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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. what professional is least likely to report abuse?
P2-metabolite - phase 1 biotx much more affected than phase 2
Doctors
^BP -> a-HTN
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

2. what normally prevents syncope?
3 reflexes: baroreceptor - renal nerve - ANF
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
^morbidity + mortality - -frailest @ greatest risk
Map of people - perceptions - etc - varies by perspective

3. How does sliding scale glycemic control relate to elderly?
A-blockers - B-blockers - TCA
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

4. restrain requirements
Doctors
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

5. how is the CAM used to diagnose delirium?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
NMDR antagonist - use: dementia
Cholinesterase inhib - use: dementia

6. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
A-blockers - B-blockers - TCA
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

7. ACE inhib + diuretic: interaction outcome
Begin @25-50% recommended dose - APAP may be dose-limiting
Respect for autonomy - nonmaleficence - beneficence - justice
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Hypotension - ^K+

8. ACE inhib + K+: interaction outcome
Diagnosis - risk/benefit analysis to choose Rx
^K+
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

9. how is syncope related to elderly admission to hospital?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
80% of hospital admission for syncope for >65yo
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

10. i2 + atypical Sx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Stress: #1 - functional - urge - overflow
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

11. what can enhance reporting in elderly?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Beers criteria - medication appropriateness index (12 ?)
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Screen for potentially embarrassing dx - patient/Dr trust

12. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Delayed absorption - like competitive inhib
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

13. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Electrolyte imbalance - arrhythmia
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Phenytoin

14. delirium: mgmt
^SV (diastolic stroke volume)
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Cholinesterase inhib - use: dementia
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

15. 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
Electrolyte imbalance - arrhythmia
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Vertigo - presyncope - disequilibrium - lightheadedness

16. What is capacity?
Tx underlying etio - + Kegels - pessary - surgery
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Determined by Dr for a patient - -> used to determine competency
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

17. What is a mattering map?
Mechanical loading - skin care - avoid friction/shear
Determined by Dr for a patient - -> used to determine competency
Map of people - perceptions - etc - varies by perspective
Phenytoin

18. what ADR are common in elderly patient?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Falls - delirium - malnutrition - P ulcers - opportunistic i2

19. what Rx are commonly monifoted in elderly for ADR?
Stress: #1 - functional - urge - overflow
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Hyperuricemia -> gout

20. red flags for further inquiry
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Parkinsonism -> l-DOPA

21. What are the risks of uncontrolled ISH?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
CVA: stroke - AMI: acute MI - HF
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Delayed absorption - like competitive inhib

22. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Hypotension - ^K+
Legal: Cruzan v Hamon

23. 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
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
^morbidity + mortality - -frailest @ greatest risk
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

24. refusing intervention
CNS suppression -> cholinesterase inhibitors
Threats/ terrorizing - isolation - denying food/privileges/liberty
Breast cancer + 2o LBP
Legal: Cruzan v Hamon

25. Beers criteria
Treat underlying disease/lack resources
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
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Confusion - sedation - falls

26. Why is abuse underreported?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
A-blockers - B-blockers - TCA

27. MI + atypical Sx
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Consider responsibilities - drivin
Threats/ terrorizing - isolation - denying food/privileges/liberty
No: chest pain - yes: fatigue - nausea - low functional status - SOB

28. urge incontinence tx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Delayed absorption - like competitive inhib

29. BZD + antipsychotic: interaction outcome
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Confusion - sedation - falls
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

30. Presyncope
ANF: Na+ retention - disinhib vasoconstriction
A-blockers - B-blockers - TCA
High mortality - esp + Fx - very common in elderly
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

31. How does aging affect pharmacokinetic protein binding?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Isolated systolic HTN
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

32. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

33. acute abdomen + atypical Sx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
3 reflexes: baroreceptor - renal nerve - ANF
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

34. describe the % of ADR considered preventable - and of those serious
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Phenytoin
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
30% preventable - of these - 40% serious - of these 40% preventable

35. osteoporosis epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
High mortality - esp + Fx - very common in elderly
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

36. LBW equation
3 reflexes: baroreceptor - renal nerve - ANF
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

37. NSAID may lead to what prescription cascade?
Treat underlying disease/lack resources
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
^BP -> a-HTN
Serum Cr: used for Cr clearance equation

38. thiazide diuretic may lead to what prescription cascade?
^ANS tone -> ^periph vasoconstriction - ^HR
Hyperuricemia -> gout
^BP -> a-HTN
5% - underreported

39. Syncope prognosis based on etio
^BP -> a-HTN
IdioPx - psychiatric: depression - anxiety - somatoform
Worse for cardiac causes v noncardia
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

40. osteoporosis
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Isolated systolic HTN
Universal - progressive - partially encoded (genetic) - destructive -

41. documenting elderly abuse

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42. thyroid dx + atypical Sx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Insiduous onset
Injury - neglect - physical/psychosocial - financial - violation of rights

43. incontinence complication
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
^BP -> a-HTN
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Cachexia - PEM - FTT - obesity

44. incontinence epidemiology
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
F>M (until 80yo) - stress incontinence #1 - $26B/yr

45. PEM
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
80% of hospital admission for syncope for >65yo
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

46. driving considerations
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Make sure to discuss with patient - some states require reporting

47. overflow incontinence tx
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

48. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Figure out a good diet - social aspect - resources - dental/oral comfort
^SV (diastolic stroke volume)
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

49. 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
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Diagnosis - risk/benefit analysis to choose Rx

50. what receptors increase sensitivity with aging?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Electrolyte imbalance - arrhythmia