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Aging Physiology And Pharmacology

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1. Approach to idioPx - recurrent syncope
Doctors
Serum Cr: used for Cr clearance equation
P2-metab: Lorazepam - Trazepam - Oxazepam
Consider responsibilities - drivin

2. What are the rf for elderly abuse?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
Catch-all of unspecified dizziness

3. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
CVA: stroke - AMI: acute MI - HF

4. cachexia
Mechanical loading - skin care - avoid friction/shear
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

5. antiarrhythmic + diuretic: interaction outcome
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Electrolyte imbalance - arrhythmia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
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

6. narcotics may lead to what prescription cascade?
Constipation -> laxatives
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
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
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

7. What is polypharmacy
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
NMDR antagonist - use: dementia
>9 Rx
Breast cancer + 2o LBP

8. How does an 80yo renal fcn compare to that of a 20yo?
Doctors
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
1/2

9. delirium diagnosis
Injury - neglect - physical/psychosocial - financial - violation of rights
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
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
>9 Rx

10. What is capacity?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Determined by Dr for a patient - -> used to determine competency
Bone loss -> osteopenia -> osteoporosis -> Fx
Screen for potentially embarrassing dx - patient/Dr trust

11. documenting elderly abuse

12. What is the bone deterioration cascade?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Bone loss -> osteopenia -> osteoporosis -> Fx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

13. what Rx are commonly monifoted in elderly for ADR?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
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
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

14. conservator
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Phenytoin

15. What are the key points of safe prescription for elderly - lecture
Pressure ulcer - fecal impaction - dehydration
Diagnosis - risk/benefit analysis to choose Rx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Vertigo - presyncope - disequilibrium - lightheadedness

16. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
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

17. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Make sure to discuss with patient - some states require reporting
Beers criteria - medication appropriateness index (12 ?)

18. What is the STOPP criteria?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Hyperuricemia -> gout
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
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

19. elderly abuse epidemiology
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Isolated systolic HTN
5% - underreported
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

20. What are the common types of elder mistreatment?
CVA: stroke - AMI: acute MI - HF
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Figure out a good diet - social aspect - resources - dental/oral comfort
^morbidity + mortality - -frailest @ greatest risk

21. pressure ulcer: staging
Treat underlying disease/lack resources
Vertigo - presyncope - disequilibrium - lightheadedness
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

22. Presyncope
Multisystemic vulnerability - -lowered reserves
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Electrolyte imbalance - arrhythmia
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

23. Alb-bound Rx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Beers criteria - medication appropriateness index (12 ?)
NMDR antagonist - use: dementia
Phenytoin

24. falls epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
5% - underreported
Phenytoin
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

25. LBW equation
Cholinesterase inhib - use: dementia
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

26. functional incontinence tx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Therapy - SSRI
Environment modification: obstacles - mobility - -bladder fcn ok
Appointed by court if no substituted judgment -conservator of finance -conservator of person

27. which benzodiazepines are most appropriate for elderly?
Constipation -> laxatives
Temporalis muscle wasting = temporal wasting
Stress: #1 - functional - urge - overflow
P2-metab: Lorazepam - Trazepam - Oxazepam

28. 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
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

29. How does aging affect Rx pharmacokinetic distribution?
High mortality - esp + Fx - very common in elderly
CNS suppression -> cholinesterase inhibitors
^ANS tone -> ^periph vasoconstriction - ^HR
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

30. delirium: Rx that contribute
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
5% - underreported
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

31. What are the rf for caregiver to abuse elderly?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Parkinsonism -> l-DOPA

32. What is a mattering map?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
3 reflexes: baroreceptor - renal nerve - ANF
Map of people - perceptions - etc - varies by perspective

33. osteoporosis epidemiology
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
High mortality - esp + Fx - very common in elderly
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
No: chest pain - yes: fatigue - nausea - low functional status - SOB

34. delirium incidence
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Injury - neglect - physical/psychosocial - financial - violation of rights

35. what % of hospitalizations of elderly are due to ADR + noncompliance?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
NMDR antagonist - use: dementia
28% - ADR: 17% - non-compliance 11%
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

36. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Begin @25-50% recommended dose - APAP may be dose-limiting
Insiduous onset

37. what normally prevents syncope?
>60yo - low abuse risk - ^ monitoring possible
3 reflexes: baroreceptor - renal nerve - ANF
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Therapy - SSRI

38. How does baroreceptor reflex prevent syncope?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
^ANS tone -> ^periph vasoconstriction - ^HR
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

39. What are the 3 sentinel events for LT care?
Confusion - sedation - falls
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Pressure ulcer - fecal impaction - dehydration

40. MI + atypical Sx
Cholinesterase inhib - use: dementia
28% - ADR: 17% - non-compliance 11%
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

41. who is a good candidate for opioid tx?
Worse for cardiac causes v noncardia
Hypotension - ^K+
Voice - character - plot - context - time - reader
>60yo - low abuse risk - ^ monitoring possible

42. physical neglect
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
P2-metab: Lorazepam - Trazepam - Oxazepam
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

43. How does aging affect pharmacokinetics?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

44. How does aging impact syncope-preventing reflexes
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
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Tx underlying etio - + Kegels - pessary - surgery
Legal: Cruzan v Hamon

45. What drugs can contribute to syncope?
Temporalis muscle wasting = temporal wasting
>60yo - low abuse risk - ^ monitoring possible
Hyperuricemia -> gout
A-blockers - B-blockers - TCA

46. ACE inhib + diuretic: interaction outcome
High mortality - esp + Fx - very common in elderly
Hypotension - ^K+
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
30% preventable - of these - 40% serious - of these 40% preventable

47. lipid-soluble Rx
Diagnosis - risk/benefit analysis to choose Rx
Vertigo - presyncope - disequilibrium - lightheadedness
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

48. how may hypertension compensate for aging?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Make sure to discuss with patient - some states require reporting

49. Cockcroft Gault equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
IdioPx - psychiatric: depression - anxiety - somatoform
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

50. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction