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Aging Physiology And Pharmacology

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1. galantamine
5% - underreported
Cholinesterase inhib - use: dementia
Electrolyte imbalance - arrhythmia
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

2. What are the 4 basic ethical principles?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Respect for autonomy - nonmaleficence - beneficence - justice
Catch-all of unspecified dizziness
A-blockers - B-blockers - TCA

3. refusing intervention
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Legal: Cruzan v Hamon
Used to calculate renal fcn - clearance of Cr adjusted for age
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

4. How does aging affect Rx pharmacokinetic metabolism?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Therapy - SSRI
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
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

5. delirium: tx approach
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
CVA: stroke - AMI: acute MI - HF
>9 Rx
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

6. ACE inhib + K+: interaction outcome
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
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Temporalis muscle wasting = temporal wasting
^K+

7. How does renal nerve prevent syncope?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Confusion - sedation - falls
Pressure ulcer - fecal impaction - dehydration
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

8. fall sequelae

9. malignancy + atypical Sx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Breast cancer + 2o LBP
Screen for potentially embarrassing dx - patient/Dr trust

10. How does aging affect Rx renal elimination?
Voice - character - plot - context - time - reader
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
High mortality - esp + Fx - very common in elderly

11. LBW equation
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Falls - delirium - malnutrition - P ulcers - opportunistic i2
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

12. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
A-blockers - B-blockers - TCA
Injury - neglect - physical/psychosocial - financial - violation of rights

13. overflow incontinence tx
Screen for potentially embarrassing dx - patient/Dr trust
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Vertigo - presyncope - disequilibrium - lightheadedness
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

14. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

15. documenting elderly abuse

16. What are the 4 forms of dizziness?
Universal - progressive - partially encoded (genetic) - destructive -
Delayed absorption - like competitive inhib
Vertigo - presyncope - disequilibrium - lightheadedness
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

17. ADR rf
Phenytoin
P2-metabolite - phase 1 biotx much more affected than phase 2
High mortality - esp + Fx - very common in elderly
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

18. narcotics may lead to what prescription cascade?
Hyperuricemia -> gout
Constipation -> laxatives
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
^K+

19. driving considerations
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Make sure to discuss with patient - some states require reporting

20. incontinence epidemiology
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
F>M (until 80yo) - stress incontinence #1 - $26B/yr

21. What is the preferred depression treatment in elderly?
Therapy - SSRI
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
>60yo - low abuse risk - ^ monitoring possible
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

22. What are common medical causes of syncope?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
F>M (until 80yo) - stress incontinence #1 - $26B/yr

23. What are the pharmacodynamic changes associated with aging?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Receptors changes: # - sensitivity - counter-regulatory moa

24. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

25. delirium: mgmt
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

26. What is capacity?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Determined by Dr for a patient - -> used to determine competency
Temporalis muscle wasting = temporal wasting

27. rivastigmine
Doctors
Map of people - perceptions - etc - varies by perspective
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Cholinesterase inhib - use: dementia

28. violation of rights
Treat underlying disease/lack resources
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
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

29. cachexia
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Isolated systolic HTN
Phenytoin

30. frailty
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Multisystemic vulnerability - -lowered reserves
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

31. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Serum Cr: used for Cr clearance equation

32. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Receptors changes: # - sensitivity - counter-regulatory moa
^K+
^SV (diastolic stroke volume)

33. frailty signs
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

34. How does baroreceptor reflex prevent syncope?
Make sure to discuss with patient - some states require reporting
^ANS tone -> ^periph vasoconstriction - ^HR
3 reflexes: baroreceptor - renal nerve - ANF
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

35. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

36. 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
Therapy - SSRI
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
Isolated systolic HTN

37. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Confusion - sedation - falls

38. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Tx underlying etio - + Kegels - pessary - surgery
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

39. elderly abuse epidemiology
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
5% - underreported
Bone loss -> osteopenia -> osteoporosis -> Fx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

40. osteoporosis epidemiology
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
High mortality - esp + Fx - very common in elderly
>9 Rx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

41. What is a mattering map?
^K+
Map of people - perceptions - etc - varies by perspective
Worse for cardiac causes v noncardia
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

42. tube feeding
Bone loss -> osteopenia -> osteoporosis -> Fx
1/2
Hyperuricemia -> gout
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

43. What is a PE sign of cachexia?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
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
Screen for potentially embarrassing dx - patient/Dr trust
Temporalis muscle wasting = temporal wasting

44. acute abdomen + atypical Sx
Legal: Cruzan v Hamon
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Pressure ulcer - fecal impaction - dehydration
Make sure to discuss with patient - some states require reporting

45. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Consider responsibilities - drivin
F>M (until 80yo) - stress incontinence #1 - $26B/yr

46. what professional is least likely to report abuse?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Parkinsonism -> l-DOPA
Doctors

47. MRP: medication related problems
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Diagnosis - risk/benefit analysis to choose Rx
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

48. donepezil
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
^K+
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Cholinesterase inhib - use: dementia

49. What drugs can contribute to syncope?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Injury - neglect - physical/psychosocial - financial - violation of rights
A-blockers - B-blockers - TCA
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

50. What are the common types of elder mistreatment?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards