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Aging Physiology And Pharmacology

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1. documenting elderly abuse

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2. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Environment modification: obstacles - mobility - -bladder fcn ok

3. How does ANF prevent syncope?
P2-metabolite - phase 1 biotx much more affected than phase 2
Vertigo - presyncope - disequilibrium - lightheadedness
ANF: Na+ retention - disinhib vasoconstriction
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

4. what ADR are common in elderly patient?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

5. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Cholinesterase inhib - use: dementia
Worse for cardiac causes v noncardia
Breast cancer + 2o LBP

6. What is the preferred depression treatment in elderly?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Therapy - SSRI
Map of people - perceptions - etc - varies by perspective
Confusion - sedation - falls

7. What are the narrative elements of clinical ethics?
Prescribing - monitoring - patient adherence
Voice - character - plot - context - time - reader
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
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

8. What are the 4 basic ethical principles?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Worse for cardiac causes v noncardia
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Respect for autonomy - nonmaleficence - beneficence - justice

9. describe the % of ADR considered preventable - and of those serious
30% preventable - of these - 40% serious - of these 40% preventable
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
CNS suppression -> cholinesterase inhibitors
Pressure ulcer - fecal impaction - dehydration

10. What is polypharmacy
Determined by Dr for a patient - -> used to determine competency
>9 Rx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Legal: Cruzan v Hamon

11. What are the vascular changes of presyncope?
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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Diagnosis - risk/benefit analysis to choose Rx

12. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Receptors changes: # - sensitivity - counter-regulatory moa
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

13. galantamine
Confusion - sedation - falls
^BP -> a-HTN
Cholinesterase inhib - use: dementia
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

14. How does aging affect Rx pharmacokinetic metabolism?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
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
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

15. MI + atypical Sx
Make sure to discuss with patient - some states require reporting
Cholinesterase inhib - use: dementia
Hypotension - ^K+
No: chest pain - yes: fatigue - nausea - low functional status - SOB

16. refusing intervention
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
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
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Legal: Cruzan v Hamon

17. What are the common types of elder mistreatment?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Begin @25-50% recommended dose - APAP may be dose-limiting
Breast cancer + 2o LBP
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

18. What are common scenarios of untreated indications in elderly?
Figure out a good diet - social aspect - resources - dental/oral comfort
Hyperuricemia -> gout
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

19. What is the natural history of syncope?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Receptors changes: # - sensitivity - counter-regulatory moa
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

20. How does baroreceptor reflex prevent syncope?
Electrolyte imbalance - arrhythmia
28% - ADR: 17% - non-compliance 11%
Cachexia - PEM - FTT - obesity
^ANS tone -> ^periph vasoconstriction - ^HR

21. How does aging affect GI absorption rate of Rx?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Insiduous onset
Delayed absorption - like competitive inhib

22. What is capacity?
P2-metab: Lorazepam - Trazepam - Oxazepam
Legal: Cruzan v Hamon
Determined by Dr for a patient - -> used to determine competency
Bone loss -> osteopenia -> osteoporosis -> Fx

23. What are the key points of safe prescription for elderly - lecture
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Diagnosis - risk/benefit analysis to choose Rx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

24. What are the 3 stages of ADRs?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Prescribing - monitoring - patient adherence

25. MRP: medication related problems
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

26. what can enhance reporting in elderly?
Vertigo - presyncope - disequilibrium - lightheadedness
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Screen for potentially embarrassing dx - patient/Dr trust

27. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

28. what illnesses are underreported in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
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
No: chest pain - yes: fatigue - nausea - low functional status - SOB

29. what professional is least likely to report abuse?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Doctors
Breast cancer + 2o LBP
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

30. Presyncope
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Electrolyte imbalance - arrhythmia
Voice - character - plot - context - time - reader

31. frailty signs
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
CNS suppression -> cholinesterase inhibitors
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

32. How does aging affect Rx renal elimination?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Legal: Cruzan v Hamon
Worse for cardiac causes v noncardia

33. which benzodiazepines are most appropriate for elderly?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
P2-metab: Lorazepam - Trazepam - Oxazepam
Vertigo - presyncope - disequilibrium - lightheadedness

34. elderly abuse epidemiology
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
No: fever - leukocytosis - yes: falls - appetite change - low functional status
5% - underreported
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

35. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
^K+
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

36. Why is abuse underreported?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Cholinesterase inhib - use: dementia
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

37. functional incontinence tx
5% - underreported
Universal - progressive - partially encoded (genetic) - destructive -
Environment modification: obstacles - mobility - -bladder fcn ok
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

38. urinary incontinence types
Stress: #1 - functional - urge - overflow
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
BMD (bone mineral density): T-score >2.5 std dev below normal 1
A-blockers - B-blockers - TCA

39. What are the rf for caregiver to abuse elderly?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Insiduous onset
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

40. what drugs can cause dizziness?
3 reflexes: baroreceptor - renal nerve - ANF
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Isolated systolic HTN

41. red flags for further inquiry
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
#1 patient's last competent indication of wishes - substituted judgment - beneficence
5% - underreported
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

42. How does an 80yo renal fcn compare to that of a 20yo?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
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
1/2
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

43. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Legal: Cruzan v Hamon
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

44. PEM
^K+
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
NMDR antagonist - use: dementia

45. What is the epidemiology of dizziness?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Receptors changes: # - sensitivity - counter-regulatory moa
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

46. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
A-blockers - B-blockers - TCA
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

47. fall sequelae

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48. memantine
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Vertigo - presyncope - disequilibrium - lightheadedness
NMDR antagonist - use: dementia

49. incontinence epidemiology
Hypotension - ^K+
Vertigo - presyncope - disequilibrium - lightheadedness
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Legal: Cruzan v Hamon

50. What are the hazards of elderly hospitalization?
80% of hospital admission for syncope for >65yo
^morbidity + mortality - -frailest @ greatest risk
Beers criteria - medication appropriateness index (12 ?)
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD