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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. What is the Cockcroft Gault equation?
Used to calculate renal fcn - clearance of Cr adjusted for age
Figure out a good diet - social aspect - resources - dental/oral comfort
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Cholinesterase inhib - use: dementia

2. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Cachexia - PEM - FTT - obesity
Begin @25-50% recommended dose - APAP may be dose-limiting
Cholinesterase inhib - use: dementia

3. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
>60yo - low abuse risk - ^ monitoring possible
^BP -> a-HTN
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

4. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
Cholinesterase inhib - use: dementia
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

5. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Threats/ terrorizing - isolation - denying food/privileges/liberty

6. antiarrhythmic + diuretic: interaction outcome
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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Electrolyte imbalance - arrhythmia

7. incontinence complication
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Environment modification: obstacles - mobility - -bladder fcn ok

8. delirium diagnosis
30% preventable - of these - 40% serious - of these 40% preventable
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
#1 patient's last competent indication of wishes - substituted judgment - beneficence

9. violation of rights
5% - underreported
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Serum Cr: used for Cr clearance equation

10. MRP: medication related problems
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Beers criteria - medication appropriateness index (12 ?)

11. Approach to idioPx - recurrent syncope
Appointed by court if no substituted judgment -conservator of finance -conservator of person
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Consider responsibilities - drivin
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

12. What are rf for osteoporosis?
Temporalis muscle wasting = temporal wasting
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

13. how is cachexia different from wasting?
Treat underlying disease/lack resources
Confusion - sedation - falls
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
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

14. How does aging impact syncope-preventing reflexes
#1 patient's last competent indication of wishes - substituted judgment - beneficence
CNS suppression -> cholinesterase inhibitors
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

15. What is the STOPP criteria?
CVA: stroke - AMI: acute MI - HF
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Treat underlying disease/lack resources
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

16. Aging descriptors
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Catch-all of unspecified dizziness
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

17. What are the common causes of lightheadedness?
Diagnosis - risk/benefit analysis to choose Rx
Therapy - SSRI
Threats/ terrorizing - isolation - denying food/privileges/liberty
IdioPx - psychiatric: depression - anxiety - somatoform

18. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Worse for cardiac causes v noncardia
Map of people - perceptions - etc - varies by perspective
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

19. What is a PE sign of cachexia?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Temporalis muscle wasting = temporal wasting
Stress: #1 - functional - urge - overflow
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

20. osteopenia
Make sure to discuss with patient - some states require reporting
^BP -> a-HTN
^K+
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

21. What are common medical causes of syncope?
P2-metabolite - phase 1 biotx much more affected than phase 2
Confusion - sedation - falls
Voice - character - plot - context - time - reader
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

22. delirium: Rx that contribute
>9 Rx
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Hyperuricemia -> gout
Consider responsibilities - drivin

23. narcotics may lead to what prescription cascade?
NMDR antagonist - use: dementia
Legal: Cruzan v Hamon
Constipation -> laxatives
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

24. Disequilibrium
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
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
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
>9 Rx

25. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

26. ACE inhib + K+: interaction outcome
^K+
Delayed absorption - like competitive inhib
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Determined by Dr for a patient - -> used to determine competency

27. malignancy + atypical Sx
Breast cancer + 2o LBP
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
5% - underreported

28. refusing intervention
Make sure to discuss with patient - some states require reporting
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Legal: Cruzan v Hamon
P2-metab: Lorazepam - Trazepam - Oxazepam

29. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/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
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

30. what professional is least likely to report abuse?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Doctors
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
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

31. Presyncope
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Appointed by court if no substituted judgment -conservator of finance -conservator of person

32. frailty
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Multisystemic vulnerability - -lowered reserves
Diagnosis - risk/benefit analysis to choose Rx

33. What is START criteria?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

34. fall causes
^BP -> a-HTN
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
^K+

35. What is abuse?
Injury - neglect - physical/psychosocial - financial - violation of rights
Constipation -> laxatives
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Confusion - sedation - falls

36. frailty raises vulnerability to...
Map of people - perceptions - etc - varies by perspective
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

37. What is the bone deterioration cascade?
Bone loss -> osteopenia -> osteoporosis -> Fx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Parkinsonism -> l-DOPA

38. How does aging affect GI absorption of Rx?
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
Respect for autonomy - nonmaleficence - beneficence - justice
Electrical: change in HR - structural: aortic outflow obstruction

39. How does aging increase incontinence?
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
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Appointed by court if no substituted judgment -conservator of finance -conservator of person

40. fall sequelae

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41. using long-acting opioids in elderly
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Hypotension - ^K+
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Cholinesterase inhib - use: dementia

42. What are the possible cardiac causes of presyncope?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
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
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Electrical: change in HR - structural: aortic outflow obstruction

43. What are the hazards of elderly hospitalization?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
BMD (bone mineral density): T-score >2.5 std dev below normal 1
^morbidity + mortality - -frailest @ greatest risk
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

44. What are the key points of safe prescription for elderly - lecture
Cholinesterase inhib - use: dementia
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
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Diagnosis - risk/benefit analysis to choose Rx

45. opioid tx in elderly
Hypotension - ^K+
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
Begin @25-50% recommended dose - APAP may be dose-limiting
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

46. What are common scenarios of untreated indications in elderly?
Stress: #1 - functional - urge - overflow
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Map of people - perceptions - etc - varies by perspective

47. Cockcroft Gault equation
Determined by Dr for a patient - -> used to determine competency
Legal: Cruzan v Hamon
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

48. donepezil
Confusion - sedation - falls
Cholinesterase inhib - use: dementia
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

49. depression + atypical Sx
1/2
^BP -> a-HTN
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
ANF: Na+ retention - disinhib vasoconstriction

50. what % of hospitalizations of elderly are due to ADR + noncompliance?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Prescribing - monitoring - patient adherence
28% - ADR: 17% - non-compliance 11%