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Aging Physiology And Pharmacology

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1. What are the common types of elder mistreatment?
80% of hospital admission for syncope for >65yo
Begin @25-50% recommended dose - APAP may be dose-limiting
A-blockers - B-blockers - TCA
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

2. What are the vascular changes of presyncope?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Begin @25-50% recommended dose - APAP may be dose-limiting
Cholinesterase inhib - use: dementia

3. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Respect for autonomy - nonmaleficence - beneficence - justice

4. what can enhance reporting in elderly?
Environment modification: obstacles - mobility - -bladder fcn ok
Screen for potentially embarrassing dx - patient/Dr trust
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

5. acute abdomen + atypical Sx
P2-metabolite - phase 1 biotx much more affected than phase 2
Parkinsonism -> l-DOPA
^K+
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

6. How does aging impact syncope-preventing reflexes
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

7. Approach to idioPx - recurrent syncope
High mortality - esp + Fx - very common in elderly
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Therapy - SSRI
Consider responsibilities - drivin

8. what ADR are common in elderly patient?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Mechanical loading - skin care - avoid friction/shear
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

9. delirium: tx approach
Temporalis muscle wasting = temporal wasting
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

10. What are the rf for elderly abuse?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Make sure to discuss with patient - some states require reporting
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
F>M (until 80yo) - stress incontinence #1 - $26B/yr

11. What is the STOPP criteria?
A-blockers - B-blockers - TCA
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
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
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

12. pulm edema + atypical Sx
Bone loss -> osteopenia -> osteoporosis -> Fx
Insiduous onset
30% preventable - of these - 40% serious - of these 40% preventable
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

13. conservator
CNS suppression -> cholinesterase inhibitors
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Cholinesterase inhib - use: dementia
Appointed by court if no substituted judgment -conservator of finance -conservator of person

14. How does aging affect pharmacokinetics?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Vertigo - presyncope - disequilibrium - lightheadedness
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

15. delirium predisposing rf
CVA: stroke - AMI: acute MI - HF
Used to calculate renal fcn - clearance of Cr adjusted for age
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

16. cachexia
Determined by Dr for a patient - -> used to determine competency
Therapy - SSRI
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

17. What is the bone deterioration cascade?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Bone loss -> osteopenia -> osteoporosis -> Fx
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

18. What are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
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
Vertigo - presyncope - disequilibrium - lightheadedness

19. clues of neglect
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

20. thyroid dx + atypical Sx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
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
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

21. What are the common causes of lightheadedness?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
IdioPx - psychiatric: depression - anxiety - somatoform
^ANS tone -> ^periph vasoconstriction - ^HR

22. osteopenia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Serum Cr: used for Cr clearance equation
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

23. delirium diagnosis
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Voice - character - plot - context - time - reader
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

24. What is the best approach to malnutrition
Multisystemic vulnerability - -lowered reserves
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Treat underlying disease/lack resources
Beers criteria - medication appropriateness index (12 ?)

25. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Hypothetical plan - serves as patient's last competent indicated wishes

26. What is polypharmacy
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
A-blockers - B-blockers - TCA
^ANS tone -> ^periph vasoconstriction - ^HR
>9 Rx

27. falls epidemiology
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
30% preventable - of these - 40% serious - of these 40% preventable
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

28. ACE inhib + K+: interaction outcome
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
^K+
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

29. opioid tx in elderly
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Begin @25-50% recommended dose - APAP may be dose-limiting
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

30. what nutritional interventions help underweight?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
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
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

31. Alb-bound Rx
Prescribing - monitoring - patient adherence
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Phenytoin
Vertigo - presyncope - disequilibrium - lightheadedness

32. What is ISH?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Isolated systolic HTN
Constipation -> laxatives

33. malignancy + atypical Sx
Universal - progressive - partially encoded (genetic) - destructive -
Breast cancer + 2o LBP
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

34. osteoporosis etio
Beers criteria - medication appropriateness index (12 ?)
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Diagnosis - risk/benefit analysis to choose Rx
>9 Rx

35. how may hypertension compensate for aging?
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
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Cachexia - PEM - FTT - obesity
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

36. What is START criteria?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Begin @25-50% recommended dose - APAP may be dose-limiting
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

37. 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
^SV (diastolic stroke volume)
NMDR antagonist - use: dementia
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

38. MRP: medication related problems
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
NMDR antagonist - use: dementia
Stress: #1 - functional - urge - overflow
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

39. memantine
NMDR antagonist - use: dementia
ANF: Na+ retention - disinhib vasoconstriction
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

40. What are the 3 sentinel events for LT care?
No: fever - leukocytosis - yes: falls - appetite change - low functional status
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Pressure ulcer - fecal impaction - dehydration
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

41. What is the preferred depression treatment in elderly?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Pressure ulcer - fecal impaction - dehydration
Therapy - SSRI
ANF: Na+ retention - disinhib vasoconstriction

42. physical neglect
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Pressure ulcer - fecal impaction - dehydration
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

43. frailty signs
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Serum Cr: used for Cr clearance equation
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

44. delirium: medical rf
Bone loss -> osteopenia -> osteoporosis -> Fx
^BP -> a-HTN
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

45. osteoporosis epidemiology
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
High mortality - esp + Fx - very common in elderly
Respect for autonomy - nonmaleficence - beneficence - justice
P2-metabolite - phase 1 biotx much more affected than phase 2

46. dementia tx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Map of people - perceptions - etc - varies by perspective
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

47. delirium incidence
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
P2-metabolite - phase 1 biotx much more affected than phase 2
Therapy - SSRI
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

48. What is the epidemiology of dizziness?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
80% of hospital admission for syncope for >65yo
Electrical: change in HR - structural: aortic outflow obstruction

49. donepezil
Figure out a good diet - social aspect - resources - dental/oral comfort
A-blockers - B-blockers - TCA
Serum Cr: used for Cr clearance equation
Cholinesterase inhib - use: dementia

50. BZD + antipsychotic: interaction outcome
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
CNS suppression -> cholinesterase inhibitors
Confusion - sedation - falls