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Aging Physiology And Pharmacology

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1. advanced directive/care plan

2. dementia tx
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

3. What are the risks of uncontrolled ISH?
Serum Cr: used for Cr clearance equation
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
CVA: stroke - AMI: acute MI - HF
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

4. how can you determine whether Rx is appropriate to use in elderly patient?
Constipation -> laxatives
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Beers criteria - medication appropriateness index (12 ?)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

5. driving considerations
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Cachexia - PEM - FTT - obesity
Make sure to discuss with patient - some states require reporting
Doctors

6. What are the rf for caregiver to abuse elderly?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

7. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Map of people - perceptions - etc - varies by perspective
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Stress: #1 - functional - urge - overflow

8. BZD + antidepressant: interaction outcome
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Confusion - sedation - falls
^morbidity + mortality - -frailest @ greatest risk
CVA: stroke - AMI: acute MI - HF

9. how is cachexia different from wasting?
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

10. Aging descriptors
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Prescribing - monitoring - patient adherence
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

11. What are common scenarios of untreated indications in elderly?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
NMDR antagonist - use: dementia

12. memantine
^K+
Map of people - perceptions - etc - varies by perspective
^BP -> a-HTN
NMDR antagonist - use: dementia

13. ADR rf
Multisystemic vulnerability - -lowered reserves
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Respect for autonomy - nonmaleficence - beneficence - justice

14. What are common physical abuse Sx in elderly?
Consider responsibilities - drivin
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

15. What are the 3 stages of ADRs?
Begin @25-50% recommended dose - APAP may be dose-limiting
Map of people - perceptions - etc - varies by perspective
Treat underlying disease/lack resources
Prescribing - monitoring - patient adherence

16. what normally prevents syncope?
3 reflexes: baroreceptor - renal nerve - ANF
Legal: Cruzan v Hamon
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

17. fall causes
Figure out a good diet - social aspect - resources - dental/oral comfort
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

18. pulm edema + atypical Sx
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Insiduous onset
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
CVA: stroke - AMI: acute MI - HF

19. vision changes: elderly
High mortality - esp + Fx - very common in elderly
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

20. frailty
Multisystemic vulnerability - -lowered reserves
30% preventable - of these - 40% serious - of these 40% preventable
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

21. urge incontinence tx
^SV (diastolic stroke volume)
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Constipation -> laxatives
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

22. What is the Cockcroft Gault equation?
P2-metab: Lorazepam - Trazepam - Oxazepam
Used to calculate renal fcn - clearance of Cr adjusted for age
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Multisystemic vulnerability - -lowered reserves

23. What are rf for osteoporosis?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Insiduous onset
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

24. preventing malnutrition
Screen for potentially embarrassing dx - patient/Dr trust
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Figure out a good diet - social aspect - resources - dental/oral comfort
>60yo - low abuse risk - ^ monitoring possible

25. What is the bone deterioration cascade?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Bone loss -> osteopenia -> osteoporosis -> Fx
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

26. osteopenia
P2-metab: Lorazepam - Trazepam - Oxazepam
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Falls - delirium - malnutrition - P ulcers - opportunistic i2
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

27. urinary incontinence types
Stress: #1 - functional - urge - overflow
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
P2-metab: Lorazepam - Trazepam - Oxazepam

28. red flags for further inquiry
Determined by Dr for a patient - -> used to determine competency
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

29. How does aging affect pharmacokinetic Rx distribution?
Cholinesterase inhib - use: dementia
Breast cancer + 2o LBP
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Delayed absorption - like competitive inhib

30. How does aging affect GI absorption of Rx?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Confusion - sedation - falls

31. How does ANF prevent syncope?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
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
ANF: Na+ retention - disinhib vasoconstriction
Legal: Cruzan v Hamon

32. metoclopramide may lead to what prescription cascade?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Parkinsonism -> l-DOPA
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

33. Disequilibrium
Beers criteria - medication appropriateness index (12 ?)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
30% preventable - of these - 40% serious - of these 40% preventable

34. What are common medical causes of syncope?
Phenytoin
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

35. surrogate decision making heirarchy

36. malnutrition
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
1/2
Hypothetical plan - serves as patient's last competent indicated wishes

37. BZD + antipsychotic: interaction outcome
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Treat underlying disease/lack resources
Confusion - sedation - falls
Figure out a good diet - social aspect - resources - dental/oral comfort

38. cachexia
Respect for autonomy - nonmaleficence - beneficence - justice
Multisystemic vulnerability - -lowered reserves
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

39. osteoporosis
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Vertigo - presyncope - disequilibrium - lightheadedness
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
BMD (bone mineral density): T-score >2.5 std dev below normal 1

40. Syncope prognosis based on etio
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
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Worse for cardiac causes v noncardia

41. thiazide diuretic may lead to what prescription cascade?
Hyperuricemia -> gout
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
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
^K+

42. acute abdomen + atypical Sx
^ANS tone -> ^periph vasoconstriction - ^HR
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Cachexia - PEM - FTT - obesity

43. Why is abuse underreported?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Receptors changes: # - sensitivity - counter-regulatory moa
Threats/ terrorizing - isolation - denying food/privileges/liberty

44. What are the 4 forms of dizziness?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Tx underlying etio - + Kegels - pessary - surgery
Vertigo - presyncope - disequilibrium - lightheadedness
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

45. substituted judgment
Therapy - SSRI
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Map of people - perceptions - etc - varies by perspective
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

46. narcotics may lead to what prescription cascade?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Constipation -> laxatives
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

47. lipid-soluble Rx
Catch-all of unspecified dizziness
>60yo - low abuse risk - ^ monitoring possible
Therapy - SSRI
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

48. MRP: medication related problems
80% of hospital admission for syncope for >65yo
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
3 reflexes: baroreceptor - renal nerve - ANF

49. documenting elderly abuse

50. tube feeding
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Map of people - perceptions - etc - varies by perspective
3 reflexes: baroreceptor - renal nerve - ANF
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2