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Aging Physiology And Pharmacology

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1. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
NMDR antagonist - use: dementia
Temporalis muscle wasting = temporal wasting
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

2. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Pressure ulcer - fecal impaction - dehydration
BMD (bone mineral density): T-score >2.5 std dev below normal 1

3. What are the rf for elderly abuse?
Hypothetical plan - serves as patient's last competent indicated wishes
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

4. What are the rf for caregiver to abuse elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Hyperuricemia -> gout
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

5. What are the common types of elder mistreatment?
ANF: Na+ retention - disinhib vasoconstriction
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Mechanical loading - skin care - avoid friction/shear
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

6. osteoporosis epidemiology
CNS suppression -> cholinesterase inhibitors
High mortality - esp + Fx - very common in elderly
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

7. who is a good candidate for opioid tx?
CNS suppression -> cholinesterase inhibitors
>60yo - low abuse risk - ^ monitoring possible
Diagnosis - risk/benefit analysis to choose Rx
Beers criteria - medication appropriateness index (12 ?)

8. MI + atypical Sx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
No: chest pain - yes: fatigue - nausea - low functional status - SOB

9. pulm edema + atypical Sx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Insiduous onset
Confusion - sedation - falls
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

10. vision changes: elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Stress: #1 - functional - urge - overflow
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
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

11. Aging descriptors
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

12. pressure ulcer: staging
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Multisystemic vulnerability - -lowered reserves
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Delayed absorption - like competitive inhib

13. frailty raises vulnerability to...
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
^SV (diastolic stroke volume)
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

14. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
NMDR antagonist - use: dementia
Tx underlying etio - + Kegels - pessary - surgery
Prescribing - monitoring - patient adherence

15. What are common physical abuse Sx in elderly?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

16. dementia tx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Treat underlying disease/lack resources

17. How does aging affect Rx pharmacokinetic metabolism?
^ANS tone -> ^periph vasoconstriction - ^HR
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
80% of hospital admission for syncope for >65yo

18. physical neglect
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
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. What is the Cockcroft Gault equation?
Hyperuricemia -> gout
Used to calculate renal fcn - clearance of Cr adjusted for age
Bone loss -> osteopenia -> osteoporosis -> Fx
Voice - character - plot - context - time - reader

20. metoclopramide may lead to what prescription cascade?
A-blockers - B-blockers - TCA
Parkinsonism -> l-DOPA
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

21. How does aging increase incontinence?
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
Cholinesterase inhib - use: dementia
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Electrolyte imbalance - arrhythmia

22. fall causes
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
^ANS tone -> ^periph vasoconstriction - ^HR
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

23. delirium diagnosis
Parkinsonism -> l-DOPA
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

24. delirium: mgmt
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
IdioPx - psychiatric: depression - anxiety - somatoform
CNS suppression -> cholinesterase inhibitors

25. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Universal - progressive - partially encoded (genetic) - destructive -
^BP -> a-HTN
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

26. malnutrition
Insiduous onset
Beers criteria - medication appropriateness index (12 ?)
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
^SV (diastolic stroke volume)

27. thyroid dx + atypical Sx
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Therapy - SSRI

28. What is ISH?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
28% - ADR: 17% - non-compliance 11%
Isolated systolic HTN
Electrolyte imbalance - arrhythmia

29. Approach to idioPx - recurrent syncope
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
Isolated systolic HTN
Consider responsibilities - drivin
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

30. psychological abuse
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Threats/ terrorizing - isolation - denying food/privileges/liberty
Hypotension - ^K+
^morbidity + mortality - -frailest @ greatest risk

31. urge incontinence tx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Therapy - SSRI
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

32. narcotics may lead to what prescription cascade?
Constipation -> laxatives
CVA: stroke - AMI: acute MI - HF
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

33. what normally prevents syncope?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
3 reflexes: baroreceptor - renal nerve - ANF

34. stress incontinence tx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Tx underlying etio - + Kegels - pessary - surgery
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

35. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

36. Disequilibrium
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Cholinesterase inhib - use: dementia
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

37. What are the pharmacodynamic changes associated with aging?
Pressure ulcer - fecal impaction - dehydration
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Receptors changes: # - sensitivity - counter-regulatory moa
Legal: Cruzan v Hamon

38. acute abdomen + atypical Sx
Doctors
Delayed absorption - like competitive inhib
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
No: chest pain - yes: fatigue - nausea - low functional status - SOB

39. restrain requirements
>9 Rx
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
High mortality - esp + Fx - very common in elderly
Doctors

40. Syncope prognosis based on etio
Worse for cardiac causes v noncardia
Prescribing - monitoring - patient adherence
Injury - neglect - physical/psychosocial - financial - violation of rights
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

41. What is abuse?
^morbidity + mortality - -frailest @ greatest risk
Electrolyte imbalance - arrhythmia
Injury - neglect - physical/psychosocial - financial - violation of rights
#1 patient's last competent indication of wishes - substituted judgment - beneficence

42. refusing intervention
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Electrolyte imbalance - arrhythmia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Legal: Cruzan v Hamon

43. What are the risks of uncontrolled ISH?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
P2-metab: Lorazepam - Trazepam - Oxazepam
CVA: stroke - AMI: acute MI - HF
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

44. How does aging affect pharmacokinetics?
Temporalis muscle wasting = temporal wasting
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Catch-all of unspecified dizziness

45. nutrition syndromes
Confusion - sedation - falls
Stress: #1 - functional - urge - overflow
Cachexia - PEM - FTT - obesity
Hyperuricemia -> gout

46. What is polypharmacy
Map of people - perceptions - etc - varies by perspective
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
>9 Rx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

47. urinary incontinence types
28% - ADR: 17% - non-compliance 11%
Worse for cardiac causes v noncardia
P2-metab: Lorazepam - Trazepam - Oxazepam
Stress: #1 - functional - urge - overflow

48. Beers criteria: what 10 Rx should elderly avoid or use + caution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Phenytoin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

49. what mechanical loading helps to prevent pressure ulcers?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
30% preventable - of these - 40% serious - of these 40% preventable

50. delirium predisposing rf
^SV (diastolic stroke volume)
Worse for cardiac causes v noncardia
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment