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Aging Physiology And Pharmacology

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1. substituted judgment
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
A-blockers - B-blockers - TCA
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

2. nutrition syndromes
Cachexia - PEM - FTT - obesity
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

3. What is abuse?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Pressure ulcer - fecal impaction - dehydration
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Injury - neglect - physical/psychosocial - financial - violation of rights

4. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Temporalis muscle wasting = temporal wasting

5. Cockcroft Gault equation
Therapy - SSRI
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
^SV (diastolic stroke volume)
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

6. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
^SV (diastolic stroke volume)
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Electrolyte imbalance - arrhythmia

7. what normally prevents syncope?
Insiduous onset
3 reflexes: baroreceptor - renal nerve - ANF
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

8. How does the aging heart compensate for lower HR to maintain unchanged CO?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Doctors
^SV (diastolic stroke volume)
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

9. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
>9 Rx
Legal: Cruzan v Hamon
Isolated systolic HTN

10. How does sliding scale glycemic control relate to elderly?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Temporalis muscle wasting = temporal wasting
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

11. MI + atypical Sx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Threats/ terrorizing - isolation - denying food/privileges/liberty
Prescribing - monitoring - patient adherence
No: chest pain - yes: fatigue - nausea - low functional status - SOB

12. depression + atypical Sx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

13. What is polypharmacy
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Multisystemic vulnerability - -lowered reserves
>9 Rx
Temporalis muscle wasting = temporal wasting

14. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Universal - progressive - partially encoded (genetic) - destructive -
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

15. how can you determine whether Rx is appropriate to use in elderly patient?
Doctors
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
1/2
Beers criteria - medication appropriateness index (12 ?)

16. Why is abuse underreported?
P2-metab: Lorazepam - Trazepam - Oxazepam
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
Cholinesterase inhib - use: dementia
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

17. donepezil
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cholinesterase inhib - use: dementia
Begin @25-50% recommended dose - APAP may be dose-limiting
Map of people - perceptions - etc - varies by perspective

18. metoclopramide may lead to what prescription cascade?
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
Map of people - perceptions - etc - varies by perspective
Parkinsonism -> l-DOPA
Used to calculate renal fcn - clearance of Cr adjusted for age

19. Syncope prognosis based on etio
Determined by Dr for a patient - -> used to determine competency
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Worse for cardiac causes v noncardia

20. What are the narrative elements of clinical ethics?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Isolated systolic HTN
Voice - character - plot - context - time - reader
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

21. incontinence complication
No: fever - leukocytosis - yes: falls - appetite change - low functional status
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Vertigo - presyncope - disequilibrium - lightheadedness
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

22. What is START criteria?
^BP -> a-HTN
Respect for autonomy - nonmaleficence - beneficence - justice
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

23. What are the rf for elderly abuse?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

24. What are the 4 forms of dizziness?
Screen for potentially embarrassing dx - patient/Dr trust
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Vertigo - presyncope - disequilibrium - lightheadedness

25. How to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
#1 patient's last competent indication of wishes - substituted judgment - beneficence
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

26. NSAID may lead to what prescription cascade?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
^BP -> a-HTN

27. fall sequelae

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28. what Rx are commonly monifoted in elderly for ADR?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Insiduous onset

29. BZD + antipsychotic: interaction outcome
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Cholinesterase inhib - use: dementia
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Confusion - sedation - falls

30. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Cholinesterase inhib - use: dementia
Cachexia - PEM - FTT - obesity

31. vertigo
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Voice - character - plot - context - time - reader
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

32. How does an 80yo renal fcn compare to that of a 20yo?
Serum Cr: used for Cr clearance equation
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
1/2
Delayed absorption - like competitive inhib

33. What are the pharmacodynamic changes associated with aging?
Receptors changes: # - sensitivity - counter-regulatory moa
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
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

34. i2 + atypical Sx
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Determined by Dr for a patient - -> used to determine competency
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

35. elderly abuse epidemiology
5% - underreported
Respect for autonomy - nonmaleficence - beneficence - justice
Confusion - sedation - falls
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

36. What are the hazards of elderly hospitalization?
^morbidity + mortality - -frailest @ greatest risk
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Breast cancer + 2o LBP
Hypotension - ^K+

37. malignancy + atypical Sx
Breast cancer + 2o LBP
5% - underreported
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

38. osteoporosis etio
Receptors changes: # - sensitivity - counter-regulatory moa
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
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

39. MRP: medication related problems
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Cholinesterase inhib - use: dementia
Delayed absorption - like competitive inhib

40. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Threats/ terrorizing - isolation - denying food/privileges/liberty
80% of hospital admission for syncope for >65yo
Electrical: change in HR - structural: aortic outflow obstruction

41. which benzodiazepines are most appropriate for elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
Diagnosis - risk/benefit analysis to choose Rx
Threats/ terrorizing - isolation - denying food/privileges/liberty
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

42. what ADR are common in elderly patient?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Confusion - sedation - falls
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

43. What is capacity?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Determined by Dr for a patient - -> used to determine competency
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
No: fever - leukocytosis - yes: falls - appetite change - low functional status

44. what receptors decrease sensitivity with aging?
Voice - character - plot - context - time - reader
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
NMDR antagonist - use: dementia

45. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
BMD (bone mineral density): T-score >2.5 std dev below normal 1

46. conservator
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Make sure to discuss with patient - some states require reporting
Appointed by court if no substituted judgment -conservator of finance -conservator of person
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

47. What are common medical causes of syncope?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Temporalis muscle wasting = temporal wasting
Electrolyte imbalance - arrhythmia

48. LBW equation
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
30% preventable - of these - 40% serious - of these 40% preventable
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

49. what drugs can cause dizziness?
Diagnosis - risk/benefit analysis to choose Rx
Catch-all of unspecified dizziness
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

50. How does aging affect pharmacokinetic Rx distribution?
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
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
^morbidity + mortality - -frailest @ greatest risk
Voice - character - plot - context - time - reader

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Aging Physiology And Pharmacology

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