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Aging Physiology And Pharmacology

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1. How does aging affect pharmacokinetics?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

2. donepezil
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Serum Cr: used for Cr clearance equation
Cholinesterase inhib - use: dementia
Make sure to discuss with patient - some states require reporting

3. delirium: tx approach
Respect for autonomy - nonmaleficence - beneficence - justice
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

4. NSAID may lead to what prescription cascade?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Treat underlying disease/lack resources
^BP -> a-HTN

5. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Legal: Cruzan v Hamon
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
^K+

6. 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
Therapy - SSRI
5% - underreported
Bone loss -> osteopenia -> osteoporosis -> Fx

7. What are the possible cardiac causes of presyncope?
Constipation -> laxatives
Electrical: change in HR - structural: aortic outflow obstruction
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Consider responsibilities - drivin

8. urge incontinence tx
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

9. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Beers criteria - medication appropriateness index (12 ?)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
^morbidity + mortality - -frailest @ greatest risk

10. Disequilibrium
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Tx underlying etio - + Kegels - pessary - surgery
Isolated systolic HTN
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

11. What are the rf for caregiver to abuse elderly?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
CNS suppression -> cholinesterase inhibitors
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

12. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Serum Cr: used for Cr clearance equation
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Diagnosis - risk/benefit analysis to choose Rx

13. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
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

14. How does aging affect Rx renal elimination?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Tx underlying etio - + Kegels - pessary - surgery
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Catch-all of unspecified dizziness

15. Alb-bound Rx
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
Phenytoin
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Screen for potentially embarrassing dx - patient/Dr trust

16. rivastigmine
Receptors changes: # - sensitivity - counter-regulatory moa
Cholinesterase inhib - use: dementia
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

17. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
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
1/2

18. What is the bone deterioration cascade?
Bone loss -> osteopenia -> osteoporosis -> Fx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

19. BZD + antidepressant: interaction outcome
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Breast cancer + 2o LBP
Confusion - sedation - falls
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

20. lipid-soluble Rx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Bone loss -> osteopenia -> osteoporosis -> Fx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

21. nutrition syndromes
Cachexia - PEM - FTT - obesity
Doctors
Confusion - sedation - falls
Hyperuricemia -> gout

22. What is the preferred depression treatment in elderly?
80% of hospital admission for syncope for >65yo
28% - ADR: 17% - non-compliance 11%
Therapy - SSRI
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

23. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Voice - character - plot - context - time - reader
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

24. How to prevent pressure ulcers?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Beers criteria - medication appropriateness index (12 ?)
Mechanical loading - skin care - avoid friction/shear

25. how may hypertension compensate for aging?
^ANS tone -> ^periph vasoconstriction - ^HR
Determined by Dr for a patient - -> used to determine competency
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
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

26. frailty signs
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

27. how is syncope related to elderly admission to hospital?
A-blockers - B-blockers - TCA
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
80% of hospital admission for syncope for >65yo
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

28. clues of neglect
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Voice - character - plot - context - time - reader
Breast cancer + 2o LBP

29. what mechanical loading helps to prevent pressure ulcers?
Confusion - sedation - falls
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Make sure to discuss with patient - some states require reporting
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

30. substituted judgment
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Treat underlying disease/lack resources
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

31. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Insiduous onset
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Respect for autonomy - nonmaleficence - beneficence - justice

32. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
28% - ADR: 17% - non-compliance 11%
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

33. What are the risks of uncontrolled ISH?
Confusion - sedation - falls
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
CVA: stroke - AMI: acute MI - HF

34. refusing intervention
Legal: Cruzan v Hamon
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
CVA: stroke - AMI: acute MI - HF
Screen for potentially embarrassing dx - patient/Dr trust

35. which benzodiazepines are most appropriate for elderly?
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
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
P2-metab: Lorazepam - Trazepam - Oxazepam

36. restrain requirements
Constipation -> laxatives
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

37. fall sequelae

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38. What are the pharmacodynamic changes associated with aging?
Receptors changes: # - sensitivity - counter-regulatory moa
Diagnosis - risk/benefit analysis to choose Rx
Doctors
CNS suppression -> cholinesterase inhibitors

39. What are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
No: fever - leukocytosis - yes: falls - appetite change - low functional status

40. How does ANF prevent syncope?
Begin @25-50% recommended dose - APAP may be dose-limiting
ANF: Na+ retention - disinhib vasoconstriction
Constipation -> laxatives
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

41. thiazide diuretic may lead to what prescription cascade?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Parkinsonism -> l-DOPA
Hyperuricemia -> gout
80% of hospital admission for syncope for >65yo

42. ADR rf
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
CVA: stroke - AMI: acute MI - HF
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

43. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
5% - underreported
ANF: Na+ retention - disinhib vasoconstriction
Universal - progressive - partially encoded (genetic) - destructive -

44. What is the best approach to malnutrition
Electrolyte imbalance - arrhythmia
28% - ADR: 17% - non-compliance 11%
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Treat underlying disease/lack resources

45. How does aging affect pharmacokinetic protein binding?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

46. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
Beers criteria - medication appropriateness index (12 ?)
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

47. How does baroreceptor reflex prevent syncope?
^ANS tone -> ^periph vasoconstriction - ^HR
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

48. What is the natural history of syncope?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

49. Presyncope
Voice - character - plot - context - time - reader
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

50. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
Injury - neglect - physical/psychosocial - financial - violation of rights
Confusion - sedation - falls
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory