Week 4 Flashcards
define elderly
“young old” 65-74
“middle old” 75-84
“old” old >85 y.o
effects of covid on the baby boomer population
has possibly hasten the death of the baby boomer populatoin. either directly through COVID-19 or other factors
physiologic changes that occur in aging
Fat: increase in fat goes form 15 to 30%
Skelatel muscle decreases
bone density decreases
intracellular water decrceases
extracellular water remains the same
in genral, FATTER, WEAKER, DRIER
physiologic changes that occur in aging
CV system
anatomical: decreased contraction and filling capacity
physiological:
changes in conduction, decreased efficiency, decreased catacholamines
conduction system:
decrease d/t fibrosis or ischemia
“irritable”
Arteirla
*increased stiffness
*atherosclerosis
Venular:;
*decreased valves
*thrombosis, PE
Dx R/T aging cv system
*HTN
*TIA/CVA
physiologic changes that occur in aging
central nervous system
decreased rate of conduction
decreased strength of transmission
threshold for arousal blurred
reduced adaptation to physiologic stressors
increased recovery time in autonomic system
physiologic changes that occur in aging
Respiratory system
normal at rest,compromised at stress (known as duspena on exertion)
anatomical:
*decreased elasticity,
*muscle weakness
*skelatal deformities
function
*decreased ventilation
*decreased PaO2
physiologic changes that occur in aging
genitourinRY KIDNEYS
anatomic:
*nephron degeneration
Physiologic
*decreased ability to concentrate urime
decresed renal blood flow
decreased acid base adaptation when sressed
kidneys and problems w. aging kidneys
inadequate fluid intake
fluid loss d/t vomiting or diarrhea
shock d/t hemorrhage
cardiac failure
sepsis
injudicious use of diuretics
sod phosphate enemas
Genitourinary-bladder changes
gyno changes in women
*estrogen deprivation
atrophy
decreased secretions
results in urinary incontinance, dyspareunia, s/s menopause
reproductive chanhges in man
*gradual decrease of testosterone
decreased libido and sexual function, decreased energy and increased bodyfat,osteoporosis, decreased muscle mass, and decreased body hair
associated: diabetes mellitus, CV disease, and metabolic syndrome
*BPH
*erectile dysfunction
physiologic changes that occur in aging
GI
geenral: dentition and nutrition
esophageal: decreased motility, hiatal hernia
stomach: decreased acid production, intrinsic factos and motility
colon: decreased motility
pancreatic: decreased secretions
liver: decreased size, blood flow and CYP450
physiologic changes that occur in aging
Musculoskelatal
sturcutre and function
*atrophy
*decreased O2
joints:
erosion
degenration
calcification/ossification
skelatal degeration
*OP
*kyphosis
*fracturs and falls
physiologic changes that occur in aging
skin and derm sensory
change in skin, nails and hair
*decreased elasticity
decreased turgor
increased pigmentation
decreased vision
decreased hearing
other
leading causes of death in elderly
heart disease
malgnant neoplasms
chromic lower respiratory diseases
cerebrovascular diseases
define geriatric
*diminished homeostatic reserve capacity of all organ systems called homeostasis
in absence of stressors, homestasis causes no symptoms and very few restrictions on routine activities
progressive risk of homeostatic failure w. increasing age
(DECREASE OF FUNCTIONAL RESERVE)
define geriatric syndromes
multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older perosn vulnerable to situational challenges
facotrs of geriatric syndromes
- multiple risk factors and organ systems involved
- dx strategies to identify underlying causes sometimes ineffective, burdensome, dangerous, and costly
3.tpx mgmt of clinical manifestations can be helpful even in the absense of a firm dx or clarification of the underlying cause
could have a multiple etiologic factors and multiple pathogenic pathways causing SS
Geriatric Syndromes AGS GRS
DEMENTIA
DELERIUM
URINARY INCONTINENCE
FALLS
PRESSURE ULCERS
POLYPHARMACY
and others
delerium vs dementia
onset:
delerium: sudden w. deifnite beginning point
dementia: slow and gradual
duration:
delerium: days-weeks
dementia: usually permanent
cause:
delerium:almost always another ocnditions (infection, drugs, dehydration
dementia:: usualy chronic brian disorder
course:
delerium:usually reversible
dementia: slow progressive
attentioin
delerium: greatly impaires
dementia: unimpaire duntil dementia is severe
LOC:
delerium: variabily impaired
dementia: unimpaired until severe
orientation time/place
delerium: varies
dementia: impaired
memory
delerium: varies
dementia: lost, especially for recent events
need for medical attention:
delerium: immediate
dementia: required but less urgent
define frailty
occurs more in >90 y.o (>32%)
excess vulnerability to stressors, w. reduced abilty to maintain or regain homestasis after destabilizing event
(cdue to cumaltive decline in many phsyiologic sytems.vdpeletes homeostatic reserves
contributing factors of frailty
chornic malnutrition
sarcopenia
decreased metabolic rate and activity
decreased appetite
other effects of stressor events
*falls
delerium (BOTH OF THESE OFTEN TRIGGERED BY ADMIN OF DRUGS)
fluctuating disability
increased care needs
admission to hospital
admission to long term care
five phenotypical model indicators of frailty and their associated measures
weightloss (>4-5 kg or recorded wieghtloss of >/5% /year
self reported exauhstion
low energy expenditure (<383 kcal/weel) or <270 kcal/week in women
slow galt speed (standardized cutoff times to walk 4-57m
weak grip strength
medications and frailty
polypharmacy could have a potential effect on frai.ty, however it being adirect cause is unclear
clinical geriatric approach
maintenance of independence and prevent disability
multiple comorbidites
atypical presentation
*NOTE any symptom in an elderyly pt should be considered a drug side effect until proven otherwise
iatragenic cascade
drug thats can cause side effects, and they are put on more drugs to treat other SE.
