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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. what nutritional interventions help underweight?
3 reflexes: baroreceptor - renal nerve - ANF
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Isolated systolic HTN
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

2. What is the preferred depression treatment in elderly?
3 reflexes: baroreceptor - renal nerve - ANF
Therapy - SSRI
^SV (diastolic stroke volume)
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

3. elderly abuse epidemiology
5% - underreported
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Serum Cr: used for Cr clearance equation
Electrolyte imbalance - arrhythmia

4. which benzodiazepines are most appropriate for elderly?
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Determined by Dr for a patient - -> used to determine competency
Stress: #1 - functional - urge - overflow
P2-metab: Lorazepam - Trazepam - Oxazepam

5. What are the rf for caregiver to abuse elderly?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Begin @25-50% recommended dose - APAP may be dose-limiting
P2-metab: Lorazepam - Trazepam - Oxazepam

6. lipid-soluble Rx
^ANS tone -> ^periph vasoconstriction - ^HR
Hypothetical plan - serves as patient's last competent indicated wishes
Treat underlying disease/lack resources
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

7. What are the risks of uncontrolled ISH?
Hypotension - ^K+
Worse for cardiac causes v noncardia
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
CVA: stroke - AMI: acute MI - HF

8. advanced directive/care plan

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9. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

10. i2 + atypical Sx
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

11. MI + atypical Sx
^K+
Cholinesterase inhib - use: dementia
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

12. Presyncope
Breast cancer + 2o LBP
Phenytoin
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Confusion - sedation - falls

13. vertigo
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

14. What is the STOPP criteria?
Cholinesterase inhib - use: dementia
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
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Breast cancer + 2o LBP

15. refusing intervention
Hypotension - ^K+
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Figure out a good diet - social aspect - resources - dental/oral comfort
Legal: Cruzan v Hamon

16. What are the possible cardiac causes of presyncope?
80% of hospital admission for syncope for >65yo
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Electrical: change in HR - structural: aortic outflow obstruction
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

17. What are common physical abuse Sx in elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
Cholinesterase inhib - use: dementia
Phenytoin
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

18. how is cachexia different from wasting?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

19. dementia tx
Tx underlying etio - + Kegels - pessary - surgery
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

20. delirium: Rx that contribute
^SV (diastolic stroke volume)
Bone loss -> osteopenia -> osteoporosis -> Fx
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
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. how can you determine whether Rx is appropriate to use in elderly patient?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Beers criteria - medication appropriateness index (12 ?)
Injury - neglect - physical/psychosocial - financial - violation of rights

22. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
^ANS tone -> ^periph vasoconstriction - ^HR
Voice - character - plot - context - time - reader
30% preventable - of these - 40% serious - of these 40% preventable

23. delirium predisposing rf
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

24. describe the % of ADR considered preventable - and of those serious
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Worse for cardiac causes v noncardia
30% preventable - of these - 40% serious - of these 40% preventable
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

25. what professional is least likely to report abuse?
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Doctors
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Legal: Cruzan v Hamon

26. what normally prevents syncope?
30% preventable - of these - 40% serious - of these 40% preventable
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
3 reflexes: baroreceptor - renal nerve - ANF

27. How does the aging heart compensate for lower HR to maintain unchanged CO?
Parkinsonism -> l-DOPA
^SV (diastolic stroke volume)
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

28. How does aging affect Rx pharmacokinetic metabolism?
80% of hospital admission for syncope for >65yo
Parkinsonism -> l-DOPA
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Environment modification: obstacles - mobility - -bladder fcn ok

29. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
Phenytoin
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

30. lightheadedness
Catch-all of unspecified dizziness
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Phenytoin
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

31. Beers criteria
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
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
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Therapy - SSRI

32. who is a good candidate for opioid tx?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
5% - underreported
Consider responsibilities - drivin
>60yo - low abuse risk - ^ monitoring possible

33. NSAID may lead to what prescription cascade?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
^BP -> a-HTN
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
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

34. How does aging affect GI absorption of Rx?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

35. urge incontinence tx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
NMDR antagonist - use: dementia
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Injury - neglect - physical/psychosocial - financial - violation of rights

36. tube feeding
Temporalis muscle wasting = temporal wasting
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
^morbidity + mortality - -frailest @ greatest risk

37. What are the narrative elements of clinical ethics?
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Voice - character - plot - context - time - reader
A-blockers - B-blockers - TCA
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

38. acute abdomen + atypical Sx
ANF: Na+ retention - disinhib vasoconstriction
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
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
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

39. Disequilibrium
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Legal: Cruzan v Hamon
Vertigo - presyncope - disequilibrium - lightheadedness

40. preventing malnutrition
Cholinesterase inhib - use: dementia
Diagnosis - risk/benefit analysis to choose Rx
Figure out a good diet - social aspect - resources - dental/oral comfort
Beers criteria - medication appropriateness index (12 ?)

41. What is polypharmacy
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Mechanical loading - skin care - avoid friction/shear
>9 Rx

42. how is syncope related to elderly admission to hospital?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Cachexia - PEM - FTT - obesity
Parkinsonism -> l-DOPA
80% of hospital admission for syncope for >65yo

43. What is the natural history of syncope?
Beers criteria - medication appropriateness index (12 ?)
Insiduous onset
Serum Cr: used for Cr clearance equation
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

44. How does aging affect pharmacokinetic Rx distribution?
Electrical: change in HR - structural: aortic outflow obstruction
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Beers criteria - medication appropriateness index (12 ?)

45. How does renal nerve prevent syncope?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
A-blockers - B-blockers - TCA
Insiduous onset

46. what receptors decrease sensitivity with aging?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Falls - delirium - malnutrition - P ulcers - opportunistic i2
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
High mortality - esp + Fx - very common in elderly

47. falls epidemiology
Therapy - SSRI
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

48. osteoporosis
Map of people - perceptions - etc - varies by perspective
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Destrusor overactivity -> urge - BPH -> overflow - more urine output later in day - atrophic vaginitis - ^PVR: post-void residual -> overflow - v total bladder capacity -> overflow - v sphincter tone -> stress
Cholinesterase inhib - use: dementia

49. malnutrition
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Pressure ulcer - fecal impaction - dehydration

50. frailty raises vulnerability to...
Voice - character - plot - context - time - reader
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible