Assement of aging

Measurement of function is preferred

function types

(3)

Physical  function = evaluated through one's ability to comple bsic and instrumental activities of daily living (ADL's and IADL's). Also screened for falls with instruments to evaluate gait and balance

Mental function = evaluated with mental status exams and addtional screens for

depression

Medical = evaluation of pat's med regimen

Physiologic Changes with age that may change pharmacokinetics.

(GI, skin, body compostion,liver,renal)

Absorption changes

with aging

(oral, transdermal)

1. Iron, vit b12 & calcium decreased with hypo or achlorhydria. 
2. Most drugs ar absorbed by passive diffusion without sig changes with aging
3. Transdermal formulations often require a subcut fat layer to for drug reservoir for absorbtion.

Metabolism

changes with aging

1. Morphine and propranolol are substantially reduced because of reduction in 1st pass metabolism
2. Changes in metabolism through phase I (oxicdative) and cyp 450 enzymes are variable and confounded by age,sex, concomitant drugs and genetics.

Elimination

changes with aging

1. cockcoft-Gault most accepted method for est crcl in the elderly
2. Four-variable mod of diet in renal disease equation is the most accpeted method  to estimate gfr for dianosing chronic kid disease
3. Dose med as needed using est renal function

Distribution

alterations with aging

1. Lipid soluble benzos have increased half-life
2. Highly albumin bound drugs such as phenytoin may have larger fraction of free drug (less albumin in elderly)
3. Basic drugs such as propranolol may have decreased free fraction because of changes in glycoprotien concentrations
4. p-glycoprotein, an efflux tansporter for the brain may be decreased with aging, which may lead to higher brain concentrations

eGFR=

186 * (serum creat)^-1.154 * (age)^-0.203  * (0.742 if female) * (1.210 if african american)

Function and Medications

Mobility

3 areas

1.  Bone and Muscle integrity
2. Balance/dizziness/falls
3. extrapyramidal symptoms

Mobility

Bone and Muscle integrity-Meds that impair

1. Glucocorticosteroids
2. long term use of ppi
3. phenytoin

Mobility

Bone and Muscle integrity-Interventions that promote function

1. Vitamin d
2. calcium
3. bisphosphonates

Mobility

Balance/dizziness/falls-Interventions that promote function

Mental state

meds that impair function

anticholinergics

antimuscarinic

benzos

pentazocine

skeletal muscle relaxants

tricyclics, esp amitryptyline

gastrointestinal antispasmodics

anihistamines, esp diphenydramine

Mental state

Interventions that promote function

Emotional

Drugs that may impair function

Methyldopa

reserpine

anastrozole

interferon

tamoxifen

Emotional state

Interventions that may promote Function

Continence

Drugs that may impair function

Anticholinergics

alpha-blockers

alpha-agonists

Most common types of dementia

(4)

Alzheimer's

Lewey Body dementia

vascular causes of dementia

Pick's disease

Alcohol abuse

normopressure hydrocephalus

thyroid dysfunction

Dehydration and electrolyte distrubance

vit B-12 deficiency

medications

Medications that commonly cause mental status changes in the elderly

Anticholinergics and drugs with    anticholinergic  properties

Narcotics

Glucocorticosteroids

Benzos and sedative/hypnotics

some NSAID's

Common assessment instruments used for Alzheimer's disease.

Mental state assessment (MMSE)

(2)

Folstein MMSE - range 0-30, higher scores indicate better mental functioning

ADAS-cog (Alzheimer's desease assessment scale-cognitive) - range 0-70, higher scores indicate better mental functioning.

Katz ADL's

Various scales to measure IADL's

Neuopsychiatric inventory- NPI ranges from 10-120, higher scores indicate more severe behavior problems

Behavioral pathology in Alzheimer's disease -ranges from 0-75 with higher scores indicate more behavioral problems

Folstein Mini-Mental State Exam

ranges

Mild 20-24          loss of IADL's

Moderate 10-19   needs assit with ADL's

Severe <10         Dependency in basic ADL

Alzheimer Meds

2 types

Cholinesterase inhibitors

Glutamatergic therapy

Alzheimer's Disease Meds-Cholinesterase Inhibitors

(3)

Donepezil-aricept

Rivastigmine-Exelon

Galantamine-Razadyne

Alzheimer's Disease meds

Cholinesterase inhibitors

Donepezil

(starting dose,maint dose,dosage forms,stage indicated,comments)

Starting:   5mg

Maint:      10mg (up to 23mg)

Dosage forms: oral, ODt

Stage: mild, moderate, severe

Comments: Risk of Bradycardia,syncope.               May be use in combination with               Memantine.

Alzheimer's treatment pearls

(7)

1. Start with cholinesterase inhib in mild to mod affected patients.
2. No cholinesterase inhib is proven to be  better than another.
3. Results for memantine are similar to those for cholinesterase inhib, but only indicated in mod-severe.
4. Patients usually have statistically sig changes in measures of cognition, gloabal assessment and occasionally ADL function. NOT usually clinically meaningful.
5. Evaluate at 3-6 months for stabilization or improvement.
6. Conflicting evidence for discontinuation of meds should a patient decline or become unresponsive to treatment.
7. when prevention is no longer a therapeutic goal for a patient, consider discontinuing meds, a taper recomended for patients at higher doses. Rebound agitation may occur for the first 1-2 weeks.

Dementia

Behavioral symptoms

2 types

Psychosis

Agitation

Dementia 

Psychosis Behaviorial symptoms

(3)

Delusions

paranoia

Hallucinations

Dementia

Agitation Behavioral symptoms

(4)

aggression and combativeness

hyperactivity (wandering & pacing)

Hyper-vocalization

disinhibition

NPI 144 scale

BEHAVE-AD 75 scale

CMAI 203 scale

higher the numer, more severe behavioral problems