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Aging Physiology And Pharmacology

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1. How does aging affect pharmacokinetics?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Receptors changes: # - sensitivity - counter-regulatory moa
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Figure out a good diet - social aspect - resources - dental/oral comfort

2. What is abuse?
NMDR antagonist - use: dementia
Injury - neglect - physical/psychosocial - financial - violation of rights
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

3. documenting elderly abuse

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4. refusing intervention
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
NMDR antagonist - use: dementia
Legal: Cruzan v Hamon
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

5. functional incontinence tx
Voice - character - plot - context - time - reader
Environment modification: obstacles - mobility - -bladder fcn ok
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Temporalis muscle wasting = temporal wasting

6. What are the key points of safe prescription for elderly - lecture
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
3 reflexes: baroreceptor - renal nerve - ANF
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Diagnosis - risk/benefit analysis to choose Rx

7. opioid tx in elderly
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Begin @25-50% recommended dose - APAP may be dose-limiting

8. What is the STOPP criteria?
Parkinsonism -> l-DOPA
PPI: PUD uncomplicated >8wk - aspirin wo CAD/CVA/PVD - duplicate Rx - loop diuretics LT: HTN; can use for ankle edema - LT NSAID use (>3mo): mild OA - falls: BZD - opiates - neuroepileptics - vasodilators: orthostatic patient risk
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

9. What are the rf for caregiver to abuse elderly?
NMDR antagonist - use: dementia
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Multisystemic vulnerability - -lowered reserves

10. vertigo
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Serum Cr: used for Cr clearance equation
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

11. What are the hazards of elderly hospitalization?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
>60yo - low abuse risk - ^ monitoring possible
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
^morbidity + mortality - -frailest @ greatest risk

12. BZD + antidepressant: interaction outcome
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
A-blockers - B-blockers - TCA
Diagnosis - risk/benefit analysis to choose Rx
Confusion - sedation - falls

13. incontinence complication
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Cachexia - PEM - FTT - obesity

14. lightheadedness
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Prescribing - monitoring - patient adherence
Voice - character - plot - context - time - reader
Catch-all of unspecified dizziness

15. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
1/2
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
No: fever - leukocytosis - yes: falls - appetite change - low functional status

16. incontinence epidemiology
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
F>M (until 80yo) - stress incontinence #1 - $26B/yr
>9 Rx
Legal: Cruzan v Hamon

17. Why is abuse underreported?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Hypotension - ^K+
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Electrical: change in HR - structural: aortic outflow obstruction

18. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
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
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

19. What are the pharmacodynamic changes associated with aging?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Phenytoin
Stress: #1 - functional - urge - overflow
Receptors changes: # - sensitivity - counter-regulatory moa

20. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
Worse for cardiac causes v noncardia
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

21. What are the vascular changes of presyncope?
^SV (diastolic stroke volume)
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Therapy - SSRI

22. What is the best approach to malnutrition
Treat underlying disease/lack resources
Cholinesterase inhib - use: dementia
>9 Rx
Determined by Dr for a patient - -> used to determine competency

23. How does aging affect pharmacokinetic protein binding?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

24. Approach to idioPx - recurrent syncope
Mechanical loading - skin care - avoid friction/shear
Consider responsibilities - drivin
Universal - progressive - partially encoded (genetic) - destructive -
#1 patient's last competent indication of wishes - substituted judgment - beneficence

25. How does aging increase incontinence?
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
Phenytoin
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Treat underlying disease/lack resources

26. delirium diagnosis
High mortality - esp + Fx - very common in elderly
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Bone loss -> osteopenia -> osteoporosis -> Fx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

27. frailty raises vulnerability to...
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Falls - delirium - malnutrition - P ulcers - opportunistic i2
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

28. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

29. osteoporosis
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
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
BMD (bone mineral density): T-score >2.5 std dev below normal 1

30. MRP: medication related problems
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
1/2
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
28% - ADR: 17% - non-compliance 11%

31. how is the CAM used to diagnose delirium?
^SV (diastolic stroke volume)
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

32. thiazide diuretic may lead to what prescription cascade?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Hyperuricemia -> gout
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

33. Beers criteria
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
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
Confusion - sedation - falls
^K+

34. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Electrical: change in HR - structural: aortic outflow obstruction
Worse for cardiac causes v noncardia

35. psychological abuse
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Threats/ terrorizing - isolation - denying food/privileges/liberty
>9 Rx
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

36. ADR rf
Prescribing - monitoring - patient adherence
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Phenytoin
Figure out a good diet - social aspect - resources - dental/oral comfort

37. How does aging affect pharmacokinetic Rx distribution?
^morbidity + mortality - -frailest @ greatest risk
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

38. pulm edema + atypical Sx
>60yo - low abuse risk - ^ monitoring possible
Insiduous onset
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

39. frailty
P2-metabolite - phase 1 biotx much more affected than phase 2
Multisystemic vulnerability - -lowered reserves
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
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

40. driving considerations
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Make sure to discuss with patient - some states require reporting

41. ACE inhib + K+: interaction outcome
^K+
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
>9 Rx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

42. nutrition syndromes
CVA: stroke - AMI: acute MI - HF
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Cachexia - PEM - FTT - obesity
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

43. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
^K+
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

44. How does aging affect Rx renal elimination?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Used to calculate renal fcn - clearance of Cr adjusted for age

45. what normally prevents syncope?
Hyperuricemia -> gout
Determined by Dr for a patient - -> used to determine competency
3 reflexes: baroreceptor - renal nerve - ANF
ANF: Na+ retention - disinhib vasoconstriction

46. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

47. How does aging affect Rx pharmacokinetic distribution?
Confusion - sedation - falls
Respect for autonomy - nonmaleficence - beneficence - justice
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
Hyperuricemia -> gout

48. rule of doable effect
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

49. narcotics may lead to what prescription cascade?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Treat underlying disease/lack resources
Constipation -> laxatives
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

50. What are the 3 stages of ADRs?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Isolated systolic HTN
Prescribing - monitoring - patient adherence
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers