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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 are the rf for caregiver to abuse elderly?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

2. malignancy + atypical Sx
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Breast cancer + 2o LBP
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
ANF: Na+ retention - disinhib vasoconstriction

3. How does aging increase incontinence?
Hypotension - ^K+
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
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

4. nutrition syndromes
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Cachexia - PEM - FTT - obesity

5. How does aging affect pharmacokinetics?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Phenytoin
ANF: Na+ retention - disinhib vasoconstriction

6. What are the rf for elderly abuse?
Determined by Dr for a patient - -> used to determine competency
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

7. Aging descriptors
ANF: Na+ retention - disinhib vasoconstriction
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

8. acute abdomen + atypical Sx
ANF: Na+ retention - disinhib vasoconstriction
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
1/2
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

9. NSAID may lead to what prescription cascade?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
^BP -> a-HTN
Threats/ terrorizing - isolation - denying food/privileges/liberty
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

10. PEM
Catch-all of unspecified dizziness
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

11. narcotics may lead to what prescription cascade?
Constipation -> laxatives
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Insiduous onset
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

12. What is capacity?
28% - ADR: 17% - non-compliance 11%
Determined by Dr for a patient - -> used to determine competency
ANF: Na+ retention - disinhib vasoconstriction
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

13. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Cholinesterase inhib - use: dementia

14. Why is abuse underreported?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Hyperuricemia -> gout
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

15. What is the bone deterioration cascade?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Prescribing - monitoring - patient adherence
Bone loss -> osteopenia -> osteoporosis -> Fx
^SV (diastolic stroke volume)

16. what drugs can cause dizziness?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Begin @25-50% recommended dose - APAP may be dose-limiting
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

17. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
P2-metab: Lorazepam - Trazepam - Oxazepam
Catch-all of unspecified dizziness
5% - underreported

18. Alb-bound Rx
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Phenytoin
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
P2-metab: Lorazepam - Trazepam - Oxazepam

19. frailty signs
>60yo - low abuse risk - ^ monitoring possible
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

20. How does renal nerve prevent syncope?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

21. galantamine
Electrical: change in HR - structural: aortic outflow obstruction
High mortality - esp + Fx - very common in elderly
Delayed absorption - like competitive inhib
Cholinesterase inhib - use: dementia

22. lipid-soluble Rx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Temporalis muscle wasting = temporal wasting
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

23. tube feeding
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

24. thyroid dx + atypical Sx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

25. what normally prevents syncope?
3 reflexes: baroreceptor - renal nerve - ANF
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Respect for autonomy - nonmaleficence - beneficence - justice
Parkinsonism -> l-DOPA

26. driving considerations
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Make sure to discuss with patient - some states require reporting
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Diagnosis - risk/benefit analysis to choose Rx

27. How does aging impact syncope-preventing reflexes
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Prescribing - monitoring - patient adherence
Confusion - sedation - falls

28. BZD + antipsychotic: interaction outcome
NMDR antagonist - use: dementia
Confusion - sedation - falls
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

29. osteoporosis etio
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

30. Beers criteria
CNS suppression -> cholinesterase inhibitors
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
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
Delayed absorption - like competitive inhib

31. What are the 3 stages of ADRs?
1/2
Treat underlying disease/lack resources
Prescribing - monitoring - patient adherence
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

32. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
^BP -> a-HTN

33. What is polypharmacy
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Stress: #1 - functional - urge - overflow
>9 Rx
Electrolyte imbalance - arrhythmia

34. What is sCr?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Serum Cr: used for Cr clearance equation
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

35. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Hypotension - ^K+

36. osteopenia
Vertigo - presyncope - disequilibrium - lightheadedness
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Injury - neglect - physical/psychosocial - financial - violation of rights

37. Presyncope
P2-metabolite - phase 1 biotx much more affected than phase 2
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Isolated systolic HTN

38. How does aging affect Rx pharmacokinetic distribution?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
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
Insiduous onset

39. What is ISH?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Cachexia - PEM - FTT - obesity
Isolated systolic HTN

40. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
CVA: stroke - AMI: acute MI - HF
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

41. What drugs can contribute to syncope?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Begin @25-50% recommended dose - APAP may be dose-limiting
A-blockers - B-blockers - TCA
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

42. MRP: medication related problems
3 reflexes: baroreceptor - renal nerve - ANF
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Hypotension - ^K+
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

43. What are the vascular changes of presyncope?
Vertigo - presyncope - disequilibrium - lightheadedness
Stress: #1 - functional - urge - overflow
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

44. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Environment modification: obstacles - mobility - -bladder fcn ok
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

45. violation of rights
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
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

46. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
High mortality - esp + Fx - very common in elderly
28% - ADR: 17% - non-compliance 11%

47. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Temporalis muscle wasting = temporal wasting
Treat underlying disease/lack resources
>9 Rx

48. Approach to idioPx - recurrent syncope
IdioPx - psychiatric: depression - anxiety - somatoform
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Consider responsibilities - drivin
Make sure to discuss with patient - some states require reporting

49. delirium: mgmt
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
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
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

50. preventing malnutrition
Make sure to discuss with patient - some states require reporting
Figure out a good diet - social aspect - resources - dental/oral comfort
Stress: #1 - functional - urge - overflow
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR