Rr-Symptoms-Geriatric-Syndrome

Front 1

Iatrogenic Illness among elderly

Back 1

- Nearly 1 in 3 acutely hospitalized patients
- Adverse drug reactions are the most common iatrogenic illness
- Results are function losses and increased costs

Front 2

Polypharmacy Stats for old people

Back 2

AV 4.5 prescription drugs
12-17 prescription annually
Use over 25% of all prescription meds
Use 3.5 OTC

Front 3

5 I's associated with the elderly

Back 3

Iatrogenic
Immobility
Incompetence
Impaired Homeostasis
Incontinence

Front 4

Illnesses associated with elderly

Back 4

Infection
Physical (trauma)
Immunologic
Neoplastic
Geriatric (metabolic)
Iatrogenic
Psychiatric
Idiopathic

Front 5

Back 5

Front 6

Mrs. J is an 89 year old woman with
hypothyroidism. She is on replacement with
Synthroid 0.20 mg qd. She recently had a hip
fracture which was repaired. She has noted weight
loss, jittery feelings, and malaise.


Which of the following pharmacokinetic changes with aging accounts for her fracture and symptoms?

Back 6

Volume of Distribution

Front 7

Factors affecting drug disposition and response in the elderly

Back 7

Distribution:

- Body composition
- Reduced total body water
- Reduced lead body mass/kg
- Body weight
- Increased body fat
- Protein binding
- Reduced serum albumin

Front 8

Mr S is a 72 year old man with severe COPD. He is
O2 dependent. He is on multiple bronchodilators.
You are also forced to use steroids to treat his
symptoms and cannot wean him. You decide to use
high dose vitamin D to try to antagonize the effects
of the steroid on bone. On an office visit, his wife
reports he is lethargic.

Back 8

Pharmacokinetic change seen with aging that can affect vit D -- can lead to hypercalcemia.

Lethargy can be due to hypoxia, enemia, muscargenics (due to bronchodilators)

Front 9

Back 9

Front 10

The use of triazolam has been associated with what side effect?

Back 10

Daytime drowsiness

Front 11

1. Which of the following medications should be avoided as hypnotics in older patients?
a. diazepam
b. flurazepam
c. oxazepam
d. lorazepam

Back 11

Diazepam and Flurazepam -- long acting
Phase I Metabolism (affected by aging)

Front 12

Phase II: Hepatic Metabolism

Back 12

- Mediated by cytoplasmic enzymes
- Addition of water soluble moieties to drug (e.g: acetylation, glucuronication, sulfation, glycine conjugation)
- Not commonly altered with age

Front 13

Mrs K is an 80 year old woman living in a nursing home with dementia. She spikes a 103 degree fever and is admitted to your service.

What are the considerations for Mrs K’s fever?

Back 13

Pneumonia
UTI
Pressure Ulcer
GI - C. diff
B symptoms of lymphoma
Pulmonary Embolus
Autoimmune issues - RA

Front 14

Mrs K has a serum creatinine of 1.0mg/dl. She weighs 72 kg. You feel she needs gentamicin. How do you go
about dosing her? How would your approach differ is
she were 40 years old? How would you follow her?

Back 14

Creatinine clearance decreased with age. Less drug is excreted with age. Decreased dosage for older people.

If you dose her too high can result in nephrotoxicity (gentamicin is aminoglycoside)

Front 15

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Front 16

Pharmacokinetics

Back 16

Processes of drug absorption, distribution and elimination from the body

Front 17

Pharmacodynamics

Back 17

Target organ sensitivity to drug

Front 18

Pharmacodynamic issues

Back 18

- Receptors and receptor binding
- Translation of receptor initiated response into biochem rxn
- Cellular response to biochemical event

Front 19

Mr T is a 75 year old man with new onset of atrial
fibrillation. You decide to cardiovert him. You use I.V.
valium for sedation. You aim to achieve a blood level of drug that has worked well for you in the past. To your surprise, his plane of anesthesia is deeper than you predicted. He has respiratory failure and must be
intubated and placed on a ventilator.

What went wrong? Does the problem have a
pharmacokinetic basis?

Back 19

Organ sensitivity to drug
Pharmacodynamics helps to explain the problem

Front 20

Increased pharmacodynamic sensitivity

Back 20

Benzos
Anesthetic
Opioids
Dihydropyridines (transient in naive patients)

Front 21

Mr Y is a 78 year old man who has lung cancer
with metastases to the brain. You administer
decadron with good effect and he receives
radiation for palliation. Two weeks later, he
becomes lethargic.

What pharmacodynamic effect of aging might
explain his picture?

Back 21

Counter regulatory to insulin. Can become hypoglycemic and that made him lethargic

Front 22

Decreased pharmacodynamic sensitivity

Back 22

Can affect the beta adrenergic receptor

Front 23

Mrs B is an 88 year old woman with pernicious anemia, arthritis, atherosclerotic heart disease, and hypertension. She is managed with vitamin B12, ibuprofen, aspirin, nifedipine, and a thiazide diuretic. She has noted some insomnia so flurazepam is prescribed. She gradually becomes depressed. Her appetite is poor and she is non functional. Emergent ECT is considered.

What would be your approach to this patient?

Back 23

Flurazepam caused the side effect.

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Front 25

Avoiding adverse drug effects in older patients

Back 25

- Start low, go slow
- Watch for key risk factors:
-- greater than or equal to 6 concurrent chronic diagnoses
-- greater than or equal to 12 doses of meds per day
-- greater than or equal to 9 drugs
-- 1 prior drug reaction
-- low body weight or bmi
-- age 85 or older
-- estimated CrCl < 50 mL/min

** worry most about GFR, then vol of distribution, then hepatic metabolism

Front 26

Primary Frailty

Back 26

Intrinsic to the aging process
A physiologic process with mult-factorial conrtibuting cases

Front 27

Secondary Frailty

Back 27

Associated with progression or end-stage of chronic progressive disease associated with inflammation and wasting:

For ex:
- HIV/AIDS
- COPD
- Cancer
- Dementia

Front 28

Domains affects by Frailty

Back 28

Balance
Motor speed and processing
Strength and endurance
Nutrition
Mobility
Physical activity
Cognition

Front 29

Frailty Syndrome

Back 29

As an operational phenotype:
Shrinking: weight loss: unintention > 10lbs per year
and sarcopenia
Weakness
Poor endurance
Low Activity

Front 30

Sarcopenia

Back 30

Low muscle mass: > 2SD below the mean measured in young adults aged 18-39
Low muscle function defined by low gait speed - rate of < 0.8 m/s in the 4 m walk test

Front 31

Weakness

Back 31

Grip strength: lowest 20% by gender and BMI

Front 32

Poor Endurance

Back 32

Exhaustion by self-report
Slowness: walking time/15ft - slowest 20% by gender and height

Front 33

Low Activity

Back 33

Caloric intake - lowest 20$
- Males < 383 Kcal/wk
- Female < 270 Kcal/wk

Front 34

Scoring of frailty

Back 34

Greater than or equal to 3 items = frail
1-2 : hypothesized "pre-fail"
0 : robust

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Back 35

Front 36

Rockwood Frailty Index

Back 36

Accumulation of comorbidities

Front 37

Frailty Index

Back 37

accumulation of deficits. “Studies of frailty as deficit
accumulation demonstrate remarkable consistency in
how deficits accumulate with age, the limit to how
many things can go wrong, and how deficit counts
change over time.”

Front 38

Comorbidity Accumulation

Back 38

Highest weight on sensory loss and self-perceived health
Next highest on loss of ADL abilities - "disability"
Next is systemic dysfunction - either diagnosed comorbidities like PD, or functional complaints

Front 39

Proposed Pathophysiology of Frailty

Back 39

Balance between stressor reactions of senescence or apoptosis across the musculoskeletal, immunologic, and neuroendocrine systems.

