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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 is the bone deterioration cascade?
Injury - neglect - physical/psychosocial - financial - violation of rights
Confusion - sedation - falls
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Bone loss -> osteopenia -> osteoporosis -> Fx

2. How does ANF prevent syncope?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
ANF: Na+ retention - disinhib vasoconstriction
Voice - character - plot - context - time - reader

3. What is sCr?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
5% - underreported
Serum Cr: used for Cr clearance equation
Appointed by court if no substituted judgment -conservator of finance -conservator of person

4. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Consider responsibilities - drivin
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

5. urinary incontinence types
Stress: #1 - functional - urge - overflow
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

6. Why is abuse underreported?
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
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

7. narcotics may lead to what prescription cascade?
Constipation -> laxatives
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Parkinsonism -> l-DOPA

8. Alb-bound Rx
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Phenytoin
Bone loss -> osteopenia -> osteoporosis -> Fx

9. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

10. How does the aging heart compensate for lower HR to maintain unchanged CO?
Electrical: change in HR - structural: aortic outflow obstruction
^SV (diastolic stroke volume)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Receptors changes: # - sensitivity - counter-regulatory moa

11. 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)
Bone loss -> osteopenia -> osteoporosis -> Fx
Cholinesterase inhib - use: dementia

12. physical neglect
^SV (diastolic stroke volume)
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Stress: #1 - functional - urge - overflow
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

13. What is polypharmacy
Vertigo - presyncope - disequilibrium - lightheadedness
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
>9 Rx

14. cachexia
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
5% - underreported
>60yo - low abuse risk - ^ monitoring possible
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

15. how may hypertension compensate for aging?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Determined by Dr for a patient - -> used to determine competency
Receptors changes: # - sensitivity - counter-regulatory moa
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

16. donepezil
Cholinesterase inhib - use: dementia
Multisystemic vulnerability - -lowered reserves
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Delayed absorption - like competitive inhib

17. describe the % of ADR considered preventable - and of those serious
Map of people - perceptions - etc - varies by perspective
30% preventable - of these - 40% serious - of these 40% preventable
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

18. nutrition syndromes
Bone loss -> osteopenia -> osteoporosis -> Fx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Determined by Dr for a patient - -> used to determine competency
Cachexia - PEM - FTT - obesity

19. BZD + antipsychotic: interaction outcome
Delayed absorption - like competitive inhib
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
Confusion - sedation - falls

20. How does aging affect pharmacokinetic Rx distribution?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

21. Disequilibrium
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

22. how is the CAM used to diagnose delirium?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

23. surrogate decision making heirarchy

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24. What are the common causes of lightheadedness?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Worse for cardiac causes v noncardia
IdioPx - psychiatric: depression - anxiety - somatoform
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

25. How does renal nerve prevent syncope?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Consider responsibilities - drivin
ANF: Na+ retention - disinhib vasoconstriction
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

26. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
>9 Rx

27. frailty signs
1/2
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Used to calculate renal fcn - clearance of Cr adjusted for age

28. metoclopramide may lead to what prescription cascade?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Make sure to discuss with patient - some states require reporting
Parkinsonism -> l-DOPA

29. what nutritional interventions help underweight?
>60yo - low abuse risk - ^ monitoring possible
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

30. what professional is least likely to report abuse?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Doctors

31. lipid-soluble Rx
28% - ADR: 17% - non-compliance 11%
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Phenytoin

32. how is cachexia different from wasting?
Confusion - sedation - falls
>60yo - low abuse risk - ^ monitoring possible
Injury - neglect - physical/psychosocial - financial - violation of rights
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

33. clues of neglect
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
CNS suppression -> cholinesterase inhibitors
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

34. driving considerations
Make sure to discuss with patient - some states require reporting
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Doctors
Catch-all of unspecified dizziness

35. using long-acting opioids in elderly
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Tx underlying etio - + Kegels - pessary - surgery
5% - underreported
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

36. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
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
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

37. What are common medical causes of syncope?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Isolated systolic HTN
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

38. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
>60yo - low abuse risk - ^ monitoring possible
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
^K+

39. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Parkinsonism -> l-DOPA

40. How does sliding scale glycemic control relate to elderly?
>60yo - low abuse risk - ^ monitoring possible
Stress: #1 - functional - urge - overflow
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

41. Beers criteria
Figure out a good diet - social aspect - resources - dental/oral comfort
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
Cholinesterase inhib - use: dementia
Hypotension - ^K+

42. How does baroreceptor reflex prevent syncope?
P2-metabolite - phase 1 biotx much more affected than phase 2
>60yo - low abuse risk - ^ monitoring possible
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
^ANS tone -> ^periph vasoconstriction - ^HR

43. thiazide diuretic may lead to what prescription cascade?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Hyperuricemia -> gout
Mechanical loading - skin care - avoid friction/shear

44. What are rf for osteoporosis?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Consider responsibilities - drivin
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

45. How does aging affect Rx pharmacokinetic metabolism?
80% of hospital admission for syncope for >65yo
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Cholinesterase inhib - use: dementia
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

46. LBW equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

47. delirium incidence
Delayed absorption - like competitive inhib
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Multisystemic vulnerability - -lowered reserves
Therapy - SSRI

48. What is the best approach to malnutrition
Beers criteria - medication appropriateness index (12 ?)
Delayed absorption - like competitive inhib
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Treat underlying disease/lack resources

49. overflow incontinence tx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

50. delirium: medical rf
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies