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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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Match each statement with the correct term.
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1. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Environment modification: obstacles - mobility - -bladder fcn ok
Mechanical loading - skin care - avoid friction/shear
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

2. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Used to calculate renal fcn - clearance of Cr adjusted for age

3. Beers criteria
Vd v plasma prot-binding: usually ^Vd - when prot-binding significant: changes in enzymes - changes in metab/elim - lab value interp (total v free) - ^t1/2
Hypothetical plan - serves as patient's last competent indicated wishes
Reduce exposure to PIM: pot inapprop med - category 1: avoid in elderly regardless of dx - category 2: pot inapprop dept on dx - category 3: used with caution
5% - underreported

4. vision changes: elderly
^morbidity + mortality - -frailest @ greatest risk
>9 Rx
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

5. delirium: Rx that contribute
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
>9 Rx
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

6. fall sequelae

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7. what ADR are common in elderly patient?
>9 Rx
Hyperuricemia -> gout
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
No: fever - leukocytosis - yes: falls - appetite change - low functional status

8. galantamine
Cholinesterase inhib - use: dementia
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
High mortality - esp + Fx - very common in elderly
Bone loss -> osteopenia -> osteoporosis -> Fx

9. falls epidemiology
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Cholinesterase inhib - use: dementia
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

10. How to prevent pressure ulcers?
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Mechanical loading - skin care - avoid friction/shear
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

11. frailty
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Multisystemic vulnerability - -lowered reserves
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

12. fall causes
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

13. opioid tx in elderly
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Begin @25-50% recommended dose - APAP may be dose-limiting
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

14. Syncope prognosis based on etio
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Worse for cardiac causes v noncardia
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Respect for autonomy - nonmaleficence - beneficence - justice

15. How does the aging heart compensate for lower HR to maintain unchanged CO?
^K+
^SV (diastolic stroke volume)
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
3 reflexes: baroreceptor - renal nerve - ANF

16. What is polypharmacy
P2-metab: Lorazepam - Trazepam - Oxazepam
1/2
>9 Rx
Falls - delirium - malnutrition - P ulcers - opportunistic i2

17. How does baroreceptor reflex prevent syncope?
Used to calculate renal fcn - clearance of Cr adjusted for age
^ANS tone -> ^periph vasoconstriction - ^HR
CNS suppression -> cholinesterase inhibitors
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

18. What is a PE sign of cachexia?
Determined by Dr for a patient - -> used to determine competency
Temporalis muscle wasting = temporal wasting
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Injury - neglect - physical/psychosocial - financial - violation of rights

19. delirium: mgmt
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Bone loss -> osteopenia -> osteoporosis -> Fx
Voice - character - plot - context - time - reader
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

20. What is the STOPP criteria?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Therapy - SSRI
PPI: PUD uncomplicated >8wk - aspirin wo CAD/CVA/PVD - duplicate Rx - loop diuretics LT: HTN; can use for ankle edema - LT NSAID use (>3mo): mild OA - falls: BZD - opiates - neuroepileptics - vasodilators: orthostatic patient risk

21. What are the key points of safe prescription for elderly - lecture
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Diagnosis - risk/benefit analysis to choose Rx
Phenytoin
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

22. surrogate decision making heirarchy

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23. Cockcroft Gault equation
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

24. frailty signs
Pressure ulcer - fecal impaction - dehydration
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Vd v plasma prot-binding: usually ^Vd - when prot-binding significant: changes in enzymes - changes in metab/elim - lab value interp (total v free) - ^t1/2
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

25. metoclopramide may lead to what prescription cascade?
Written doc - don't alter it - pertinent +/- - use patient/caregiver's own words - photos - report: concise - precise - likeliness of abuse: definite/accident/indeterminate - body map for forensic documentation
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Parkinsonism -> l-DOPA

26. substituted judgment
IdioPx - psychiatric: depression - anxiety - somatoform
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Doctors
Injury - neglect - physical/psychosocial - financial - violation of rights

27. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Make sure to discuss with patient - some states require reporting
Cachexia - PEM - FTT - obesity

28. donepezil
Voice - character - plot - context - time - reader
CNS suppression -> cholinesterase inhibitors
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Cholinesterase inhib - use: dementia

29. cachexia
IdioPx - psychiatric: depression - anxiety - somatoform
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
^BP -> a-HTN
No: chest pain - yes: fatigue - nausea - low functional status - SOB

30. nutrition syndromes
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Cachexia - PEM - FTT - obesity

31. what drugs can cause dizziness?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Screen for potentially embarrassing dx - patient/Dr trust

32. MI + atypical Sx
Injury - neglect - physical/psychosocial - financial - violation of rights
No: chest pain - yes: fatigue - nausea - low functional status - SOB
IdioPx - psychiatric: depression - anxiety - somatoform
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

33. acute abdomen + atypical Sx
Electrolyte imbalance - arrhythmia
^ANS tone -> ^periph vasoconstriction - ^HR
ANF: Na+ retention - disinhib vasoconstriction
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

34. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Hypotension - ^K+

35. What is the bone deterioration cascade?
Prescribing - monitoring - patient adherence
ANF: Na+ retention - disinhib vasoconstriction
Isolated systolic HTN
Bone loss -> osteopenia -> osteoporosis -> Fx

36. vertigo
Make sure to discuss with patient - some states require reporting
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Isolated systolic HTN
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

37. What is the epidemiology of dizziness?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
A-blockers - B-blockers - TCA
Receptors changes: # - sensitivity - counter-regulatory moa

38. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
Cholinesterase inhib - use: dementia
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

39. What are the pharmacodynamic changes associated with aging?
Make sure to discuss with patient - some states require reporting
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Receptors changes: # - sensitivity - counter-regulatory moa

40. what receptors increase sensitivity with aging?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

41. elderly abuse epidemiology
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
5% - underreported
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

42. what illnesses are underreported in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

43. BZD + antidepressant: interaction outcome
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Confusion - sedation - falls
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Appointed by court if no substituted judgment -conservator of finance -conservator of person

44. osteoporosis
Appointed by court if no substituted judgment -conservator of finance -conservator of person
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Electrolyte imbalance - arrhythmia
BMD (bone mineral density): T-score >2.5 std dev below normal 1

45. ADR rf
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Mechanical loading - skin care - avoid friction/shear
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

46. Aging features
Threats/ terrorizing - isolation - denying food/privileges/liberty
CVA: stroke - AMI: acute MI - HF
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Universal - progressive - partially encoded (genetic) - destructive -

47. urinary incontinence types
Written doc - don't alter it - pertinent +/- - use patient/caregiver's own words - photos - report: concise - precise - likeliness of abuse: definite/accident/indeterminate - body map for forensic documentation
Stress: #1 - functional - urge - overflow
Breast cancer + 2o LBP
Figure out a good diet - social aspect - resources - dental/oral comfort

48. NSAID may lead to what prescription cascade?
^BP -> a-HTN
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

49. what mechanical loading helps to prevent pressure ulcers?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Used to calculate renal fcn - clearance of Cr adjusted for age

50. Alb-bound Rx
Legal: Cruzan v Hamon
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Phenytoin