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Aging Physiology And Pharmacology

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1. 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
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

2. Aging principles
Hypotension - ^K+
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

3. osteoporosis
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Stress: #1 - functional - urge - overflow
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

4. What is the Cockcroft Gault equation?
Electrical: change in HR - structural: aortic outflow obstruction
Hypothetical plan - serves as patient's last competent indicated wishes
Beers criteria - medication appropriateness index (12 ?)
Used to calculate renal fcn - clearance of Cr adjusted for age

5. delirium diagnosis
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Confusion - sedation - falls

6. pressure ulcer: staging
Begin @25-50% recommended dose - APAP may be dose-limiting
Delayed absorption - like competitive inhib
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
No: fever - leukocytosis - yes: falls - appetite change - low functional status

7. How does aging affect pharmacokinetic protein binding?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Cholinesterase inhib - use: dementia

8. thyroid dx + atypical Sx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Consider responsibilities - drivin
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

9. delirium: tx approach
>60yo - low abuse risk - ^ monitoring possible
Breast cancer + 2o LBP
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

10. fall sequelae

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11. malnutrition
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Delayed absorption - like competitive inhib
Voice - character - plot - context - time - reader

12. lightheadedness
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Catch-all of unspecified dizziness
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

13. What are common medical causes of syncope?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
5% - underreported
No: chest pain - yes: fatigue - nausea - low functional status - SOB

14. what % of hospitalizations of elderly are due to ADR + noncompliance?
Breast cancer + 2o LBP
28% - ADR: 17% - non-compliance 11%
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Figure out a good diet - social aspect - resources - dental/oral comfort

15. What is the STOPP criteria?
Therapy - SSRI
>9 Rx
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
Isolated systolic HTN

16. i2 + atypical Sx
Treat underlying disease/lack resources
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
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

17. elderly abuse epidemiology
5% - underreported
ANF: Na+ retention - disinhib vasoconstriction
CNS suppression -> cholinesterase inhibitors
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

18. What is abuse?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Constipation -> laxatives
Injury - neglect - physical/psychosocial - financial - violation of rights
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

19. What are the key points of safe prescription for elderly - lecture
Diagnosis - risk/benefit analysis to choose Rx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

20. How does the aging heart compensate for lower HR to maintain unchanged CO?
Vertigo - presyncope - disequilibrium - lightheadedness
Worse for cardiac causes v noncardia
^SV (diastolic stroke volume)
Hypothetical plan - serves as patient's last competent indicated wishes

21. delirium: mgmt
Insiduous onset
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Vertigo - presyncope - disequilibrium - lightheadedness
Injury - neglect - physical/psychosocial - financial - violation of rights

22. conservator
Cachexia - PEM - FTT - obesity
Appointed by court if no substituted judgment -conservator of finance -conservator of person
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

23. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
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
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

24. What are common scenarios of untreated indications in elderly?
Breast cancer + 2o LBP
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

25. How does aging affect Rx pharmacokinetic distribution?
Bone loss -> osteopenia -> osteoporosis -> Fx
Appointed by court if no substituted judgment -conservator of finance -conservator of person
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
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

26. How does aging affect pharmacokinetic Rx distribution?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
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
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Cachexia - PEM - FTT - obesity

27. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Cholinesterase inhib - use: dementia
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

28. cachexia
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Prescribing - monitoring - patient adherence
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

29. how is the CAM used to diagnose delirium?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
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
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

30. clues of neglect
Phenytoin
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

31. What are the common causes of lightheadedness?
Multisystemic vulnerability - -lowered reserves
IdioPx - psychiatric: depression - anxiety - somatoform
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
^BP -> a-HTN

32. tube feeding
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

33. falls epidemiology
Cholinesterase inhib - use: dementia
3 reflexes: baroreceptor - renal nerve - ANF
#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)

34. what normally prevents syncope?
^morbidity + mortality - -frailest @ greatest risk
3 reflexes: baroreceptor - renal nerve - ANF
Universal - progressive - partially encoded (genetic) - destructive -
Legal: Cruzan v Hamon

35. What are the common types of elder mistreatment?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
^BP -> a-HTN
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
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

36. what illnesses are underreported in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Electrical: change in HR - structural: aortic outflow obstruction
Cholinesterase inhib - use: dementia

37. 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
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Respect for autonomy - nonmaleficence - beneficence - justice
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

38. LBW equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Electrolyte imbalance - arrhythmia
Used to calculate renal fcn - clearance of Cr adjusted for age

39. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
A-blockers - B-blockers - TCA
Beers criteria - medication appropriateness index (12 ?)
Vertigo - presyncope - disequilibrium - lightheadedness

40. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
IdioPx - psychiatric: depression - anxiety - somatoform
P2-metab: Lorazepam - Trazepam - Oxazepam
BMD (bone mineral density): T-score >2.5 std dev below normal 1

41. What are the rf for caregiver to abuse elderly?
Confusion - sedation - falls
Diagnosis - risk/benefit analysis to choose Rx
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

42. What is the natural history of syncope?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
28% - ADR: 17% - non-compliance 11%
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

43. frailty
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Multisystemic vulnerability - -lowered reserves
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

44. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
High mortality - esp + Fx - very common in elderly
ANF: Na+ retention - disinhib vasoconstriction
P2-metabolite - phase 1 biotx much more affected than phase 2

45. What is the bone deterioration cascade?
Hypotension - ^K+
28% - ADR: 17% - non-compliance 11%
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Bone loss -> osteopenia -> osteoporosis -> Fx

46. what ADR are common in elderly patient?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
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
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

47. osteoporosis epidemiology
80% of hospital admission for syncope for >65yo
High mortality - esp + Fx - very common in elderly
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

48. MRP: medication related problems
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

49. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Treat underlying disease/lack resources

50. How to prevent pressure ulcers?
Serum Cr: used for Cr clearance equation
Vertigo - presyncope - disequilibrium - lightheadedness
Mechanical loading - skin care - avoid friction/shear
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids