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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 normally prevents syncope?
Insiduous onset
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
3 reflexes: baroreceptor - renal nerve - ANF
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

2. What are the key points of safe prescription for elderly - lecture
1/2
Diagnosis - risk/benefit analysis to choose Rx
^morbidity + mortality - -frailest @ greatest risk
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

3. How does aging affect Rx pharmacokinetic metabolism?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Delayed absorption - like competitive inhib

4. How does aging affect pharmacokinetic Rx distribution?
NMDR antagonist - use: dementia
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Screen for potentially embarrassing dx - patient/Dr trust

5. PEM
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
^K+
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

6. What is the best approach to malnutrition
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Treat underlying disease/lack resources
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

7. How does aging impact syncope-preventing reflexes
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Screen for potentially embarrassing dx - patient/Dr trust

8. Alb-bound Rx
Phenytoin
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
3 reflexes: baroreceptor - renal nerve - ANF

9. what nutritional interventions help underweight?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Therapy - SSRI
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

10. documenting elderly abuse

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11. How does the aging heart compensate for lower HR to maintain unchanged CO?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Parkinsonism -> l-DOPA
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
^SV (diastolic stroke volume)

12. rivastigmine
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Cholinesterase inhib - use: dementia
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

13. osteoporosis
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

14. pulm edema + atypical Sx
Insiduous onset
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
High mortality - esp + Fx - very common in elderly
>9 Rx

15. How does aging affect Rx renal elimination?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Vertigo - presyncope - disequilibrium - lightheadedness
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

16. who is a good candidate for opioid tx?
Vertigo - presyncope - disequilibrium - lightheadedness
Receptors changes: # - sensitivity - counter-regulatory moa
Appointed by court if no substituted judgment -conservator of finance -conservator of person
>60yo - low abuse risk - ^ monitoring possible

17. nutrition syndromes
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Cachexia - PEM - FTT - obesity
Make sure to discuss with patient - some states require reporting
Hypotension - ^K+

18. urge incontinence tx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
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
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

19. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
Mechanical loading - skin care - avoid friction/shear
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Confusion - sedation - falls

20. LBW equation
CNS suppression -> cholinesterase inhibitors
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Stress: #1 - functional - urge - overflow
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

21. What are the risks of uncontrolled ISH?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Cholinesterase inhib - use: dementia
CVA: stroke - AMI: acute MI - HF

22. incontinence epidemiology
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
28% - ADR: 17% - non-compliance 11%
Doctors
F>M (until 80yo) - stress incontinence #1 - $26B/yr

23. what professional is least likely to report abuse?
Diagnosis - risk/benefit analysis to choose Rx
Doctors
CVA: stroke - AMI: acute MI - HF
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

24. stress incontinence tx
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Tx underlying etio - + Kegels - pessary - surgery
Determined by Dr for a patient - -> used to determine competency
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

25. cachexia
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
P2-metab: Lorazepam - Trazepam - Oxazepam
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

26. fall causes
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
ANF: Na+ retention - disinhib vasoconstriction
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Temporalis muscle wasting = temporal wasting

27. What is the natural history of syncope?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Universal - progressive - partially encoded (genetic) - destructive -
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

28. What are common scenarios of untreated indications in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Determined by Dr for a patient - -> used to determine competency
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

29. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Isolated systolic HTN

30. Beers criteria: what 10 Rx should elderly avoid or use + caution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
30% preventable - of these - 40% serious - of these 40% preventable
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

31. What are the rf for caregiver to abuse elderly?
Serum Cr: used for Cr clearance equation
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Tx underlying etio - + Kegels - pessary - surgery

32. fall sequelae

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33. What is the preferred depression treatment in elderly?
Beers criteria - medication appropriateness index (12 ?)
Hyperuricemia -> gout
Therapy - SSRI
Worse for cardiac causes v noncardia

34. What is the bone deterioration cascade?
Legal: Cruzan v Hamon
^morbidity + mortality - -frailest @ greatest risk
Bone loss -> osteopenia -> osteoporosis -> Fx
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

35. What is abuse?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Injury - neglect - physical/psychosocial - financial - violation of rights
Stress: #1 - functional - urge - overflow

36. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Insiduous onset

37. Presyncope
Determined by Dr for a patient - -> used to determine competency
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Worse for cardiac causes v noncardia
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

38. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
>60yo - low abuse risk - ^ monitoring possible
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Cholinesterase inhib - use: dementia

39. What are the 4 forms of dizziness?
^K+
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Vertigo - presyncope - disequilibrium - lightheadedness

40. substituted judgment
^BP -> a-HTN
Cholinesterase inhib - use: dementia
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
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

41. elderly abuse epidemiology
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
>9 Rx
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
5% - underreported

42. physical neglect
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

43. how is the CAM used to diagnose delirium?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

44. preventing malnutrition
#1 patient's last competent indication of wishes - substituted judgment - beneficence
A-blockers - B-blockers - TCA
Figure out a good diet - social aspect - resources - dental/oral comfort
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

45. What are the narrative elements of clinical ethics?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Voice - character - plot - context - time - reader
Constipation -> laxatives

46. Syncope prognosis based on etio
5% - underreported
Worse for cardiac causes v noncardia
Cachexia - PEM - FTT - obesity
Bone loss -> osteopenia -> osteoporosis -> Fx

47. Cockcroft Gault equation
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
No: fever - leukocytosis - yes: falls - appetite change - low functional status
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

48. What is a mattering map?
^BP -> a-HTN
^morbidity + mortality - -frailest @ greatest risk
Map of people - perceptions - etc - varies by perspective
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

49. restrain requirements
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Constipation -> laxatives

50. What is the STOPP criteria?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
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