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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. falls epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

2. Alb-bound Rx
Make sure to discuss with patient - some states require reporting
Phenytoin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Respect for autonomy - nonmaleficence - beneficence - justice

3. pressure ulcer: staging
Phenytoin
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Receptors changes: # - sensitivity - counter-regulatory moa

4. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Insiduous onset

5. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Tx underlying etio - + Kegels - pessary - surgery
Beers criteria - medication appropriateness index (12 ?)
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

6. What is the epidemiology of dizziness?
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
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

7. How to prevent pressure ulcers?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Mechanical loading - skin care - avoid friction/shear
Injury - neglect - physical/psychosocial - financial - violation of rights
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

8. Disequilibrium
Screen for potentially embarrassing dx - patient/Dr trust
80% of hospital admission for syncope for >65yo
ANF: Na+ retention - disinhib vasoconstriction
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

9. what nutritional interventions help underweight?
Mechanical loading - skin care - avoid friction/shear
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

10. What is the natural history of syncope?
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
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Respect for autonomy - nonmaleficence - beneficence - justice

11. How does aging increase incontinence?
Diagnosis - risk/benefit analysis to choose Rx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Hypotension - ^K+
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

12. tube feeding
NMDR antagonist - use: dementia
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
CNS suppression -> cholinesterase inhibitors
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

13. what Rx are commonly monifoted in elderly for ADR?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Mechanical loading - skin care - avoid friction/shear
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

14. What is the STOPP criteria?
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
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
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

15. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Confusion - sedation - falls
NMDR antagonist - use: dementia

16. physical neglect
Hyperuricemia -> gout
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

17. incontinence complication
Multisystemic vulnerability - -lowered reserves
Environment modification: obstacles - mobility - -bladder fcn ok
Serum Cr: used for Cr clearance equation
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

18. How does baroreceptor reflex prevent syncope?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
^ANS tone -> ^periph vasoconstriction - ^HR
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Breast cancer + 2o LBP

19. memantine
#1 patient's last competent indication of wishes - substituted judgment - beneficence
NMDR antagonist - use: dementia
BMD (bone mineral density): T-score >2.5 std dev below normal 1
3 reflexes: baroreceptor - renal nerve - ANF

20. What are the rf for caregiver to abuse elderly?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Receptors changes: # - sensitivity - counter-regulatory moa
BMD (bone mineral density): T-score >2.5 std dev below normal 1

21. What are the 4 basic ethical principles?
NMDR antagonist - use: dementia
Make sure to discuss with patient - some states require reporting
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Respect for autonomy - nonmaleficence - beneficence - justice

22. How does the aging heart compensate for lower HR to maintain unchanged CO?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Tx underlying etio - + Kegels - pessary - surgery
^SV (diastolic stroke volume)
CNS suppression -> cholinesterase inhibitors

23. What drugs can contribute to syncope?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
A-blockers - B-blockers - TCA
>9 Rx
Stress: #1 - functional - urge - overflow

24. What are rf for osteoporosis?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Make sure to discuss with patient - some states require reporting
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
80% of hospital admission for syncope for >65yo

25. frailty raises vulnerability to...
28% - ADR: 17% - non-compliance 11%
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
Insiduous onset
Falls - delirium - malnutrition - P ulcers - opportunistic i2

26. anticholinergic drugs may lead to what prescription cascade?
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
80% of hospital admission for syncope for >65yo
#1 patient's last competent indication of wishes - substituted judgment - beneficence
CNS suppression -> cholinesterase inhibitors

27. restrain requirements
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Cachexia - PEM - FTT - obesity
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

28. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
CVA: stroke - AMI: acute MI - HF
Pressure ulcer - fecal impaction - dehydration

29. What are the 4 forms of dizziness?
Doctors
Prescribing - monitoring - patient adherence
Receptors changes: # - sensitivity - counter-regulatory moa
Vertigo - presyncope - disequilibrium - lightheadedness

30. What are the common types of elder mistreatment?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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
^K+
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

31. urge incontinence tx
Injury - neglect - physical/psychosocial - financial - violation of rights
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Map of people - perceptions - etc - varies by perspective
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

32. metoclopramide may lead to what prescription cascade?
Screen for potentially embarrassing dx - patient/Dr trust
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Phenytoin
Parkinsonism -> l-DOPA

33. what mechanical loading helps to prevent pressure ulcers?
Doctors
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
F>M (until 80yo) - stress incontinence #1 - $26B/yr
A-blockers - B-blockers - TCA

34. delirium incidence
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

35. psychological abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
Screen for potentially embarrassing dx - patient/Dr trust
>9 Rx
Hypothetical plan - serves as patient's last competent indicated wishes

36. Aging descriptors
>60yo - low abuse risk - ^ monitoring possible
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Temporalis muscle wasting = temporal wasting
ANF: Na+ retention - disinhib vasoconstriction

37. What are the pharmacodynamic changes associated with aging?
Receptors changes: # - sensitivity - counter-regulatory moa
Phenytoin
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

38. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Respect for autonomy - nonmaleficence - beneficence - justice
Treat underlying disease/lack resources

39. What are common physical abuse Sx in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Parkinsonism -> l-DOPA

40. delirium: mgmt
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
ANF: Na+ retention - disinhib vasoconstriction
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

41. How does aging affect GI absorption of Rx?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
80% of hospital admission for syncope for >65yo

42. How does aging affect pharmacokinetics?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
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

43. what drugs can cause dizziness?
Legal: Cruzan v Hamon
Used to calculate renal fcn - clearance of Cr adjusted for age
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
1/2

44. What is a mattering map?
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Map of people - perceptions - etc - varies by perspective
Figure out a good diet - social aspect - resources - dental/oral comfort
Environment modification: obstacles - mobility - -bladder fcn ok

45. what receptors decrease sensitivity with aging?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
#1 patient's last competent indication of wishes - substituted judgment - beneficence
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

46. What is START criteria?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Make sure to discuss with patient - some states require reporting
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

47. elderly abuse epidemiology
Threats/ terrorizing - isolation - denying food/privileges/liberty
5% - underreported
30% preventable - of these - 40% serious - of these 40% preventable
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

48. NSAID may lead to what prescription cascade?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
^BP -> a-HTN
Cholinesterase inhib - use: dementia

49. osteoporosis epidemiology
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
High mortality - esp + Fx - very common in elderly
Vertigo - presyncope - disequilibrium - lightheadedness
A-blockers - B-blockers - TCA

50. Syncope prognosis based on etio
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Worse for cardiac causes v noncardia