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Aging Physiology And Pharmacology

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1. narcotics may lead to what prescription cascade?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Parkinsonism -> l-DOPA
Constipation -> laxatives

2. driving considerations
Make sure to discuss with patient - some states require reporting
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Respect for autonomy - nonmaleficence - beneficence - justice
CNS suppression -> cholinesterase inhibitors

3. What drugs can contribute to syncope?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
A-blockers - B-blockers - TCA
^BP -> a-HTN
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

4. nutrition syndromes
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Cachexia - PEM - FTT - obesity

5. What is the Cockcroft Gault equation?
Injury - neglect - physical/psychosocial - financial - violation of rights
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Used to calculate renal fcn - clearance of Cr adjusted for age
Cholinesterase inhib - use: dementia

6. What is polypharmacy
>9 Rx
3 reflexes: baroreceptor - renal nerve - ANF
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Tx underlying etio - + Kegels - pessary - surgery

7. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Insiduous onset
P2-metabolite - phase 1 biotx much more affected than phase 2
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

8. what drugs can cause dizziness?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
P2-metabolite - phase 1 biotx much more affected than phase 2
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

9. how is the CAM used to diagnose delirium?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

10. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
P2-metabolite - phase 1 biotx much more affected than phase 2
Prescribing - monitoring - patient adherence
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

11. What are the 4 basic ethical principles?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Phenytoin
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Respect for autonomy - nonmaleficence - beneficence - justice

12. memantine
Parkinsonism -> l-DOPA
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
NMDR antagonist - use: dementia
3 reflexes: baroreceptor - renal nerve - ANF

13. what can enhance reporting in elderly?
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
P2-metabolite - phase 1 biotx much more affected than phase 2
Screen for potentially embarrassing dx - patient/Dr trust

14. Alb-bound Rx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Begin @25-50% recommended dose - APAP may be dose-limiting
Prescribing - monitoring - patient adherence
Phenytoin

15. frailty raises vulnerability to...
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Falls - delirium - malnutrition - P ulcers - opportunistic i2

16. How does aging affect pharmacokinetics?
Injury - neglect - physical/psychosocial - financial - violation of rights
Hypotension - ^K+
Treat underlying disease/lack resources
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

17. Beers criteria
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
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Prescribing - monitoring - patient adherence
P2-metab: Lorazepam - Trazepam - Oxazepam

18. What is capacity?
Make sure to discuss with patient - some states require reporting
Determined by Dr for a patient - -> used to determine competency
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

19. who is a good candidate for opioid tx?
Tx underlying etio - + Kegels - pessary - surgery
>60yo - low abuse risk - ^ monitoring possible
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

20. malignancy + atypical Sx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Breast cancer + 2o LBP
Isolated systolic HTN
Cholinesterase inhib - use: dementia

21. how is syncope related to elderly admission to hospital?
High mortality - esp + Fx - very common in elderly
No: fever - leukocytosis - yes: falls - appetite change - low functional status
80% of hospital admission for syncope for >65yo
Delayed absorption - like competitive inhib

22. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Isolated systolic HTN
Determined by Dr for a patient - -> used to determine competency

23. urge incontinence tx
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Stress: #1 - functional - urge - overflow
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Isolated systolic HTN

24. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
5% - underreported

25. What is the preferred depression treatment in elderly?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Pressure ulcer - fecal impaction - dehydration
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Therapy - SSRI

26. what receptors decrease sensitivity with aging?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Map of people - perceptions - etc - varies by perspective

27. cachexia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Cachexia - PEM - FTT - obesity
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

28. How to prevent pressure ulcers?
A-blockers - B-blockers - TCA
Mechanical loading - skin care - avoid friction/shear
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Begin @25-50% recommended dose - APAP may be dose-limiting

29. What are the 3 stages of ADRs?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Prescribing - monitoring - patient adherence
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Electrolyte imbalance - arrhythmia

30. ACE inhib + diuretic: interaction outcome
Cachexia - PEM - FTT - obesity
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Map of people - perceptions - etc - varies by perspective
Hypotension - ^K+

31. advanced directive/care plan

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32. How does aging affect Rx pharmacokinetic metabolism?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
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
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

33. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Pressure ulcer - fecal impaction - dehydration
Worse for cardiac causes v noncardia

34. i2 + atypical Sx
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
No: fever - leukocytosis - yes: falls - appetite change - low functional status
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
A-blockers - B-blockers - TCA

35. Presyncope
^K+
Legal: Cruzan v Hamon
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

36. Disequilibrium
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Doctors
Isolated systolic HTN

37. Why is abuse underreported?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

38. osteopenia
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Parkinsonism -> l-DOPA
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

39. MI + atypical Sx
Pressure ulcer - fecal impaction - dehydration
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Treat underlying disease/lack resources
No: chest pain - yes: fatigue - nausea - low functional status - SOB

40. What is ISH?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Isolated systolic HTN

41. thiazide diuretic may lead to what prescription cascade?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Hyperuricemia -> gout

42. what illnesses are underreported in elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Hypothetical plan - serves as patient's last competent indicated wishes
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

43. lightheadedness
^SV (diastolic stroke volume)
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
Prescribing - monitoring - patient adherence
Catch-all of unspecified dizziness

44. 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
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

45. What are the possible cardiac causes of presyncope?
^BP -> a-HTN
Electrical: change in HR - structural: aortic outflow obstruction
Cholinesterase inhib - use: dementia
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

46. rivastigmine
Figure out a good diet - social aspect - resources - dental/oral comfort
Cachexia - PEM - FTT - obesity
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Cholinesterase inhib - use: dementia

47. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Breast cancer + 2o LBP
3 reflexes: baroreceptor - renal nerve - ANF
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

48. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
NMDR antagonist - use: dementia
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Vertigo - presyncope - disequilibrium - lightheadedness

49. frailty
High mortality - esp + Fx - very common in elderly
>9 Rx
Multisystemic vulnerability - -lowered reserves
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

50. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Pressure ulcer - fecal impaction - dehydration
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

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Aging Physiology And Pharmacology

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