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48 Cards in this Set
- Front
- Back
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pharmacokinetics and aging
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affects bioavailability
lifestyle comorbiditiuty and concomitant meds affect drug absorption more than age alone volume of distribution affected by body fat to water ratio protein binding can be impacted in elderly impacts free drug fraction metab - hepatic mass and blood flow altered in aging assoc w/impact on cytochrome P450 system |
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cognitive impairment
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abn change in how a person thinks, emotionaly responds, or behaves
it may involve changes in one or more domains like - memory - language - perception - judgement and insight - attention - ability to perform self care and normal social/ vocational tasks and roles ADLs and IADLs |
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most common causes of cog impairment in seniors
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dementia - chronic irreversible
delirium - acute, reversible depression - chronic, usually reversible |
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delirium
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disturbance of consciousness w/inattention that develops over a short time and fluctuates
disturbances of - consciousness dec ability to focus - attention - dec ability to sustain or shift - cognition - memory deficit, disorientation, language disturbance) - excludes pre-existing, est, or evolving dementia - perception develops over a short peroid of time (hrs to days) diurnal fluctuation psychomotor variants - hyperactive 25% hypoactive 50%, mixed delirium w/ reversal of normal day/night cycle |
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differential diagnosis of delirium
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dementia
psychosis mood disorder stroke previous brain injury post ictal states communication barrier - deafness, language |
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why are frail elderly vulnerable to delirium
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- decreased psyiological reserves (homeostenosis)
- greater fragility of BBB - age related changes to excretion, metab and response to meds - polypharm - inc med:med interaction and med:dx interaction -higher chronic dx burden |
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Dementia
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characterized by cog decline and normal sensorium
leading cause of institutionalization among the elderly risk factors include age, fam hx, head trauma, CVD, substance abuse Alzheimers dementia is the most common type (2/3 of cases) followed by vascular dementia |
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diagnosis of dementia made when pt presents with
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1. memory impairment
- immediate - maybe - short term -most likely - long term - last to erode 2. cognitive impairment - aphasia - loss of the ability to understand words - apraxia - loss of the ability to carry out motor fns - agnosia- loss of the ability to identify or associate - disturbance of executive fning - abstract thought, planning, initiating, sequencing, monitoring, complex bhxs |
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dementia statistics
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prevvalence of dementia doubles every 5 yrs after age 60 until about 90
affects 30-50% ppl over 85 nursing home 60-80% |
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aracept
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for mild, mod, severe alzheimers
AchE inhibitor T1/2 70-80 donepezil metab CYP2D6, CYP3A4 initial dose 5 mg qd max dose 10 mg qd |
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galantamine
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mild, moderate alzheimers
AchE inhib food effects absorption T1/2 5-7 CYP2D5 CYP 3A4 4-12mg bid ER 8, 16, 24mg qd |
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rivastigmine
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mild moderate
also used for parkinson's dementia AchEI food affects abs T1/2 2 hrs metab nonhepatic 1.5 mg bid 6 mg bid |
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memantine
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mod, severe alzheimers
NMDA- rec antagonist food doesnt have affect on absorption t1/2 60-80 hrs nonhepatic metab 5 mg qd 10 mg bid |
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care of dementia pt
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Inform and teach the family and caregivers about the nature and progression of the disease.
Refer to Alzheimer’s society; community support Driving evaluations Power of attorney; advance directives Respite and home care programs. Future plans ? Genetic testing Maintain high level of activity (exercise programs, daily activities). Nutrition. Check for weight loss and nutritional indices (B12, albumin) Encourage personal and social functions as much as possible |
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depression is associated with ... in the elderly
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fnal decline
cognitive losses amplified phys sx and disability failure to thribe pain poor out come w/CVD or stroke |
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risk factors for late life depression
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female
special consideration in males prior episode of MDD hx `of depressive illness in a first degree relative chronic med illness |
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Major depression
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single episode
recurrent episode psychotic atypical melacholic w/seasonal pattern |
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most common risk factor for suicide
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prior attempt
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typical vs atypical depressiion
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typical - skinny awake all time
atypical eat and sleep all the time |
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types of depression
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Major depression
dysthymia bipolar d/o depressed depression due to general med condition minor depression brief, reactive mixed anxiety-depression |
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major depression criteria
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5 or more of 9 sx present for at least 2 weeks and must include symptom 1 or 2
1. depressed mood 2. anhedonia 3. wt change 4. change in sleep 5. decreased energy 6. decreased concentration 7. psychomotor agitation or retardation 8. guilt 9. suicidal thoughts must cause impairment in fn must not be due to med illness/ substance use |
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bereavement
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14% have major depression w/in 2 yrs
bereaved older ppl develop depressive syndromes or full major depression at lower rates than younger tx` indicated evven if sx do not meet strict criteria |
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asking about depression
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are you sad
are you sleeping poorly do you worry too much what have you enjoyed doing lately have you been bothered by little interest or pleasure in doing things |
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probing for suicidality
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Have you felt that life was not worth living?
