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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. osteopenia
Worse for cardiac causes v noncardia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
F>M (until 80yo) - stress incontinence #1 - $26B/yr

2. anticholinergic drugs may lead to what prescription cascade?
^BP -> a-HTN
F>M (until 80yo) - stress incontinence #1 - $26B/yr
CNS suppression -> cholinesterase inhibitors
No: chest pain - yes: fatigue - nausea - low functional status - SOB

3. dementia tx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Treat underlying disease/lack resources
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

4. stress incontinence tx
Cholinesterase inhib - use: dementia
Tx underlying etio - + Kegels - pessary - surgery
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Universal - progressive - partially encoded (genetic) - destructive -

5. pulm edema + atypical Sx
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Insiduous onset
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Diagnosis - risk/benefit analysis to choose Rx

6. What is a mattering map?
Make sure to discuss with patient - some states require reporting
Map of people - perceptions - etc - varies by perspective
ANF: Na+ retention - disinhib vasoconstriction
Legal: Cruzan v Hamon

7. What is a PE sign of cachexia?
Vertigo - presyncope - disequilibrium - lightheadedness
Parkinsonism -> l-DOPA
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Temporalis muscle wasting = temporal wasting

8. Aging descriptors
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
>9 Rx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

9. vision changes: elderly
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
30% preventable - of these - 40% serious - of these 40% preventable
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

10. How does aging affect Rx pharmacokinetic distribution?
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
CVA: stroke - AMI: acute MI - HF
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

11. what mechanical loading helps to prevent pressure ulcers?
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

12. What are the 3 stages of ADRs?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Prescribing - monitoring - patient adherence
Cholinesterase inhib - use: dementia
CVA: stroke - AMI: acute MI - HF

13. overflow incontinence tx
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Isolated systolic HTN
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

14. advanced directive/care plan

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15. NSAID may lead to what prescription cascade?
^BP -> a-HTN
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Injury - neglect - physical/psychosocial - financial - violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

16. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
3 reflexes: baroreceptor - renal nerve - ANF
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

17. driving considerations
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Make sure to discuss with patient - some states require reporting
Cachexia - PEM - FTT - obesity
Diagnosis - risk/benefit analysis to choose Rx

18. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
Appointed by court if no substituted judgment -conservator of finance -conservator of person
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

19. urge incontinence tx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
No: fever - leukocytosis - yes: falls - appetite change - low functional status

20. how may hypertension compensate for aging?
Voice - character - plot - context - time - reader
Determined by Dr for a patient - -> used to determine competency
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

21. What are common scenarios of untreated indications in elderly?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Used to calculate renal fcn - clearance of Cr adjusted for age
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
IdioPx - psychiatric: depression - anxiety - somatoform

22. What are the key points of safe prescription for elderly - lecture
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Phenytoin
Diagnosis - risk/benefit analysis to choose 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

23. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Pressure ulcer - fecal impaction - dehydration
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
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
P2-metabolite - phase 1 biotx much more affected than phase 2

24. What is abuse?
Constipation -> laxatives
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Injury - neglect - physical/psychosocial - financial - violation of rights

25. delirium: mgmt
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

26. What are the 3 sentinel events for LT care?
CVA: stroke - AMI: acute MI - HF
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Pressure ulcer - fecal impaction - dehydration
1/2

27. thyroid dx + atypical Sx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Falls - delirium - malnutrition - P ulcers - opportunistic i2

28. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Legal: Cruzan v Hamon
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Cholinesterase inhib - use: dementia

29. How to prevent pressure ulcers?
Determined by Dr for a patient - -> used to determine competency
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Mechanical loading - skin care - avoid friction/shear
IdioPx - psychiatric: depression - anxiety - somatoform

30. What are the hazards of elderly hospitalization?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
^morbidity + mortality - -frailest @ greatest risk
Bone loss -> osteopenia -> osteoporosis -> Fx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

31. delirium incidence
Mechanical loading - skin care - avoid friction/shear
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Hypothetical plan - serves as patient's last competent indicated wishes
Universal - progressive - partially encoded (genetic) - destructive -

32. How does aging affect GI absorption rate of Rx?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Voice - character - plot - context - time - reader
Delayed absorption - like competitive inhib
Breast cancer + 2o LBP

33. thiazide diuretic may lead to what prescription cascade?
Respect for autonomy - nonmaleficence - beneficence - justice
Hyperuricemia -> gout
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Doctors

34. what % of hospitalizations of elderly are due to ADR + noncompliance?
^ANS tone -> ^periph vasoconstriction - ^HR
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
28% - ADR: 17% - non-compliance 11%
Vertigo - presyncope - disequilibrium - lightheadedness

35. rivastigmine
Confusion - sedation - falls
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Cholinesterase inhib - use: dementia
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

36. memantine
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
NMDR antagonist - use: dementia
1/2
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

37. What is sCr?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Serum Cr: used for Cr clearance equation
Screen for potentially embarrassing dx - patient/Dr trust

38. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

39. preventing malnutrition
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Figure out a good diet - social aspect - resources - dental/oral comfort
Voice - character - plot - context - time - reader

40. What are the rf for caregiver to abuse elderly?
Bone loss -> osteopenia -> osteoporosis -> Fx
>9 Rx
Used to calculate renal fcn - clearance of Cr adjusted for age
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

41. What are the common causes of lightheadedness?
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: donepezil - rivastigmine - galantamine - NMDR antag: memantine
IdioPx - psychiatric: depression - anxiety - somatoform
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

42. what nutritional interventions help underweight?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

43. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Electrical: change in HR - structural: aortic outflow obstruction
80% of hospital admission for syncope for >65yo
Appointed by court if no substituted judgment -conservator of finance -conservator of person

44. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
Treat underlying disease/lack resources
Bone loss -> osteopenia -> osteoporosis -> Fx
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

45. clues of neglect
3 reflexes: baroreceptor - renal nerve - ANF
Hypothetical plan - serves as patient's last competent indicated wishes
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

46. How does baroreceptor reflex prevent syncope?
^ANS tone -> ^periph vasoconstriction - ^HR
3 reflexes: baroreceptor - renal nerve - ANF
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Catch-all of unspecified dizziness

47. pressure ulcer: staging
P2-metab: Lorazepam - Trazepam - Oxazepam
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

48. what ADR are common in elderly patient?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
IdioPx - psychiatric: depression - anxiety - somatoform
Respect for autonomy - nonmaleficence - beneficence - justice
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

49. BZD + antipsychotic: interaction outcome
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Confusion - sedation - falls
3 reflexes: baroreceptor - renal nerve - ANF
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

50. What is the bone deterioration cascade?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Voice - character - plot - context - time - reader
Bone loss -> osteopenia -> osteoporosis -> Fx
5% - underreported