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Aging Physiology And Pharmacology

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1. narcotics may lead to what prescription cascade?
Receptors changes: # - sensitivity - counter-regulatory moa
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Constipation -> laxatives

2. lightheadedness
Receptors changes: # - sensitivity - counter-regulatory moa
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Catch-all of unspecified dizziness
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

3. How does sliding scale glycemic control relate to elderly?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Determined by Dr for a patient - -> used to determine competency
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

4. 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
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
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
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

5. What are the common types of elder mistreatment?
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
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
High mortality - esp + Fx - very common in elderly

6. What is the preferred depression treatment in elderly?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Therapy - SSRI

7. What are the 4 forms of dizziness?
CVA: stroke - AMI: acute MI - HF
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Vertigo - presyncope - disequilibrium - lightheadedness
Cholinesterase inhib - use: dementia

8. how is the CAM used to diagnose delirium?
^morbidity + mortality - -frailest @ greatest risk
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
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
Treat underlying disease/lack resources

9. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Consider responsibilities - drivin
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
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

10. Alb-bound Rx
Insiduous onset
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Doctors
Phenytoin

11. What are the 4 basic ethical principles?
>9 Rx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
28% - ADR: 17% - non-compliance 11%
Respect for autonomy - nonmaleficence - beneficence - justice

12. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
Cholinesterase inhib - use: dementia
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Bone loss -> osteopenia -> osteoporosis -> Fx

13. conservator
NMDR antagonist - use: dementia
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Cholinesterase inhib - use: dementia

14. fall sequelae

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15. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

16. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Injury - neglect - physical/psychosocial - financial - violation of rights

17. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

18. How does aging impact syncope-preventing reflexes
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
P2-metab: Lorazepam - Trazepam - Oxazepam
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

19. What are the possible cardiac causes of presyncope?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Injury - neglect - physical/psychosocial - financial - violation of rights
Electrical: change in HR - structural: aortic outflow obstruction
ANF: Na+ retention - disinhib vasoconstriction

20. What is a PE sign of cachexia?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
^morbidity + mortality - -frailest @ greatest risk
Temporalis muscle wasting = temporal wasting
ANF: Na+ retention - disinhib vasoconstriction

21. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

22. Why is abuse underreported?
^morbidity + mortality - -frailest @ greatest risk
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
80% of hospital admission for syncope for >65yo

23. physical neglect
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
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

24. dementia tx
30% preventable - of these - 40% serious - of these 40% preventable
Used to calculate renal fcn - clearance of Cr adjusted for age
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

25. stress incontinence tx
Tx underlying etio - + Kegels - pessary - surgery
Begin @25-50% recommended dose - APAP may be dose-limiting
Voice - character - plot - context - time - reader
Multisystemic vulnerability - -lowered reserves

26. what professional is least likely to report abuse?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Doctors
Electrolyte imbalance - arrhythmia
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

27. metoclopramide may lead to what prescription cascade?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Parkinsonism -> l-DOPA

28. tube feeding
Multisystemic vulnerability - -lowered reserves
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Breast cancer + 2o LBP

29. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
80% of hospital admission for syncope for >65yo
^ANS tone -> ^periph vasoconstriction - ^HR
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

30. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Begin @25-50% recommended dose - APAP may be dose-limiting
Screen for potentially embarrassing dx - patient/Dr trust

31. driving considerations
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Phenytoin
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Make sure to discuss with patient - some states require reporting

32. What are the rf for elderly abuse?
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Cholinesterase inhib - use: dementia

33. What are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Legal: Cruzan v Hamon
28% - ADR: 17% - non-compliance 11%

34. falls epidemiology
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
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

35. NSAID may lead to what prescription cascade?
^BP -> a-HTN
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Threats/ terrorizing - isolation - denying food/privileges/liberty
Confusion - sedation - falls

36. nutrition syndromes
Cachexia - PEM - FTT - obesity
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Worse for cardiac causes v noncardia

37. acute abdomen + atypical Sx
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Insiduous onset

38. How does the aging heart compensate for lower HR to maintain unchanged CO?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
^SV (diastolic stroke volume)
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
5% - underreported

39. 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
30% preventable - of these - 40% serious - of these 40% preventable
Multisystemic vulnerability - -lowered reserves
Hyperuricemia -> gout

40. What is ISH?
Isolated systolic HTN
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Delayed absorption - like competitive inhib

41. substituted judgment
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Serum Cr: used for Cr clearance equation
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
F>M (until 80yo) - stress incontinence #1 - $26B/yr

42. How does aging affect Rx pharmacokinetic metabolism?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Cachexia - PEM - FTT - obesity
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

43. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Diagnosis - risk/benefit analysis to choose Rx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

44. What are rf for osteoporosis?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Cholinesterase inhib - use: dementia

45. using long-acting opioids in elderly
^SV (diastolic stroke volume)
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
A-blockers - B-blockers - TCA
#1 patient's last competent indication of wishes - substituted judgment - beneficence

46. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
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

47. surrogate decision making heirarchy

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48. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Vertigo - presyncope - disequilibrium - lightheadedness
Treat underlying disease/lack resources
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

49. What are common medical causes of syncope?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
1/2
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
BMD (bone mineral density): T-score >2.5 std dev below normal 1

50. vision changes: elderly
Confusion - sedation - falls
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Diagnosis - risk/benefit analysis to choose Rx
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity