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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
Determined by Dr for a patient - -> used to determine competency
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

2. PEM
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Insiduous onset

3. memantine
Doctors
Cholinesterase inhib - use: dementia
NMDR antagonist - use: dementia
Temporalis muscle wasting = temporal wasting

4. what normally prevents syncope?
3 reflexes: baroreceptor - renal nerve - ANF
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Electrolyte imbalance - arrhythmia
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

5. psychological abuse
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Threats/ terrorizing - isolation - denying food/privileges/liberty
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
No: chest pain - yes: fatigue - nausea - low functional status - SOB

6. violation of rights
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Delayed absorption - like competitive inhib
Consider responsibilities - drivin
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

7. narcotics may lead to what prescription cascade?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Catch-all of unspecified dizziness
^BP -> a-HTN
Constipation -> laxatives

8. pressure ulcer: staging
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
F>M (until 80yo) - stress incontinence #1 - $26B/yr
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
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

9. elderly abuse epidemiology
5% - underreported
Voice - character - plot - context - time - reader
Worse for cardiac causes v noncardia
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

10. How to prevent pressure ulcers?
Confusion - sedation - falls
Environment modification: obstacles - mobility - -bladder fcn ok
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Mechanical loading - skin care - avoid friction/shear

11. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
30% preventable - of these - 40% serious - of these 40% preventable
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

12. what nutritional interventions help underweight?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Prescribing - monitoring - patient adherence
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

13. What are the pharmacodynamic changes associated with aging?
Receptors changes: # - sensitivity - counter-regulatory moa
ANF: Na+ retention - disinhib vasoconstriction
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
Vertigo - presyncope - disequilibrium - lightheadedness

14. what professional is least likely to report abuse?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Diagnosis - risk/benefit analysis to choose Rx
Doctors
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

15. acute abdomen + atypical Sx
NMDR antagonist - use: dementia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

16. what receptors increase sensitivity with aging?
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
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Breast cancer + 2o LBP

17. delirium: mgmt
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

18. ADR rf
Cachexia - PEM - FTT - obesity
^morbidity + mortality - -frailest @ greatest risk
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
30% preventable - of these - 40% serious - of these 40% preventable

19. rivastigmine
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cholinesterase inhib - use: dementia

20. How does aging affect GI absorption of Rx?
Catch-all of unspecified dizziness
Confusion - sedation - falls
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

21. What is a PE sign of cachexia?
Prescribing - monitoring - patient adherence
Temporalis muscle wasting = temporal wasting
Hypothetical plan - serves as patient's last competent indicated wishes
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

22. what mechanical loading helps to prevent pressure ulcers?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
^morbidity + mortality - -frailest @ greatest risk
Begin @25-50% recommended dose - APAP may be dose-limiting

23. delirium incidence
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Hypothetical plan - serves as patient's last competent indicated wishes
^morbidity + mortality - -frailest @ greatest risk
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

24. delirium: Rx that contribute
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Delayed absorption - like competitive inhib
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
^SV (diastolic stroke volume)

25. How does aging affect pharmacokinetic protein binding?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Confusion - sedation - falls
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

26. How does aging affect Rx pharmacokinetic metabolism?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Hypotension - ^K+
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Hypothetical plan - serves as patient's last competent indicated wishes

27. What are the possible cardiac causes of presyncope?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Electrical: change in HR - structural: aortic outflow obstruction
ANF: Na+ retention - disinhib vasoconstriction

28. What is abuse?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Injury - neglect - physical/psychosocial - financial - violation of rights

29. fall sequelae

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30. delirium: tx approach
Isolated systolic HTN
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

31. advanced directive/care plan

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32. vertigo
Stress: #1 - functional - urge - overflow
Breast cancer + 2o LBP
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

33. documenting elderly abuse

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34. what receptors decrease sensitivity with aging?
5% - underreported
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Tx underlying etio - + Kegels - pessary - surgery
Delayed absorption - like competitive inhib

35. what illnesses are underreported in elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
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
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

36. how is cachexia different from wasting?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Environment modification: obstacles - mobility - -bladder fcn ok
Treat underlying disease/lack resources

37. How does aging affect pharmacokinetics?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

38. driving considerations
Make sure to discuss with patient - some states require reporting
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Map of people - perceptions - etc - varies by perspective
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

39. osteoporosis etio
Cachexia - PEM - FTT - obesity
Phenytoin
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
^SV (diastolic stroke volume)

40. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Map of people - perceptions - etc - varies by perspective
Worse for cardiac causes v noncardia

41. nutrition syndromes
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
80% of hospital admission for syncope for >65yo
Cachexia - PEM - FTT - obesity

42. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
Used to calculate renal fcn - clearance of Cr adjusted for age
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Voice - character - plot - context - time - reader

43. which benzodiazepines are most appropriate for elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Electrical: change in HR - structural: aortic outflow obstruction

44. 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
Tx underlying etio - + Kegels - pessary - surgery
Threats/ terrorizing - isolation - denying food/privileges/liberty
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

45. What are the rf for elderly abuse?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

46. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Confusion - sedation - falls
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
1/2

47. physical neglect
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Pressure ulcer - fecal impaction - dehydration
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

48. tube feeding
Isolated systolic HTN
^K+
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
28% - ADR: 17% - non-compliance 11%

49. delirium predisposing rf
Cachexia - PEM - FTT - obesity
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Mechanical loading - skin care - avoid friction/shear

50. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
BMD (bone mineral density): T-score >2.5 std dev below normal 1