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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?
Parkinsonism -> l-DOPA
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

2. lipid-soluble Rx
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
^K+
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Electrolyte imbalance - arrhythmia

3. What are the 4 basic ethical principles?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Respect for autonomy - nonmaleficence - beneficence - justice
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

4. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
5% - underreported
Multisystemic vulnerability - -lowered reserves

5. What drugs can contribute to syncope?
Prescribing - monitoring - patient adherence
Cachexia - PEM - FTT - obesity
A-blockers - B-blockers - TCA
IdioPx - psychiatric: depression - anxiety - somatoform

6. LBW equation
Make sure to discuss with patient - some states require reporting
Parkinsonism -> l-DOPA
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

7. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Universal - progressive - partially encoded (genetic) - destructive -

8. malnutrition
Environment modification: obstacles - mobility - -bladder fcn ok
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Mechanical loading - skin care - avoid friction/shear

9. What is the natural history of syncope?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
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

10. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

11. What are common physical abuse Sx in elderly?
IdioPx - psychiatric: depression - anxiety - somatoform
P2-metabolite - phase 1 biotx much more affected than phase 2
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

12. what % of hospitalizations of elderly are due to ADR + noncompliance?
Vertigo - presyncope - disequilibrium - lightheadedness
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
28% - ADR: 17% - non-compliance 11%
1/2

13. How does aging increase incontinence?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
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
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

14. Alb-bound Rx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
5% - underreported
Phenytoin
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

15. What is a mattering map?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Map of people - perceptions - etc - varies by perspective
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Diagnosis - risk/benefit analysis to choose Rx

16. depression + atypical Sx
#1 patient's last competent indication of wishes - substituted judgment - beneficence
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Temporalis muscle wasting = temporal wasting
Cholinesterase inhib - use: dementia

17. galantamine
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Confusion - sedation - falls
Cholinesterase inhib - use: dementia
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

18. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
>9 Rx
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

19. What is capacity?
Determined by Dr for a patient - -> used to determine competency
Vertigo - presyncope - disequilibrium - lightheadedness
Isolated systolic HTN
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

20. delirium: medical rf
Serum Cr: used for Cr clearance equation
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

21. thiazide diuretic may lead to what prescription cascade?
Insiduous onset
Hyperuricemia -> gout
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

22. Cockcroft Gault equation
Hyperuricemia -> gout
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Screen for potentially embarrassing dx - patient/Dr trust

23. vision changes: elderly
CVA: stroke - AMI: acute MI - HF
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Diagnosis - risk/benefit analysis to choose Rx
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

24. What are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Consider responsibilities - drivin
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

25. What are the common causes of lightheadedness?
Diagnosis - risk/benefit analysis to choose Rx
IdioPx - psychiatric: depression - anxiety - somatoform
Electrolyte imbalance - arrhythmia
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

26. incontinence epidemiology
Worse for cardiac causes v noncardia
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Temporalis muscle wasting = temporal wasting
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

27. What are common medical causes of syncope?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Cholinesterase inhib - use: dementia

28. donepezil
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cholinesterase inhib - use: dementia
Phenytoin
Begin @25-50% recommended dose - APAP may be dose-limiting

29. delirium predisposing rf
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
3 reflexes: baroreceptor - renal nerve - ANF
P2-metabolite - phase 1 biotx much more affected than phase 2

30. psychological abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
>9 Rx

31. thyroid dx + atypical Sx
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Temporalis muscle wasting = temporal wasting
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

32. What is a PE sign of cachexia?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Temporalis muscle wasting = temporal wasting

33. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Doctors
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Cholinesterase inhib - use: dementia

34. Why is abuse underreported?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Determined by Dr for a patient - -> used to determine competency
Isolated systolic HTN

35. ACE inhib + K+: interaction outcome
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
^K+
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
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

36. BZD + antidepressant: interaction outcome
Hypotension - ^K+
Confusion - sedation - falls
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
80% of hospital admission for syncope for >65yo

37. How does the aging heart compensate for lower HR to maintain unchanged CO?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
^SV (diastolic stroke volume)
Therapy - SSRI
Constipation -> laxatives

38. ACE inhib + diuretic: interaction outcome
Begin @25-50% recommended dose - APAP may be dose-limiting
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Hypotension - ^K+

39. How does aging affect Rx pharmacokinetic metabolism?
5% - underreported
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

40. 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
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Constipation -> laxatives
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

41. What are rf for osteoporosis?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Catch-all of unspecified dizziness
Injury - neglect - physical/psychosocial - financial - violation of rights

42. documenting elderly abuse

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43. What are common scenarios of untreated indications in elderly?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

44. PEM
Cachexia - PEM - FTT - obesity
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

45. Disequilibrium
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
3 reflexes: baroreceptor - renal nerve - ANF
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

46. anticholinergic drugs may lead to what prescription cascade?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Voice - character - plot - context - time - reader
CNS suppression -> cholinesterase inhibitors
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

47. ADR rf
3 reflexes: baroreceptor - renal nerve - ANF
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
F>M (until 80yo) - stress incontinence #1 - $26B/yr
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

48. elderly abuse epidemiology
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Screen for potentially embarrassing dx - patient/Dr trust
5% - underreported

49. pulm edema + atypical Sx
P2-metabolite - phase 1 biotx much more affected than phase 2
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Insiduous onset
Stress: #1 - functional - urge - overflow

50. osteoporosis etio
Electrical: change in HR - structural: aortic outflow obstruction
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Determined by Dr for a patient - -> used to determine competency
Figure out a good diet - social aspect - resources - dental/oral comfort