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Aging Physiology And Pharmacology

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1. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Confusion - sedation - falls
^K+
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

2. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Threats/ terrorizing - isolation - denying food/privileges/liberty
High mortality - esp + Fx - very common in elderly
Constipation -> laxatives

3. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Multisystemic vulnerability - -lowered reserves
Falls - delirium - malnutrition - P ulcers - opportunistic i2

4. osteoporosis
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Hypothetical plan - serves as patient's last competent indicated wishes
Hyperuricemia -> gout
BMD (bone mineral density): T-score >2.5 std dev below normal 1

5. stress incontinence tx
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
1/2
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Tx underlying etio - + Kegels - pessary - surgery

6. preventing malnutrition
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
5% - underreported
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Figure out a good diet - social aspect - resources - dental/oral comfort

7. dementia tx
Cholinesterase inhib - use: dementia
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Parkinsonism -> l-DOPA
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

8. ACE inhib + diuretic: interaction outcome
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
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Prescribing - monitoring - patient adherence
Hypotension - ^K+

9. What are the common causes of lightheadedness?
Therapy - SSRI
IdioPx - psychiatric: depression - anxiety - somatoform
Falls - delirium - malnutrition - P ulcers - opportunistic i2
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

10. fall sequelae

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11. MI + atypical Sx
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
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
No: chest pain - yes: fatigue - nausea - low functional status - SOB

12. rivastigmine
P2-metabolite - phase 1 biotx much more affected than phase 2
Cholinesterase inhib - use: dementia
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

13. How does aging affect GI absorption of Rx?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Receptors changes: # - sensitivity - counter-regulatory moa
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

14. narcotics may lead to what prescription cascade?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
>60yo - low abuse risk - ^ monitoring possible
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Constipation -> laxatives

15. What is a mattering map?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Map of people - perceptions - etc - varies by perspective

16. fall causes
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Vertigo - presyncope - disequilibrium - lightheadedness
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

17. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Electrical: change in HR - structural: aortic outflow obstruction
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

18. clues of neglect
Breast cancer + 2o LBP
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
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
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

19. frailty
Mechanical loading - skin care - avoid friction/shear
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Multisystemic vulnerability - -lowered reserves

20. Beers criteria
Diagnosis - risk/benefit analysis to choose Rx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
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
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

21. What is sCr?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Serum Cr: used for Cr clearance equation
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

22. osteoporosis etio
Determined by Dr for a patient - -> used to determine competency
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Delayed absorption - like competitive inhib
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

23. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Legal: Cruzan v Hamon
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
A-blockers - B-blockers - TCA

24. what nutritional interventions help underweight?
Respect for autonomy - nonmaleficence - beneficence - justice
^K+
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

25. elderly abuse epidemiology
No: fever - leukocytosis - yes: falls - appetite change - low functional status
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
5% - underreported

26. What is ISH?
CVA: stroke - AMI: acute MI - HF
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Isolated systolic HTN
80% of hospital admission for syncope for >65yo

27. How does baroreceptor reflex prevent syncope?
3 reflexes: baroreceptor - renal nerve - ANF
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Hyperuricemia -> gout
^ANS tone -> ^periph vasoconstriction - ^HR

28. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Hypotension - ^K+
ANF: Na+ retention - disinhib vasoconstriction

29. Aging features
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Universal - progressive - partially encoded (genetic) - destructive -
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

30. how is cachexia different from wasting?
Screen for potentially embarrassing dx - patient/Dr trust
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Prescribing - monitoring - patient adherence
>9 Rx

31. PEM
CVA: stroke - AMI: acute MI - HF
Threats/ terrorizing - isolation - denying food/privileges/liberty
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

32. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Beers criteria - medication appropriateness index (12 ?)

33. 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
Mechanical loading - skin care - avoid friction/shear
Pressure ulcer - fecal impaction - dehydration
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

34. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Universal - progressive - partially encoded (genetic) - destructive -
Doctors
Tx underlying etio - + Kegels - pessary - surgery

35. What is abuse?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
ANF: Na+ retention - disinhib vasoconstriction
Injury - neglect - physical/psychosocial - financial - violation of rights
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

36. conservator
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Used to calculate renal fcn - clearance of Cr adjusted for age
No: chest pain - yes: fatigue - nausea - low functional status - SOB

37. cachexia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Appointed by court if no substituted judgment -conservator of finance -conservator of person

38. delirium predisposing rf
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
28% - ADR: 17% - non-compliance 11%
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

39. psychological abuse
Breast cancer + 2o LBP
Threats/ terrorizing - isolation - denying food/privileges/liberty
Determined by Dr for a patient - -> used to determine competency
Serum Cr: used for Cr clearance equation

40. thyroid dx + atypical Sx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Hypotension - ^K+
Therapy - SSRI
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

41. malignancy + atypical Sx
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Breast cancer + 2o LBP

42. What are the hazards of elderly hospitalization?
Breast cancer + 2o LBP
^morbidity + mortality - -frailest @ greatest risk
>60yo - low abuse risk - ^ monitoring possible
Environment modification: obstacles - mobility - -bladder fcn ok

43. What are the rf for caregiver to abuse elderly?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

44. What are the common types of elder mistreatment?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
P2-metabolite - phase 1 biotx much more affected than phase 2
3 reflexes: baroreceptor - renal nerve - ANF

45. What is the epidemiology of dizziness?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
P2-metab: Lorazepam - Trazepam - Oxazepam
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

46. How does aging affect pharmacokinetics?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Voice - character - plot - context - time - reader
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

47. How does aging impact syncope-preventing reflexes
NMDR antagonist - use: dementia
IdioPx - psychiatric: depression - anxiety - somatoform
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Hypothetical plan - serves as patient's last competent indicated wishes

48. lipid-soluble Rx
Universal - progressive - partially encoded (genetic) - destructive -
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

49. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Tx underlying etio - + Kegels - pessary - surgery
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

50. delirium: Rx that contribute
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
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

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Aging Physiology And Pharmacology

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