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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. Cockcroft Gault equation
Hypothetical plan - serves as patient's last competent indicated wishes
Injury - neglect - physical/psychosocial - financial - violation of rights
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
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

2. How does aging affect pharmacokinetic protein binding?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

3. metoclopramide may lead to what prescription cascade?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Parkinsonism -> l-DOPA
Receptors changes: # - sensitivity - counter-regulatory moa

4. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Catch-all of unspecified dizziness
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
No: chest pain - yes: fatigue - nausea - low functional status - SOB

5. fall sequelae

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6. MI + atypical Sx
Prescribing - monitoring - patient adherence
Hypotension - ^K+
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
No: chest pain - yes: fatigue - nausea - low functional status - SOB

7. psychological abuse
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Respect for autonomy - nonmaleficence - beneficence - justice
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Threats/ terrorizing - isolation - denying food/privileges/liberty

8. what can enhance reporting in elderly?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Electrolyte imbalance - arrhythmia
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Screen for potentially embarrassing dx - patient/Dr trust

9. fall causes
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

10. How does baroreceptor reflex prevent syncope?
Cholinesterase inhib - use: dementia
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
^ANS tone -> ^periph vasoconstriction - ^HR
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

11. how can you determine whether Rx is appropriate to use in elderly patient?
Beers criteria - medication appropriateness index (12 ?)
Confusion - sedation - falls
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
1/2

12. What drugs can contribute to syncope?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Figure out a good diet - social aspect - resources - dental/oral comfort
A-blockers - B-blockers - TCA
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

13. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
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
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Diagnosis - risk/benefit analysis to choose Rx

14. antiarrhythmic + diuretic: interaction outcome
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
Electrolyte imbalance - arrhythmia
Threats/ terrorizing - isolation - denying food/privileges/liberty
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

15. Aging descriptors
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

16. Alb-bound Rx
Phenytoin
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
A-blockers - B-blockers - TCA
Treat underlying disease/lack resources

17. How does the aging heart compensate for lower HR to maintain unchanged CO?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
^SV (diastolic stroke volume)
Beers criteria - medication appropriateness index (12 ?)
Consider responsibilities - drivin

18. LBW equation
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
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
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Cholinesterase inhib - use: dementia

19. donepezil
Cachexia - PEM - FTT - obesity
Begin @25-50% recommended dose - APAP may be dose-limiting
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Cholinesterase inhib - use: dementia

20. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
^BP -> a-HTN
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Hypotension - ^K+

21. documenting elderly abuse

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22. refusing intervention
80% of hospital admission for syncope for >65yo
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Legal: Cruzan v Hamon

23. what Rx are commonly monifoted in elderly for ADR?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Electrolyte imbalance - arrhythmia
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Cholinesterase inhib - use: dementia

24. How does aging impact syncope-preventing reflexes
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Confusion - sedation - falls
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

25. Syncope prognosis based on etio
Worse for cardiac causes v noncardia
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Hyperuricemia -> gout
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

26. rivastigmine
P2-metab: Lorazepam - Trazepam - Oxazepam
Beers criteria - medication appropriateness index (12 ?)
Cholinesterase inhib - use: dementia
Consider responsibilities - drivin

27. urinary incontinence types
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Stress: #1 - functional - urge - overflow
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

28. what illnesses are underreported in elderly?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Map of people - perceptions - etc - varies by perspective

29. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Consider responsibilities - drivin
Tx underlying etio - + Kegels - pessary - surgery

30. What are the possible cardiac causes of presyncope?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Worse for cardiac causes v noncardia
Electrical: change in HR - structural: aortic outflow obstruction

31. elderly abuse epidemiology
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Tx underlying etio - + Kegels - pessary - surgery
5% - underreported

32. osteoporosis etio
Electrical: change in HR - structural: aortic outflow obstruction
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Legal: Cruzan v Hamon
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

33. What are the vascular changes of presyncope?
Stress: #1 - functional - urge - overflow
^morbidity + mortality - -frailest @ greatest risk
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

34. narcotics may lead to what prescription cascade?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Constipation -> laxatives
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Hypotension - ^K+

35. What is the best approach to malnutrition
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
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
Treat underlying disease/lack resources
5% - underreported

36. which benzodiazepines are most appropriate for elderly?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
P2-metab: Lorazepam - Trazepam - Oxazepam
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Environment modification: obstacles - mobility - -bladder fcn ok

37. What are the common types of elder mistreatment?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Respect for autonomy - nonmaleficence - beneficence - justice
Legal: Cruzan v Hamon
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

38. Presyncope
^BP -> a-HTN
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
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
Phenytoin

39. What are the key points of safe prescription for elderly - lecture
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Diagnosis - risk/benefit analysis to choose Rx
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

40. what drugs can cause dizziness?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
^morbidity + mortality - -frailest @ greatest risk
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Prescribing - monitoring - patient adherence

41. What is the bone deterioration cascade?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Bone loss -> osteopenia -> osteoporosis -> Fx
Tx underlying etio - + Kegels - pessary - surgery

42. How does aging affect pharmacokinetic Rx distribution?
Cachexia - PEM - FTT - obesity
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
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

43. PEM
Cachexia - PEM - FTT - obesity
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
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

44. What are rf for osteoporosis?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Cholinesterase inhib - use: dementia
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
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

45. What is the preferred depression treatment in elderly?
3 reflexes: baroreceptor - renal nerve - ANF
Therapy - SSRI
ANF: Na+ retention - disinhib vasoconstriction
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

46. frailty
Treat underlying disease/lack resources
Figure out a good diet - social aspect - resources - dental/oral comfort
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Multisystemic vulnerability - -lowered reserves

47. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Bone loss -> osteopenia -> osteoporosis -> Fx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Vertigo - presyncope - disequilibrium - lightheadedness

48. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
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
Threats/ terrorizing - isolation - denying food/privileges/liberty

49. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
Confusion - sedation - falls
5% - underreported
>9 Rx

50. what nutritional interventions help underweight?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Receptors changes: # - sensitivity - counter-regulatory moa
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Catch-all of unspecified dizziness