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Aging Physiology And Pharmacology

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1. LBW equation
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Prescribing - monitoring - patient adherence

2. elderly abuse epidemiology
5% - underreported
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Constipation -> laxatives
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

3. Beers criteria
^SV (diastolic stroke volume)
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
Hypothetical plan - serves as patient's last competent indicated wishes
Screen for potentially embarrassing dx - patient/Dr trust

4. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

5. How does baroreceptor reflex prevent syncope?
5% - underreported
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
>9 Rx
^ANS tone -> ^periph vasoconstriction - ^HR

6. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

7. What are the narrative elements of clinical ethics?
IdioPx - psychiatric: depression - anxiety - somatoform
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Voice - character - plot - context - time - reader
Temporalis muscle wasting = temporal wasting

8. Cockcroft Gault equation
Universal - progressive - partially encoded (genetic) - destructive -
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Treat underlying disease/lack resources
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

9. What are rf for osteoporosis?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
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
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
^SV (diastolic stroke volume)

10. Why is abuse underreported?
IdioPx - psychiatric: depression - anxiety - somatoform
Worse for cardiac causes v noncardia
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

11. refusing intervention
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Legal: Cruzan v Hamon
Mechanical loading - skin care - avoid friction/shear
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

12. How does aging affect Rx renal elimination?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Make sure to discuss with patient - some states require reporting
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

13. Disequilibrium
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Consider responsibilities - drivin
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

14. functional incontinence tx
Determined by Dr for a patient - -> used to determine competency
Environment modification: obstacles - mobility - -bladder fcn ok
Threats/ terrorizing - isolation - denying food/privileges/liberty
Isolated systolic HTN

15. what drugs can cause dizziness?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
CNS suppression -> cholinesterase inhibitors
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

16. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
Pressure ulcer - fecal impaction - dehydration
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Hyperuricemia -> gout

17. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Vertigo - presyncope - disequilibrium - lightheadedness
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Cholinesterase inhib - use: dementia

18. incontinence complication
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
^SV (diastolic stroke volume)
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

19. which benzodiazepines are most appropriate for elderly?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Cholinesterase inhib - use: dementia
P2-metab: Lorazepam - Trazepam - Oxazepam

20. Syncope prognosis based on etio
Catch-all of unspecified dizziness
Doctors
Worse for cardiac causes v noncardia
Hypothetical plan - serves as patient's last competent indicated wishes

21. thiazide diuretic may lead to what prescription cascade?
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Hyperuricemia -> gout
^K+
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

22. incontinence epidemiology
Used to calculate renal fcn - clearance of Cr adjusted for age
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Electrolyte imbalance - arrhythmia
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

23. What is the best approach to malnutrition
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Bone loss -> osteopenia -> osteoporosis -> Fx
Treat underlying disease/lack resources
Confusion - sedation - falls

24. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Begin @25-50% recommended dose - APAP may be dose-limiting
Delayed absorption - like competitive inhib
Make sure to discuss with patient - some states require reporting

25. what % of hospitalizations of elderly are due to ADR + noncompliance?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
28% - ADR: 17% - non-compliance 11%

26. How does aging increase incontinence?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
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
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

27. antiarrhythmic + diuretic: interaction outcome
Vertigo - presyncope - disequilibrium - lightheadedness
Electrolyte imbalance - arrhythmia
^SV (diastolic stroke volume)
Worse for cardiac causes v noncardia

28. BZD + antidepressant: interaction outcome
Stress: #1 - functional - urge - overflow
Confusion - sedation - falls
Environment modification: obstacles - mobility - -bladder fcn ok
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

29. What is abuse?
Hyperuricemia -> gout
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Injury - neglect - physical/psychosocial - financial - violation of rights
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

30. memantine
NMDR antagonist - use: dementia
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Isolated systolic HTN
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

31. frailty signs
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
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

32. how is syncope related to elderly admission to hospital?
Consider responsibilities - drivin
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Pressure ulcer - fecal impaction - dehydration
80% of hospital admission for syncope for >65yo

33. osteoporosis
Respect for autonomy - nonmaleficence - beneficence - justice
BMD (bone mineral density): T-score >2.5 std dev below normal 1
3 reflexes: baroreceptor - renal nerve - ANF
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

34. What are common scenarios of untreated indications in elderly?
3 reflexes: baroreceptor - renal nerve - ANF
Phenytoin
CVA: stroke - AMI: acute MI - HF
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

35. cachexia
Breast cancer + 2o LBP
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

36. what nutritional interventions help underweight?
Respect for autonomy - nonmaleficence - beneficence - justice
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Hypothetical plan - serves as patient's last competent indicated wishes
28% - ADR: 17% - non-compliance 11%

37. What is the bone deterioration cascade?
Doctors
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Bone loss -> osteopenia -> osteoporosis -> Fx
^SV (diastolic stroke volume)

38. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Beers criteria - medication appropriateness index (12 ?)
High mortality - esp + Fx - very common in elderly
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

39. how may hypertension compensate for aging?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Electrolyte imbalance - arrhythmia
Mechanical loading - skin care - avoid friction/shear
NMDR antagonist - use: dementia

40. describe the % of ADR considered preventable - and of those serious
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
30% preventable - of these - 40% serious - of these 40% preventable
Begin @25-50% recommended dose - APAP may be dose-limiting

41. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
^ANS tone -> ^periph vasoconstriction - ^HR

42. How does ANF prevent syncope?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
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)
ANF: Na+ retention - disinhib vasoconstriction

43. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Cholinesterase inhib - use: dementia
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

44. What is capacity?
Parkinsonism -> l-DOPA
Determined by Dr for a patient - -> used to determine competency
30% preventable - of these - 40% serious - of these 40% preventable
Make sure to discuss with patient - some states require reporting

45. i2 + atypical Sx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

46. What is the preferred depression treatment in elderly?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Map of people - perceptions - etc - varies by perspective
^morbidity + mortality - -frailest @ greatest risk
Therapy - SSRI

47. MRP: medication related problems
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
CNS suppression -> cholinesterase inhibitors

48. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
A-blockers - B-blockers - TCA
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

49. What are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
Used to calculate renal fcn - clearance of Cr adjusted for age
IdioPx - psychiatric: depression - anxiety - somatoform
Mechanical loading - skin care - avoid friction/shear

50. How does aging affect Rx pharmacokinetic metabolism?
Figure out a good diet - social aspect - resources - dental/oral comfort
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Serum Cr: used for Cr clearance equation
Make sure to discuss with patient - some states require reporting