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Aging Physiology And Pharmacology

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1. what receptors decrease sensitivity with aging?
Map of people - perceptions - etc - varies by perspective
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
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

2. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Hypotension - ^K+
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Receptors changes: # - sensitivity - counter-regulatory moa

3. What is a PE sign of cachexia?
Therapy - SSRI
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Temporalis muscle wasting = temporal wasting

4. which benzodiazepines are most appropriate for elderly?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
P2-metab: Lorazepam - Trazepam - Oxazepam
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
^ANS tone -> ^periph vasoconstriction - ^HR

5. fall causes
P2-metabolite - phase 1 biotx much more affected than phase 2
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Electrical: change in HR - structural: aortic outflow obstruction
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

6. Alb-bound Rx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Screen for potentially embarrassing dx - patient/Dr trust
Phenytoin
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

7. LBW equation
Temporalis muscle wasting = temporal wasting
Confusion - sedation - falls
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

8. What is ISH?
Isolated systolic HTN
Confusion - sedation - falls
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
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

9. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

10. How does aging affect Rx renal elimination?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Temporalis muscle wasting = temporal wasting

11. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Make sure to discuss with patient - some states require reporting
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

12. Presyncope
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Bone loss -> osteopenia -> osteoporosis -> Fx
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
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

13. i2 + atypical Sx
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
No: fever - leukocytosis - yes: falls - appetite change - low functional status

14. What are the 3 sentinel events for LT care?
Confusion - sedation - falls
Environment modification: obstacles - mobility - -bladder fcn ok
Pressure ulcer - fecal impaction - dehydration
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

15. what can enhance reporting in elderly?
Receptors changes: # - sensitivity - counter-regulatory moa
Screen for potentially embarrassing dx - patient/Dr trust
^SV (diastolic stroke volume)
^BP -> a-HTN

16. pressure ulcer: staging
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Hyperuricemia -> gout
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Therapy - SSRI

17. urge incontinence tx
Threats/ terrorizing - isolation - denying food/privileges/liberty
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
3 reflexes: baroreceptor - renal nerve - ANF

18. how is cachexia different from wasting?
Map of people - perceptions - etc - varies by perspective
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

19. ADR rf
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
No: fever - leukocytosis - yes: falls - appetite change - low functional status
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

20. delirium: mgmt
Environment modification: obstacles - mobility - -bladder fcn ok
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

21. delirium: medical rf
Breast cancer + 2o LBP
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Used to calculate renal fcn - clearance of Cr adjusted for age

22. how is the CAM used to diagnose delirium?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
30% preventable - of these - 40% serious - of these 40% preventable
BMD (bone mineral density): T-score >2.5 std dev below normal 1
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

23. how can you determine whether Rx is appropriate to use in elderly patient?
Consider responsibilities - drivin
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Beers criteria - medication appropriateness index (12 ?)
Delayed absorption - like competitive inhib

24. narcotics may lead to what prescription cascade?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Constipation -> laxatives

25. What is START criteria?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Universal - progressive - partially encoded (genetic) - destructive -
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Delayed absorption - like competitive inhib

26. delirium: Rx that contribute
28% - ADR: 17% - non-compliance 11%
>60yo - low abuse risk - ^ monitoring possible
Electrical: change in HR - structural: aortic outflow obstruction
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

27. metoclopramide may lead to what prescription cascade?
Cholinesterase inhib - use: dementia
^SV (diastolic stroke volume)
Parkinsonism -> l-DOPA
IdioPx - psychiatric: depression - anxiety - somatoform

28. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
IdioPx - psychiatric: depression - anxiety - somatoform
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
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

29. acute abdomen + atypical Sx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Breast cancer + 2o LBP
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

30. malnutrition
Universal - progressive - partially encoded (genetic) - destructive -
Injury - neglect - physical/psychosocial - financial - violation of rights
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

31. what professional is least likely to report abuse?
IdioPx - psychiatric: depression - anxiety - somatoform
Doctors
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
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

32. How to prevent pressure ulcers?
Injury - neglect - physical/psychosocial - financial - violation of rights
Mechanical loading - skin care - avoid friction/shear
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
P2-metabolite - phase 1 biotx much more affected than phase 2

33. What is capacity?
Confusion - sedation - falls
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
Determined by Dr for a patient - -> used to determine competency
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

34. How does aging affect pharmacokinetic protein binding?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
>9 Rx

35. anticholinergic drugs may lead to what prescription cascade?
Hypotension - ^K+
CNS suppression -> cholinesterase inhibitors
5% - underreported
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

36. substituted judgment
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
NMDR antagonist - use: dementia
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

37. red flags for further inquiry
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
P2-metabolite - phase 1 biotx much more affected than phase 2
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

38. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
^SV (diastolic stroke volume)

39. How does renal nerve prevent syncope?
Cholinesterase inhib - use: dementia
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
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

40. delirium diagnosis
1/2
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
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
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

41. Cockcroft Gault equation
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

42. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Falls - delirium - malnutrition - P ulcers - opportunistic i2
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

43. What is sCr?
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
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
#1 patient's last competent indication of wishes - substituted judgment - beneficence

44. Aging descriptors
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
High mortality - esp + Fx - very common in elderly
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

45. overflow incontinence tx
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Respect for autonomy - nonmaleficence - beneficence - justice
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

46. surrogate decision making heirarchy

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47. What are common scenarios of untreated indications in elderly?
Electrical: change in HR - structural: aortic outflow obstruction
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
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

48. osteoporosis epidemiology
Universal - progressive - partially encoded (genetic) - destructive -
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
High mortality - esp + Fx - very common in elderly
Cachexia - PEM - FTT - obesity

49. what drugs can cause dizziness?
Diagnosis - risk/benefit analysis to choose Rx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Injury - neglect - physical/psychosocial - financial - violation of rights

50. lipid-soluble Rx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA