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44 Cards in this Set

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What needs to be considered regarding renal fxn when giving meds to elderly?
1. prolonged ½-lives
2. reduced clearance → reduced maintenance dosing
What to consider regarding liver fxn when giving meds to elderly?
Drugs metabolized more slowly (greatest changes are in Phase I rxns)
Pharmacokinetic changes w/ aging:
Reduced lean body mass
Reduced total and % body water
Decrease in serum albumin
Pharmacodynamic changes w/ aging:
More sensitive to some sedative hypnotics
Blunted homeostatic control mechanisms
Increasd incidence of orthostatic hypotension
3 Commonly missed illnesses in elderly:
Dementia, Delirium, Depression/anxiety
Who gets amyloid plaques? Location?
-specific for AD
-extracellular
Who gets neurofibrillary tangles? Location?
-present in many neurodegenerative diseases
-intraneuronal
DSM-IV Definition of Dementia (Alzheimer’s Type):
Development of multiple cognitive deficits manifested by both memory impairment + one of the following:

1. aphasia: loss of ability to speak or understand speech
2. apraxia: inability to willfully perform acts
3. agnosia: loss of ability to recognize objects, persons, sounds, shapes, or smells
4. disturbance in executive functioning (i.e. mental capacity to control and apply mental skills to problem-solving strategies)
5. significant impairment in social or occupational functioning
6. gradual onset and continuing decline
7. no alternate definition
8. deficits do not occur exclusively during the course of delirium
Clinical presentation of Alzheimer’s Disease (mild stage):
• MMSE score >/= 21
• Forgetfulness, difficulty learning new info
• Trouble planning meals, managing finances, taking meds on schedule
• Depression symptoms
• Ability to perform ADLs is maintained
Clinical presentation of Alzheimer’s Disease (moderate stage):
• MMSE score b/w 10-20
• Short- and long-term memory impairment
• Difficulty performing tasks
• Agitation, behavioral symptoms common
• Deficits in intellect and reasoning
Clinical presentation of Alzheimer’s Disease (severe stage):
• MMSE score less than 9
• May groan, scream, mumble, speak gibberish
• Behavioral symptoms are common
• Failure to recognize family or faces
• Troubles w/ all essential ADLs
Evaluation for Alzheimer’s Disease:
• History: changes; acute vs chronic
• IADL’s: independent, assist, dependent (use telephone, shopping, food preparation, housekeeping, laundry, transportation, finances, medication)
• ADL’s: independent, assist, dependent (bathing, dressing, toileting, transfers, continence, feeding)
• Detect: common changes from baseline
• new or exacerbation of illness: self /spouse
• death in family
• psycho-social, environmental, economic
• vision, hearing, constipation, fluid intake
What is lost and thus causes dementia?
-Synapses are lost and cause dementia (plaques do not cause it)
-Cholinergic loss is a major contributor to dementia (especially to memory loss)
What type of neurons are shrunken in nromal aging and lost in AD?
Glutamatergic
Only FDA-approved Alzheimer’s Treatments**:
•Donepezil (Aricept)
•Memantine (Namenda)
•Rivastigmine (Exelon)
•Galantamine (Razodyne)
Prevalence of depression in community?

Prevalence of depression in nursing homes?
1-4%

42-51%
What symptoms are most common in a depressed elderly person (>65):
Death thoughts, sleep problems, appetite, energy level
(in descending order)

-Elderly do NOT complain of depressive symptoms any more than younger groups!
What fraction of acute post-MI pts are depressed?
1/3
**What is a strong independent predictor of negative outcome from sudden cardiac death in pts w/ CAD? What are the stats?**
Depression!
3.5x at 6 months
6.64x at 18 months
Depression is a risk factor for the following:
•New onset cardiac disease
•Type 2 diabetes
•Predictor of mortality in some forms of cancer
Depression in Neurological Illnesses:
•Alzheimer’s 0 - 57%
•Parkinson’s 25 - 50%
•Post stroke 30 - 60% (within first 2 years after initial stroke)
•Huntington’s 50%
What liver enzyme is involved in largest number of therapeutic drug metabolism rxns?
CYP3A4
What liver enzymes are highly involved in metabolism of SSRIs? (2)
2D6 and 3A4
What percentage of depressed elderly patients respond to antidepressants?
60-85%
What is an alternative therapy to medication for depressed elderly patients?
ECT = elctro-convulsive therapy

(5-15% of non-responders to meds may respond to ECT)
Benefits of ECT:
Fewer CV and GI side effects
More favorable outcomes in general
What is the “gold standard” in treatment of severe depression in the elderly?**
ECT!**
What kind of a condition is delirium?
A medical condition* that presents w/ acute or subacute cognitive and behavioral changes
Define: delirium
=an acute disorder of attention and cognition
DSM-IV criteria for delirium:
• Disturbance of consciousness (ie, reduced clarity of awareness of environment) with reduced ability to focus, sustain, or shift attention
• A change in cognition (such as memory deficit, disorientation, language disturbance) or development of a perceptual disturbance that is not better accounted for by preexisting, established or resolving dementia
• The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day
•There is evidence from H&P that the disturbance is due to:
1.General medical condition
2.Substance intoxication delirium
What types of patients experience high rates of delirium?
ICU patients: 30-70%
Post-op patients: 50%
What is the most frequent hospital complication in elderly patients?
Delirium
Mneumonic for causes of dementia:
“I WATCH DEATH”

infection, withdrawl, acute metabolic, trauma, CNS pathology, hypoxia, deficiencies, endocrinopaties, acute vascular, toxins and drugs, heavy metals
How is delirium assessed in ICU setting?
(1) Acute change and fluctuation in mental status and behavior AND (2) Inattention AND EITHER (3) Disorganized thinking OR (4) Altered consciousness
3 types of delirium:
1. hyperactive/agitated
2. hypoactive (often missed)
3. mixed
Compare delirium to dementia:
1. Delirium: rapid onset, primary defect in attention*, fluctuates during course of day, visual hallucinations are common, often cannot attend to MMSE or clock draw
2. Dementia: insidious onset, primary defect in short term memory, attention often normal, does not fluctuate during the day, visual hallucinations less common, can attend to MMSE or clock draw, but cannot perform well
What classes of drugs most commonly cause delirium? Why is this?
Drugs w/ anti-cholinergic activity**: Cimetidine/Ranitidine**

-steroids, TCAs, neuroleptics, furosemide, captopril, warfarin
Pathophysiology of delirium:
Impaired cerebral oxidative metabolism and multiple neurotransmitter abnormalities**
What is the Acetylcholine Hypothesis?
•ACh is the critical neurotransmitter in pathogenesis of delirium
•Anti-cholinergic meds cause acute confusional states
•Impaired cholinergic transmission – susceptible to AD
•Reciprocal relationship exists b/w cholinergic and dopaminergic activities (delirium → excess of dopaminergic activity)
What drug is the most frequently used in management of delirium?**
Haloperidol**, because of it’s safety, efficacy and multiple routes of administration that are possible.
S/Es of Haloperidol:
Sedation
Hypotension
EPS
Prolonged QT → torsades de pointes
What does it mean to take an inclusive approach to treating severe depression?**
Treat it regardless of the understanding of reasons of depression**
When is diagnostic screening for Alzheimer’s disease a must?**
-any pt >65 where a spouse, family member, or caregiver is voicing concern over a patient’s cognition or functional status**
Delirium is primarily characterized by:**
Attentional difficulty**