that i swhy it is important to identify potential side effects of drugs and don tlet them go unrecognized
tools for comprehensive geriatric assessment
TIMER: tool to impromve medications in the elderly via review
geenral approach:
a. cost and coverage
b. adherance
c. safety
d. attain tpx goals
other things to conside rin comprehensive geriatric assessment
history taking problems (communication, underreporting, etc.
medicaiton organinzation (pillbox, reminders, etc)
non adhearance
(intentional and nonintentional)
assessing and monitoring drug therapy
drug related problems in elderly
underuse
over use
innapropriate prescribing (Beers, STOPP, STOPPFrail): r/t age and disease state)
Geriatric 5 m’s
MIND
MOBILITY
MEDICATIONS
MULTICOMPLEXITY
MATTERS MOST
determinging med appropriateness in elderly
at younger elderly ages: more drugs are appropriate because they have a longer time of benefit of the drugs
as they get older, time of benefit decreases and goal of careis more palliative instead of preventative
Physiologic changes associated w. aging
Absorption
somtach emptying time-
*delayed retention of indigestibles solids
decreased rate of absorption (can be effected by analgesics and hpynotics)
*acid-labile drugs
intestinal motility:
*some have increased or decreased motility
*more commonly decrease dmotility
gastirc acid secretion
*reduced, can cause hypochlorydria/achlorhydria
gastirc bloodflow
*may decrease absorption of high permeability drugs
REDUCED FIRST PASSED EFFECT
*reach systemic circulations at higher concentrations (ex: morphine, lidociane, propanolol, verapamil)
***however, overall, no significant effect on rate or extent of absorption
absoprtion from transdermal route
dryer skin
fatter skin
less perfused skin
effects: same absorption of lipophilic compounds
decreased absoprtion of hydrophyllic compounds
cachexia: loss of muscle , can effect absorption of durgs
ex: use of fentanyl patches
* absoption is longer and degree of pain tolerance effects how long the fentanyl patch is effective in pts
absorption form a mucosal standpoint
sublingual
buccal
rectal stomal
all remian inteact
Physiologic changes associated w. aging
Distribution
decrease lean body mass
increased fat: increase lipophyllic drug vd
decreaed water: decreased vd of hydrophillic drugs (lthium, theophylline, AG, etoh)
metabolism in elderly
reduced 3a4
no change in 2d6
decrease in hydroxylation and decreased demethylation in phase 1 metabolism
some evidence of decrease in >80yo of phase 2 metabolism glucornonidation
decrease mass and volume of liver
drugs that won emetabolize well
benzos
changes in renal function due to
decrease volume, weight, renal bloodflor, and glomerular function and tubular functoin
ALWAYS CALCULATE CrCl
accumaltion of toxic metabolite accumulation
DURGS EFFECTED BY DECREASED RENAL FUNCTION
ACE
beta blockers
change sin pharmacodynamics
info limited: some drugs can increase sensitivty, some can blunt response
drug classes innaprporpaite in oldr adultas
ACH confusion, other systemic adr
BENZOS: falls, delerium
AD-increased risk of falls, tca’s, ach (paroxetine)
NSAIDS- gi toxicity, cv risks( mi, hf), aki
ACH effects
common ach meds:
antihistmaines
TCAs
PAROXETINE
atropine
oxybutnin
tolteridine
process of deprescribing
- ascertain info on all meds currently taking, and adherance for each and why
- assess pt drug regimen for risk for drug induced harm
- assess eligiabilty for d/c
4, prioritize d/c list stareting from highest harm and lowest benefit,
tisk factors to fals
age releated muscle weakness
comorbidities
consequences of falls
fear o f falling
loss of confidence, mobility and the ability to live independently
itnerventions in preventing falls
multimodal interventions cause better reduction of falls
medication management
home
goald of med mgt to prevent falls