Did you ever wish you could go to sleep and just not wake up? Is death/dying something you’ve thought about recently? Have things reached the point that you’ve thought of harming yourself? Do you have access to weapons |
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diseases associated with substance use disorder nicotine
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COPD
emphysema CVD PVD lung cancer oral cancer |
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diseases associated with substance use disorder sedative hypnotics
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w/d tremors or seizures
in OD resp depression, coma, death |
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diseases associated with substance use disorder
cocaine |
TIA,
cerebral vascular events ischemia of GI tract chest pain MI pneumothorax pneumomediastinum pulmonary infarction dyspnea cellulitis(IV) endocarditis (IV) |
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diseases associated with substance use disorder opiods
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constipation
OD - respiratory depression, coma, death |
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diseases associated with substance use disorder alcohol
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blackouts
hangovers w/d tremors or seizures DTs aspiration pneumonia cardiomyopathy cerebellar degeneration, gastritis GERD hepatitis Wernicke-Korsakoff syndrome vitamin deficiencies |
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diseases associated with substance use disorder alcohol and illicit drugs
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Hep B/C
HIV TB |
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most used or depended on illicit drugs
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1. marijuana
2. pain relievers 3. cocaine 4. tranquilizers |
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drug abuse Warning network (DAWN)
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public health surveillance system that monitors drug related visits to hospital emergency departments and drug related deaths investigated by medical examiners and coroners
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Treatment episode Data set (TEDS)
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compilation of data on the demographic and substance abuse characteristics of admissions to and discharges from substance abuse treatment
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Monitoring the Future (MTF)
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university of Michigen
35th year looks at substance initiation, use, perceived availability, estimation of risks among 8th, 10th, and 12th graders across US |
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prevalence of drug use
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1 in 4 ppl smoke
1 in 5 ppl have problems w/etoh 1 in 10 have problems with other drugs 80% of ppl w/ alcohol dependence and 70% of ppl w/cocaine dependence work every day |
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substance abuse
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a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by one or more of the following occuring w/in a 12 mo period
1. recurrent substance use resulting in FAILURE TO FULFIL A MAJOR ROLE OBLIGATION at work, school, or home (repeated absences, poor work performance related to substace use) substance related absences, suspensions or expulsions from school, negelect of children or household 2. recurrent substance USE IN SITUATIONS IN WHICH IT IS PHYSICALLY HAZARDOUS suchas driving car or operating machine 3. recurrent substance related LEGAL PROBLEMS such as arrests for substance related disorderly conduct 4. continued substance use despite HAVING PERSISTENT OR RECURRENT SOCIAL OR INTERPERSONAL PROBLEMS caused by or exacerbated by the effects of the substance - arguments with spouse abt consequences of intoxication or physical fights |
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substance dependence
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malaadaptive pattern of substance use leading to clinically significant impairment or distress as manifested by 3 or more of the following, occuring any time in the same 12 mo period
1. Tolerance 2.withdrawl 3. substance taken in larger amts or over longer period than intended 4. desire or unsuccessful effort to cut down 5. excessive time in finding, using , or recovering 6. social, occupational and reacreational activities given up 7.continued use despite knowledge of recurrent physical or psychological problems |
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tolerance
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a need for markedly increased amts of substance to achieve intoxication or the desired effect
OR markedly diminished effect w/continued use of the same amount of the substance |
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withdrawl
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the characteristic w/d syndrome for the substance
OR the same or closely related substance is taken to relieve or avoid w/d symptoms |
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specifiers for substance dependence
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specify If:
- with psychological dependence or w/o course specifiers - early full remission (early >1 mo but less than 12 - early partial remission partial at least one criteria met full no criteria met - sustained full remission greater than 12 mo - sustained partial remission - on agonist therapy - in controlled environment |
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addiction
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chronic relapsing d/o characterized by
1. compulsion to seek and take drug 2. loss of control in limiting intake 3. emergence of a negative emotional state (dysphoria, anxiety, irritability) when access to drug is prevented lasts a lifetime brain changes use repeatedly think abt it all the time look for it are abn when stop using |
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developing addiction
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bhx that progresses from impulsivity to compulsivity in 3 stage cycle
1. binge/intoxication 2. w/d/negative affect 3. preoccupation/anticipation as move from impulsive to compulsive the drive for drug taking bhx shifts from positive to negative reinforcement impulsivity and compulsivity can coexist in different stages of the addiction cycle |
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etiologies of substance use disorders
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neurobiological
genetics - hereitability of alcohol dependence ranges from 51-59% bhx - positive reinforcement initial- use for acute pleasurable effects - negative reinforcement later - use to alleviate unpleasant states environmental - parental modeling, ethnic differences in drinking customs, parental/familial psychopathology, SES status, fam aggression/violence, parental cognitive impairment = risks psychosocial - pts relationship w/others h/o positive influences during adolescence, coping skills, defense mechanisms h/o phsyical/sexual abuse, marital/partner status |
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Comorbidity
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psychiatric d/p causese substance abuse - self as self medicate
substance abuse causes psychiatric d/o both caused by common underlying d/o bowth occur independet of the o ther |
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interview of pts substance use
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age of first substance use
freq of substance sue amt f substance take during on episode route of administration conseq assoc tx history periods of abstinence in particular longest period relapses w/d complications screening CAGE MAST DAST AUDIT |
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Intrinsic abuse liability
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Pharmacokinetic determinants
Onset of action, inhalation>IV/nasal>IM/SQ>PO, half life Pharmacogenetic determinants SE Asia - high % of ppl with deficient enzymes to process alcohol Gender specific |
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Connectivity of brain with SUD
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VTA to nucleus accumbens to prefrontal cortex
Also stimulate by food nurturing and sex Memory centers hippocampus and amygdaloid are integral Cues assoc with use can activate The reward draft this can evoke desire to use when presented with cues assoc with use or emotional stressors Presentation of cues assoc with buyer increases extra cellular levels of DA in the nucleus accumbens and amygdala and increases drug seeking bhxs |
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Neurotransmitter involved in substance abuse
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DA
Endorphins NE Serotonin GABA Glutamate - |
