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Aging Physiology And Pharmacology

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1. describe the % of ADR considered preventable - and of those serious
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
30% preventable - of these - 40% serious - of these 40% preventable
Worse for cardiac causes v noncardia
Therapy - SSRI

2. memantine
Cholinesterase inhib - use: dementia
NMDR antagonist - use: dementia
CVA: stroke - AMI: acute MI - HF
ANF: Na+ retention - disinhib vasoconstriction

3. surrogate decision making heirarchy

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4. what normally prevents syncope?
Injury - neglect - physical/psychosocial - financial - violation of rights
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
3 reflexes: baroreceptor - renal nerve - ANF
Make sure to discuss with patient - some states require reporting

5. anticholinergic drugs may lead to what prescription cascade?
Beers criteria - medication appropriateness index (12 ?)
P2-metab: Lorazepam - Trazepam - Oxazepam
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
CNS suppression -> cholinesterase inhibitors

6. what % of hospitalizations of elderly are due to ADR + noncompliance?
>60yo - low abuse risk - ^ monitoring possible
28% - ADR: 17% - non-compliance 11%
^morbidity + mortality - -frailest @ greatest risk
Phenytoin

7. What are the common types of elder mistreatment?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Consider responsibilities - drivin
Cholinesterase inhib - use: dementia
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

8. What are the key points of safe prescription for elderly - lecture
Make sure to discuss with patient - some states require reporting
Diagnosis - risk/benefit analysis to choose Rx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Injury - neglect - physical/psychosocial - financial - violation of rights

9. MRP: medication related problems
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Tx underlying etio - + Kegels - pessary - surgery
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Temporalis muscle wasting = temporal wasting

10. restrain requirements
Environment modification: obstacles - mobility - -bladder fcn ok
NMDR antagonist - use: dementia
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Therapy - SSRI

11. urinary incontinence types
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Stress: #1 - functional - urge - overflow

12. Presyncope
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

13. What is the Cockcroft Gault equation?
Used to calculate renal fcn - clearance of Cr adjusted for age
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Phenytoin
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

14. using long-acting opioids in elderly
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

15. ACE inhib + K+: interaction outcome
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
P2-metab: Lorazepam - Trazepam - Oxazepam
^K+
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

16. malignancy + atypical Sx
Breast cancer + 2o LBP
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Doctors

17. ADR rf
Confusion - sedation - falls
5% - underreported
Cholinesterase inhib - use: dementia
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

18. what can enhance reporting in elderly?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
IdioPx - psychiatric: depression - anxiety - somatoform
5% - underreported
Screen for potentially embarrassing dx - patient/Dr trust

19. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Prescribing - monitoring - patient adherence
#1 patient's last competent indication of wishes - substituted judgment - beneficence
^K+

20. How does aging impact syncope-preventing reflexes
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

21. overflow incontinence tx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Hypotension - ^K+
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

22. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

23. How does aging affect GI absorption of Rx?
Delayed absorption - like competitive inhib
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Cholinesterase inhib - use: dementia
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

24. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Mechanical loading - skin care - avoid friction/shear
Catch-all of unspecified dizziness

25. what nutritional interventions help underweight?
Treat underlying disease/lack resources
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
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

26. what Rx are commonly monifoted in elderly for ADR?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Make sure to discuss with patient - some states require reporting

27. What are the common causes of lightheadedness?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
IdioPx - psychiatric: depression - anxiety - somatoform
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Parkinsonism -> l-DOPA

28. What are the vascular changes of presyncope?
Tx underlying etio - + Kegels - pessary - surgery
Injury - neglect - physical/psychosocial - financial - violation of rights
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

29. What is the bone deterioration cascade?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Consider responsibilities - drivin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Bone loss -> osteopenia -> osteoporosis -> Fx

30. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Determined by Dr for a patient - -> used to determine competency
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

31. rule of doable effect
Temporalis muscle wasting = temporal wasting
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Consider responsibilities - drivin

32. osteoporosis epidemiology
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
High mortality - esp + Fx - very common in elderly
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

33. pulm edema + atypical Sx
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Insiduous onset
Cholinesterase inhib - use: dementia

34. metoclopramide may lead to what prescription cascade?
Respect for autonomy - nonmaleficence - beneficence - justice
Parkinsonism -> l-DOPA
P2-metabolite - phase 1 biotx much more affected than phase 2
Screen for potentially embarrassing dx - patient/Dr trust

35. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Parkinsonism -> l-DOPA
^BP -> a-HTN
Cholinesterase inhib - use: dementia

36. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Vertigo - presyncope - disequilibrium - lightheadedness
Bone loss -> osteopenia -> osteoporosis -> Fx
Constipation -> laxatives
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

37. what illnesses are underreported in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
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
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)

38. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Parkinsonism -> l-DOPA
Cholinesterase inhib - use: dementia
Multisystemic vulnerability - -lowered reserves

39. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Mechanical loading - skin care - avoid friction/shear

40. What is START criteria?
>9 Rx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
30% preventable - of these - 40% serious - of these 40% preventable
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

41. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
CNS suppression -> cholinesterase inhibitors
Map of people - perceptions - etc - varies by perspective
5% - underreported

42. ACE inhib + diuretic: interaction outcome
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
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
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Hypotension - ^K+

43. What are the possible cardiac causes of presyncope?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
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
Electrical: change in HR - structural: aortic outflow obstruction

44. delirium: Rx that contribute
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Hypothetical plan - serves as patient's last competent indicated wishes
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

45. What are common scenarios of untreated indications in elderly?
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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Diagnosis - risk/benefit analysis to choose Rx

46. what ADR are common in elderly patient?
5% - underreported
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Bone loss -> osteopenia -> osteoporosis -> Fx

47. what professional is least likely to report abuse?
Doctors
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
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

48. What are common medical causes of syncope?
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
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Bone loss -> osteopenia -> osteoporosis -> Fx

49. What is the best approach to malnutrition
Phenytoin
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Treat underlying disease/lack resources
Used to calculate renal fcn - clearance of Cr adjusted for age

50. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
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

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Aging Physiology And Pharmacology

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