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Aging Physiology And Pharmacology

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1. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
Therapy - SSRI
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
>9 Rx

2. delirium: mgmt
Vertigo - presyncope - disequilibrium - lightheadedness
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

3. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

4. Disequilibrium
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

5. lightheadedness
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Prescribing - monitoring - patient adherence
Catch-all of unspecified dizziness

6. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

7. what professional is least likely to report abuse?
80% of hospital admission for syncope for >65yo
Doctors
Multisystemic vulnerability - -lowered reserves
Hypotension - ^K+

8. How does aging affect pharmacokinetic Rx distribution?
Cholinesterase inhib - use: dementia
Diagnosis - risk/benefit analysis to choose Rx
^K+
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

9. What drugs can contribute to syncope?
Delayed absorption - like competitive inhib
Figure out a good diet - social aspect - resources - dental/oral comfort
A-blockers - B-blockers - TCA
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

10. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Insiduous onset
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

11. surrogate decision making heirarchy
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
#1 patient's last competent indication of wishes - substituted judgment - beneficence
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
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

12. What are rf for osteoporosis?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Breast cancer + 2o LBP
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

13. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
Electrical: change in HR - structural: aortic outflow obstruction
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
P2-metab: Lorazepam - Trazepam - Oxazepam

14. Alb-bound Rx
Consider responsibilities - drivin
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Used to calculate renal fcn - clearance of Cr adjusted for age
Phenytoin

15. what can enhance reporting in elderly?
High mortality - esp + Fx - very common in elderly
#1 patient's last competent indication of wishes - substituted judgment - beneficence
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
Screen for potentially embarrassing dx - patient/Dr trust

16. Aging principles
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 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Diagnosis - risk/benefit analysis to choose Rx

17. osteopenia
Confusion - sedation - falls
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
^morbidity + mortality - -frailest @ greatest risk

18. Why is abuse underreported?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Multisystemic vulnerability - -lowered reserves
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Serum Cr: used for Cr clearance equation

19. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Insiduous onset
>60yo - low abuse risk - ^ monitoring possible
Catch-all of unspecified dizziness

20. memantine
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
NMDR antagonist - use: dementia
Voice - character - plot - context - time - reader

21. NSAID may lead to what prescription cascade?
Worse for cardiac causes v noncardia
^K+
^BP -> a-HTN
Tx underlying etio - + Kegels - pessary - surgery

22. What is the Cockcroft Gault equation?
Used to calculate renal fcn - clearance of Cr adjusted for age
Vertigo - presyncope - disequilibrium - lightheadedness
Figure out a good diet - social aspect - resources - dental/oral comfort
Hypotension - ^K+

23. What are the key points of safe prescription for elderly - lecture
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Diagnosis - risk/benefit analysis to choose Rx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

24. How does aging affect pharmacokinetics?
Therapy - SSRI
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

25. osteoporosis
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Threats/ terrorizing - isolation - denying food/privileges/liberty
^BP -> a-HTN
BMD (bone mineral density): T-score >2.5 std dev below normal 1

26. How does baroreceptor reflex prevent syncope?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
^ANS tone -> ^periph vasoconstriction - ^HR
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Threats/ terrorizing - isolation - denying food/privileges/liberty

27. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
A-blockers - B-blockers - TCA
P2-metabolite - phase 1 biotx much more affected than phase 2

28. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Phenytoin
^BP -> a-HTN

29. How does an 80yo renal fcn compare to that of a 20yo?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Hypotension - ^K+
1/2
Determined by Dr for a patient - -> used to determine competency

30. how can you determine whether Rx is appropriate to use in elderly patient?
Beers criteria - medication appropriateness index (12 ?)
Pressure ulcer - fecal impaction - dehydration
Electrolyte imbalance - arrhythmia
Breast cancer + 2o LBP

31. acute abdomen + atypical Sx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
^K+
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

32. What are the risks of uncontrolled ISH?
Injury - neglect - physical/psychosocial - financial - violation of rights
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
3 reflexes: baroreceptor - renal nerve - ANF
CVA: stroke - AMI: acute MI - HF

33. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Worse for cardiac causes v noncardia
Therapy - SSRI
Parkinsonism -> l-DOPA

34. cachexia
3 reflexes: baroreceptor - renal nerve - ANF
^K+
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

35. lipid-soluble Rx
^ANS tone -> ^periph vasoconstriction - ^HR
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

36. Cockcroft Gault equation
A-blockers - B-blockers - TCA
IdioPx - psychiatric: depression - anxiety - somatoform
Bone loss -> osteopenia -> osteoporosis -> Fx
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

37. opioid tx in elderly
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Begin @25-50% recommended dose - APAP may be dose-limiting

38. nutrition syndromes
IdioPx - psychiatric: depression - anxiety - somatoform
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Cachexia - PEM - FTT - obesity

39. what nutritional interventions help underweight?
IdioPx - psychiatric: depression - anxiety - somatoform
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Delayed absorption - like competitive inhib

40. metoclopramide may lead to what prescription cascade?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
P2-metabolite - phase 1 biotx much more affected than phase 2
^ANS tone -> ^periph vasoconstriction - ^HR
Parkinsonism -> l-DOPA

41. tube feeding
28% - ADR: 17% - non-compliance 11%
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

42. thyroid dx + atypical Sx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Parkinsonism -> l-DOPA
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

43. antiarrhythmic + diuretic: interaction outcome
Doctors
Electrolyte imbalance - arrhythmia
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Begin @25-50% recommended dose - APAP may be dose-limiting

44. What is the bone deterioration cascade?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Bone loss -> osteopenia -> osteoporosis -> Fx
Begin @25-50% recommended dose - APAP may be dose-limiting
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

45. What are common scenarios of untreated indications in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Receptors changes: # - sensitivity - counter-regulatory moa
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

46. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Parkinsonism -> l-DOPA

47. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Receptors changes: # - sensitivity - counter-regulatory moa
Injury - neglect - physical/psychosocial - financial - violation of rights
Constipation -> laxatives

48. frailty
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Begin @25-50% recommended dose - APAP may be dose-limiting
Multisystemic vulnerability - -lowered reserves
Threats/ terrorizing - isolation - denying food/privileges/liberty

49. What are the 3 stages of ADRs?
Prescribing - monitoring - patient adherence
Injury - neglect - physical/psychosocial - financial - 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
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

50. red flags for further inquiry
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

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