?)

4. i2 + atypical Sx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Begin @25-50% recommended dose - APAP may be dose-limiting
^BP -> a-HTN
No: fever - leukocytosis - yes: falls - appetite change - low functional status

5. fall sequelae
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

6. 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
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

7. pulm edema + atypical Sx
Receptors changes: # - sensitivity - counter-regulatory moa
Insiduous onset
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

8. urge incontinence tx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
ANF: Na+ retention - disinhib vasoconstriction
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

9. falls epidemiology
Hypothetical plan - serves as patient's last competent indicated wishes
Cholinesterase inhib - use: dementia
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

10. Alb-bound Rx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Universal - progressive - partially encoded (genetic) - destructive -
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Phenytoin

11. osteopenia
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

12. donepezil
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
80% of hospital admission for syncope for >65yo
Cholinesterase inhib - use: dementia
Environment modification: obstacles - mobility - -bladder fcn ok

13. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Electrolyte imbalance - arrhythmia
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

14. galantamine
Cholinesterase inhib - use: dementia
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Delayed absorption - like competitive inhib
ANF: Na+ retention - disinhib vasoconstriction

15. What are the pharmacodynamic changes associated with aging?
Consider responsibilities - drivin
Receptors changes: # - sensitivity - counter-regulatory moa
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

16. What is a PE sign of cachexia?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Temporalis muscle wasting = temporal wasting
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

17. how is the CAM used to diagnose delirium?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
CVA: stroke - AMI: acute MI - HF
^morbidity + mortality - -frailest @ greatest risk
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

18. vision changes: elderly
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Diagnosis - risk/benefit analysis to choose Rx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

19. rule of doable effect
Catch-all of unspecified dizziness
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
^ANS tone -> ^periph vasoconstriction - ^HR

20. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
>60yo - low abuse risk - ^ monitoring possible
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Confusion - sedation - falls

21. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
CVA: stroke - AMI: acute MI - HF
Delayed absorption - like competitive inhib
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

22. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Beers criteria - medication appropriateness index (12 ?)
Multisystemic vulnerability - -lowered reserves
P2-metabolite - phase 1 biotx much more affected than phase 2

23. Aging principles
BMD (bone mineral density): T-score >2.5 std dev below normal 1
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Make sure to discuss with patient - some states require reporting
Prescribing - monitoring - patient adherence

24. What is the preferred depression treatment in elderly?
High mortality - esp + Fx - very common in elderly
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
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
Therapy - SSRI

25. dementia tx
Figure out a good diet - social aspect - resources - dental/oral comfort
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

26. How does aging affect pharmacokinetics?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
3 reflexes: baroreceptor - renal nerve - ANF
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Appointed by court if no substituted judgment -conservator of finance -conservator of person

27. what receptors increase sensitivity with aging?
Hypothetical plan - serves as patient's last competent indicated wishes
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

28. Disequilibrium
Beers criteria - medication appropriateness index (12 ?)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
3 reflexes: baroreceptor - renal nerve - ANF
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

29. How to prevent pressure ulcers?
Multisystemic vulnerability - -lowered reserves
Temporalis muscle wasting = temporal wasting
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Mechanical loading - skin care - avoid friction/shear

30. osteoporosis etio
Serum Cr: used for Cr clearance equation
Environment modification: obstacles - mobility - -bladder fcn ok
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

31. what normally prevents syncope?
3 reflexes: baroreceptor - renal nerve - ANF
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Confusion - sedation - falls

32. what % of hospitalizations of elderly are due to ADR + noncompliance?
Electrical: change in HR - structural: aortic outflow obstruction
Beers criteria - medication appropriateness index (12 ?)
28% - ADR: 17% - non-compliance 11%
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

33. delirium: tx approach
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Parkinsonism -> l-DOPA
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

34. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Map of people - perceptions - etc - varies by perspective

35. What is the natural history of syncope?
A-blockers - B-blockers - TCA
Voice - character - plot - context - time - reader
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
F>M (until 80yo) - stress incontinence #1 - $26B/yr

36. Beers criteria
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
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
Determined by Dr for a patient - -> used to determine competency
Map of people - perceptions - etc - varies by perspective

37. what professional is least likely to report abuse?
Confusion - sedation - falls
^morbidity + mortality - -frailest @ greatest risk
Phenytoin
Doctors

38. incontinence epidemiology
Cachexia - PEM - FTT - obesity
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
F>M (until 80yo) - stress incontinence #1 - $26B/yr
No: chest pain - yes: fatigue - nausea - low functional status - SOB

39. using long-acting opioids in elderly
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Cholinesterase inhib - use: dementia
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

40. MI + atypical Sx
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
No: chest pain - yes: fatigue - nausea - low functional status - SOB

41. driving considerations
Make sure to discuss with patient - some states require reporting
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

42. How does aging affect pharmacokinetic protein binding?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

43. LBW equation
Environment modification: obstacles - mobility - -bladder fcn ok
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
Serum Cr: used for Cr clearance equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

44. What is ISH?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Breast cancer + 2o LBP
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Isolated systolic HTN

45. thyroid dx + atypical Sx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
P2-metabolite - phase 1 biotx much more affected than phase 2
Serum Cr: used for Cr clearance equation
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

46. malnutrition
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

47. What are common physical abuse Sx in elderly?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Doctors

48. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
NMDR antagonist - use: dementia
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

49. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
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
Screen for potentially embarrassing dx - patient/Dr trust
Bone loss -> osteopenia -> osteoporosis -> Fx

50. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
Worse for cardiac causes v noncardia
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

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Aging Physiology And Pharmacology

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