Front 40

Musculoskeletal pathophysiology of frailty

Back 40

• Decreased skeletal muscle mass
• Decreased VO2 max
• Decreased strength and exercise tolerance
• Diminished thermoregulation
• Decreased energy expenditure and resting metabolic rate
• Diminished muscle innervation
• Decreased glucose uptake

Front 41

Immunologic Pathophysiology of Frailty

Back 41

• Immunologic

• Decrease:
• IgG
• IgA
• IL-2
• Mitogen response

• Increase:
• IL-6
• IL-10
• CRP

Front 42

Neuroendocrine Pathophysiology of Frailty

Back 42

• Decrease:

• GH
• IGF1
• Vitamin D
• Estrogen / Testosterone (DHEA-S)

• Increased

• Insulin resistance
• Cholecystokinin
• Sympathetic tone
• Steroid dysregulation

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Front 44

Gavrilov and Gavrilova – reliability theory.

Back 44

• Aging is the progressive accumulation of random damage to a complex system of
redundant parts.
• Accumulation of damage and defects over time (aging) reduces this redundancy
until the system becomes a series of elements connected in series.
• The system’s loss of redundancy and resilience lead to vulnerability from external
or internal stressors.
• Loss of adaptability reduces responses to stressors to the equilibrium, eventually
pushing systems (organs) to failure thresholds with an increased risk of adverse
outcomes.
• THIS IS FRAILTY

Front 45

Co-occurance Secondary Fraily

Back 45

Interplay and co-occurence of multiple diseases, particularly
• Myocardial infarction
• Angina
• CHF
• Claudication
• Arthritis
• Cancer
• Diabetes
• Hypertension
• COPD

Front 46

Symmorphosis

Back 46

• The multisystem interplay and “coadjustment” of different organs and functions relative to energy available for an organism.

• Example: exercise increases O2 requirement above baseline, with resultant changes in cardiac output, capillary density, hematocrit, muscle mitochondrial count and capacity. This is measured as VO2 max.

Front 47

Causes of Frailty

Back 47

Genetic
Disease and Injury
Lifestyle
Aging

Rate of Change

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Back 48

Front 49

At risk populations for aging

Back 49

- Female
- AA
- Low Education
- Low Income
- Poorer Health
- Increased comorbid chronic disease
- Increased disability
- Impaired cognition
- Increased depressive symptoms

Front 50

Defined Risk Areas

Back 50

Falls
Hospitalization
Disability
Death

Front 51

Assessment of Frailty

Back 51

• Medical domain
• Chronic illnesses
• Falls
• Medications
• Cognitive/psychiatric domain
• Cognitive impairment / dementia
• Delirium
• Depression
• Substance abuse
• Functional domain
• Sensory deficits - especially vision and hearing
• Slowed gait, weakness, and decreased physical activity
• ADL and IADL function
• Weight loss / malnutrition
• Social domain
• Social history

Front 52

Frailty Exam

Back 52

General Exam with additional focus on:
Neuro-cognitive: cognitive testing, depression screens
• Sensory: vision, hearing
• Function: strength (especially thigh muscles and grip), range of motion (shoulders, hips, and knees), walking speed

Front 53

Labs to order

Back 53

CBC
Metabolic Panel
Inflammatory markers: CRP, ESR
25-OH D3
B12, folate
TSH
Any testing targeting chronic disease conditions

Front 54

Management of Frailty

Back 54

Treat modifiable risk factor
Improve core manifestations
-- exercise tolerance and endurance, physical activity, nutrition
Minimize risks and stressors

Front 55

Treat frailty as?

Back 55

Chronic Disease - focus on areas of impact
- Exercise programs
- Comorbid disease risk factor improvement
- Optimize access to nutrition and socialization
Frailty is a syndrome
Frailty is dynamic