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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. galantamine
Cholinesterase inhib - use: dementia
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Serum Cr: used for Cr clearance equation

2. What is abuse?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Injury - neglect - physical/psychosocial - financial - violation of rights
Delayed absorption - like competitive inhib
Threats/ terrorizing - isolation - denying food/privileges/liberty

3. overflow incontinence tx
Determined by Dr for a patient - -> used to determine competency
Confusion - sedation - falls
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
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

4. who is a good candidate for opioid tx?
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
>60yo - low abuse risk - ^ monitoring possible

5. How does aging affect Rx pharmacokinetic metabolism?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
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
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

6. What are the vascular changes of presyncope?
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

7. substituted judgment
Cholinesterase inhib - use: dementia
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

8. Why is abuse underreported?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Hypotension - ^K+
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

9. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
Worse for cardiac causes v noncardia
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
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

10. Aging features
Phenytoin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Universal - progressive - partially encoded (genetic) - destructive -
Falls - delirium - malnutrition - P ulcers - opportunistic i2

11. How does aging affect pharmacokinetic protein binding?
Determined by Dr for a patient - -> used to determine competency
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Parkinsonism -> l-DOPA

12. metoclopramide may lead to what prescription cascade?
Isolated systolic HTN
Parkinsonism -> l-DOPA
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

13. refusing intervention
Legal: Cruzan v Hamon
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Multisystemic vulnerability - -lowered reserves
Figure out a good diet - social aspect - resources - dental/oral comfort

14. delirium: Rx that contribute
Universal - progressive - partially encoded (genetic) - destructive -
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

15. incontinence complication
^ANS tone -> ^periph vasoconstriction - ^HR
Cachexia - PEM - FTT - obesity
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

16. fall sequelae

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17. how is syncope related to elderly admission to hospital?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
80% of hospital admission for syncope for >65yo

18. what receptors increase sensitivity with aging?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
P2-metab: Lorazepam - Trazepam - Oxazepam
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

19. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Tx underlying etio - + Kegels - pessary - surgery
Hypotension - ^K+
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

20. How does aging affect Rx renal elimination?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Hyperuricemia -> gout
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

21. What are the key points of safe prescription for elderly - lecture
Diagnosis - risk/benefit analysis to choose Rx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
ANF: Na+ retention - disinhib vasoconstriction
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

22. How does aging affect GI absorption of Rx?
P2-metab: Lorazepam - Trazepam - Oxazepam
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
CVA: stroke - AMI: acute MI - HF
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

23. preventing malnutrition
1/2
Worse for cardiac causes v noncardia
Figure out a good diet - social aspect - resources - dental/oral comfort
Used to calculate renal fcn - clearance of Cr adjusted for age

24. using long-acting opioids in elderly
Cholinesterase inhib - use: dementia
Confusion - sedation - falls
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Therapy - SSRI

25. How does aging affect GI absorption rate of Rx?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Delayed absorption - like competitive inhib
>60yo - low abuse risk - ^ monitoring possible
Injury - neglect - physical/psychosocial - financial - violation of rights

26. What are the hazards of elderly hospitalization?
^morbidity + mortality - -frailest @ greatest risk
3 reflexes: baroreceptor - renal nerve - ANF
BMD (bone mineral density): T-score >2.5 std dev below normal 1
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

27. What is the preferred depression treatment in elderly?
CVA: stroke - AMI: acute MI - HF
Therapy - SSRI
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
^K+

28. memantine
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
NMDR antagonist - use: dementia
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

29. red flags for further inquiry
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
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
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

30. What are common medical causes of syncope?
28% - ADR: 17% - non-compliance 11%
P2-metab: Lorazepam - Trazepam - Oxazepam
Isolated systolic HTN
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

31. malignancy + atypical Sx
Pressure ulcer - fecal impaction - dehydration
IdioPx - psychiatric: depression - anxiety - somatoform
Breast cancer + 2o LBP
5% - underreported

32. How does aging impact syncope-preventing reflexes
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Electrolyte imbalance - arrhythmia
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

33. surrogate decision making heirarchy

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34. How does an 80yo renal fcn compare to that of a 20yo?
^K+
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Vertigo - presyncope - disequilibrium - lightheadedness
1/2

35. lipid-soluble Rx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Begin @25-50% recommended dose - APAP may be dose-limiting
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

36. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Phenytoin
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

37. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

38. antiarrhythmic + diuretic: interaction outcome
ANF: Na+ retention - disinhib vasoconstriction
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Electrolyte imbalance - arrhythmia
80% of hospital admission for syncope for >65yo

39. osteoporosis
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
BMD (bone mineral density): T-score >2.5 std dev below normal 1

40. functional incontinence tx
Beers criteria - medication appropriateness index (12 ?)
Injury - neglect - physical/psychosocial - financial - violation of rights
Environment modification: obstacles - mobility - -bladder fcn ok
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

41. What is the bone deterioration cascade?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Bone loss -> osteopenia -> osteoporosis -> Fx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Threats/ terrorizing - isolation - denying food/privileges/liberty

42. delirium predisposing rf
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Figure out a good diet - social aspect - resources - dental/oral comfort
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

43. tube feeding
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
P2-metabolite - phase 1 biotx much more affected than phase 2

44. nutrition syndromes
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
30% preventable - of these - 40% serious - of these 40% preventable
Cachexia - PEM - FTT - obesity

45. frailty signs
Doctors
IdioPx - psychiatric: depression - anxiety - somatoform
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Pressure ulcer - fecal impaction - dehydration

46. How does aging increase incontinence?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
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
Serum Cr: used for Cr clearance equation
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

47. How does sliding scale glycemic control relate to elderly?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
28% - ADR: 17% - non-compliance 11%

48. stress incontinence tx
5% - underreported
Hypothetical plan - serves as patient's last competent indicated wishes
Tx underlying etio - + Kegels - pessary - surgery
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

49. anticholinergic drugs may lead to what prescription cascade?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Environment modification: obstacles - mobility - -bladder fcn ok
CNS suppression -> cholinesterase inhibitors

50. What is the best approach to malnutrition
Delayed absorption - like competitive inhib
^SV (diastolic stroke volume)
Treat underlying disease/lack resources
P2-metab: Lorazepam - Trazepam - Oxazepam