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Aging Physiology And Pharmacology

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1. Aging descriptors
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
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
High mortality - esp + Fx - very common in elderly

2. what Rx are commonly monifoted in elderly for ADR?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Vertigo - presyncope - disequilibrium - lightheadedness
Bone loss -> osteopenia -> osteoporosis -> Fx
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

3. donepezil
Cholinesterase inhib - use: dementia
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

4. What are rf for osteoporosis?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Respect for autonomy - nonmaleficence - beneficence - justice
30% preventable - of these - 40% serious - of these 40% preventable
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

5. driving considerations
Make sure to discuss with patient - some states require reporting
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
>60yo - low abuse risk - ^ monitoring possible

6. overflow incontinence tx
Diagnosis - risk/benefit analysis to choose Rx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
IdioPx - psychiatric: depression - anxiety - somatoform

7. How does aging affect pharmacokinetic Rx distribution?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
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
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

8. delirium predisposing rf
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Vertigo - presyncope - disequilibrium - lightheadedness
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

9. Aging features
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Temporalis muscle wasting = temporal wasting
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Universal - progressive - partially encoded (genetic) - destructive -

10. What are the possible cardiac causes of presyncope?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Electrical: change in HR - structural: aortic outflow obstruction
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

11. osteoporosis etio
^ANS tone -> ^periph vasoconstriction - ^HR
No: chest pain - yes: fatigue - nausea - low functional status - SOB
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

12. restrain requirements
Multisystemic vulnerability - -lowered reserves
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
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

13. physical neglect
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
^SV (diastolic stroke volume)
1/2
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

14. falls epidemiology
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Treat underlying disease/lack resources
Begin @25-50% recommended dose - APAP may be dose-limiting

15. urge incontinence tx
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

16. How does aging affect Rx pharmacokinetic metabolism?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Worse for cardiac causes v noncardia
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

17. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Begin @25-50% recommended dose - APAP may be dose-limiting
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
P2-metabolite - phase 1 biotx much more affected than phase 2
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

18. opioid tx in elderly
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Voice - character - plot - context - time - reader
Begin @25-50% recommended dose - APAP may be dose-limiting

19. PEM
1/2
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

20. delirium: medical rf
Bone loss -> osteopenia -> osteoporosis -> Fx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

21. malignancy + atypical Sx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Cholinesterase inhib - use: dementia
Breast cancer + 2o LBP
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

22. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Parkinsonism -> l-DOPA
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Legal: Cruzan v Hamon

23. elderly abuse epidemiology
5% - underreported
Tx underlying etio - + Kegels - pessary - surgery
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Determined by Dr for a patient - -> used to determine competency

24. delirium: Rx that contribute
Electrolyte imbalance - arrhythmia
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Map of people - perceptions - etc - varies by perspective

25. LBW equation
Beers criteria - medication appropriateness index (12 ?)
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
^K+

26. How does aging affect Rx pharmacokinetic distribution?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
CVA: stroke - AMI: acute MI - HF
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
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

27. What are the vascular changes of presyncope?
1/2
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

28. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
^SV (diastolic stroke volume)
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
F>M (until 80yo) - stress incontinence #1 - $26B/yr

29. preventing malnutrition
Cholinesterase inhib - use: dementia
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Figure out a good diet - social aspect - resources - dental/oral comfort

30. fall causes
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
CVA: stroke - AMI: acute MI - HF
Parkinsonism -> l-DOPA
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

31. How does aging impact syncope-preventing reflexes
80% of hospital admission for syncope for >65yo
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
^BP -> a-HTN
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

32. tube feeding
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Cholinesterase inhib - use: dementia
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

33. How does aging affect pharmacokinetics?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

34. anticholinergic drugs may lead to what prescription cascade?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Vertigo - presyncope - disequilibrium - lightheadedness
CNS suppression -> cholinesterase inhibitors
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

35. What are the common causes of lightheadedness?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
IdioPx - psychiatric: depression - anxiety - somatoform
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

36. What is ISH?
Stress: #1 - functional - urge - overflow
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
^BP -> a-HTN
Isolated systolic HTN

37. what drugs can cause dizziness?
Tx underlying etio - + Kegels - pessary - surgery
^SV (diastolic stroke volume)
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

38. Alb-bound Rx
Phenytoin
Cholinesterase inhib - use: dementia
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

39. What are the 4 basic ethical principles?
Legal: Cruzan v Hamon
Isolated systolic HTN
Respect for autonomy - nonmaleficence - beneficence - justice
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

40. which benzodiazepines are most appropriate for elderly?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
P2-metab: Lorazepam - Trazepam - Oxazepam
Electrolyte imbalance - arrhythmia

41. delirium: mgmt
>60yo - low abuse risk - ^ monitoring possible
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Pressure ulcer - fecal impaction - dehydration
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

42. How to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Threats/ terrorizing - isolation - denying food/privileges/liberty
F>M (until 80yo) - stress incontinence #1 - $26B/yr

43. what mechanical loading helps to prevent pressure ulcers?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

44. antiarrhythmic + diuretic: interaction outcome
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Therapy - SSRI
Electrolyte imbalance - arrhythmia
Make sure to discuss with patient - some states require reporting

45. ACE inhib + K+: interaction outcome
1/2
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
^K+
Consider responsibilities - drivin

46. What drugs can contribute to syncope?
3 reflexes: baroreceptor - renal nerve - ANF
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
A-blockers - B-blockers - TCA
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

47. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
High mortality - esp + Fx - very common in elderly
#1 patient's last competent indication of wishes - substituted judgment - beneficence

48. what can enhance reporting in elderly?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Receptors changes: # - sensitivity - counter-regulatory moa
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Screen for potentially embarrassing dx - patient/Dr trust

49. Beers criteria: what 10 Rx should elderly avoid or use + caution?
>9 Rx
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

50. incontinence complication
Therapy - SSRI
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Bone loss -> osteopenia -> osteoporosis -> Fx
Cholinesterase inhib - use: dementia