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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. osteoporosis etio
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Tx underlying etio - + Kegels - pessary - surgery
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

2. Beers criteria: what 10 Rx should elderly avoid or use + caution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Cachexia - PEM - FTT - obesity
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

3. How does an 80yo renal fcn compare to that of a 20yo?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
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
1/2

4. incontinence epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Cholinesterase inhib - use: dementia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

5. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Multisystemic vulnerability - -lowered reserves

6. 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
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Tx underlying etio - + Kegels - pessary - surgery
^BP -> a-HTN

7. What is capacity?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Determined by Dr for a patient - -> used to determine competency
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

8. psychological abuse
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
CVA: stroke - AMI: acute MI - HF
Threats/ terrorizing - isolation - denying food/privileges/liberty
>9 Rx

9. What are the pharmacodynamic changes associated with aging?
Receptors changes: # - sensitivity - counter-regulatory moa
Cholinesterase inhib - use: dementia
Hyperuricemia -> gout
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

10. osteoporosis
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Diagnosis - risk/benefit analysis to choose Rx
Multisystemic vulnerability - -lowered reserves
Legal: Cruzan v Hamon

11. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

12. What is the natural history of syncope?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Screen for potentially embarrassing dx - patient/Dr trust

13. What is the STOPP criteria?
ANF: Na+ retention - disinhib vasoconstriction
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
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
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

14. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
Serum Cr: used for Cr clearance equation
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
^SV (diastolic stroke volume)

15. What is a PE sign of cachexia?
Temporalis muscle wasting = temporal wasting
Universal - progressive - partially encoded (genetic) - destructive -
80% of hospital admission for syncope for >65yo
Breast cancer + 2o LBP

16. How does aging affect GI absorption rate of Rx?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Begin @25-50% recommended dose - APAP may be dose-limiting
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Delayed absorption - like competitive inhib

17. preventing malnutrition
Treat underlying disease/lack resources
Catch-all of unspecified dizziness
Map of people - perceptions - etc - varies by perspective
Figure out a good diet - social aspect - resources - dental/oral comfort

18. conservator
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Worse for cardiac causes v noncardia
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

19. What are the common causes of lightheadedness?
Confusion - sedation - falls
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
IdioPx - psychiatric: depression - anxiety - somatoform

20. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Hypothetical plan - serves as patient's last competent indicated wishes

21. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Confusion - sedation - falls
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

22. What is START criteria?
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
Parkinsonism -> l-DOPA
Screen for potentially embarrassing dx - patient/Dr trust

23. What are common physical abuse Sx in elderly?
Hypothetical plan - serves as patient's last competent indicated wishes
28% - ADR: 17% - non-compliance 11%
CNS suppression -> cholinesterase inhibitors
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

24. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
>9 Rx
Hypothetical plan - serves as patient's last competent indicated wishes

25. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
5% - underreported
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Confusion - sedation - falls

26. Aging descriptors
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Figure out a good diet - social aspect - resources - dental/oral comfort
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Injury - neglect - physical/psychosocial - financial - violation of rights

27. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Environment modification: obstacles - mobility - -bladder fcn ok

28. What is the preferred depression treatment in elderly?
Mechanical loading - skin care - avoid friction/shear
CVA: stroke - AMI: acute MI - HF
Therapy - SSRI
High mortality - esp + Fx - very common in elderly

29. which benzodiazepines are most appropriate for elderly?
Confusion - sedation - falls
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
P2-metab: Lorazepam - Trazepam - Oxazepam
Constipation -> laxatives

30. rivastigmine
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Injury - neglect - physical/psychosocial - financial - violation of rights
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cholinesterase inhib - use: dementia

31. What are the 4 basic ethical principles?
High mortality - esp + Fx - very common in elderly
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Respect for autonomy - nonmaleficence - beneficence - justice
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

32. How does aging affect Rx renal elimination?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Hypothetical plan - serves as patient's last competent indicated wishes

33. how is cachexia different from wasting?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
28% - ADR: 17% - non-compliance 11%
CVA: stroke - AMI: acute MI - HF

34. What are the key points of safe prescription for elderly - lecture
Doctors
Diagnosis - risk/benefit analysis to choose Rx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
High mortality - esp + Fx - very common in elderly

35. galantamine
^morbidity + mortality - -frailest @ greatest risk
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Cholinesterase inhib - use: dementia
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

36. NSAID may lead to what prescription cascade?
^BP -> a-HTN
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Hyperuricemia -> gout

37. ADR rf
Figure out a good diet - social aspect - resources - dental/oral comfort
Electrical: change in HR - structural: aortic outflow obstruction
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

38. what % of hospitalizations of elderly are due to ADR + noncompliance?
Breast cancer + 2o LBP
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
28% - ADR: 17% - non-compliance 11%
Cholinesterase inhib - use: dementia

39. refusing intervention
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
CNS suppression -> cholinesterase inhibitors
^BP -> a-HTN
Legal: Cruzan v Hamon

40. malignancy + atypical Sx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Breast cancer + 2o LBP
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Tx underlying etio - + Kegels - pessary - surgery

41. narcotics may lead to what prescription cascade?
Constipation -> laxatives
Confusion - sedation - falls
Hypothetical plan - serves as patient's last competent indicated wishes
Mechanical loading - skin care - avoid friction/shear

42. depression + atypical Sx
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

43. What are the 4 forms of dizziness?
Electrolyte imbalance - arrhythmia
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
30% preventable - of these - 40% serious - of these 40% preventable
Vertigo - presyncope - disequilibrium - lightheadedness

44. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
>9 Rx
3 reflexes: baroreceptor - renal nerve - ANF
Mechanical loading - skin care - avoid friction/shear

45. delirium: Rx that contribute
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
^SV (diastolic stroke volume)
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

46. 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
P2-metab: Lorazepam - Trazepam - Oxazepam
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
3 reflexes: baroreceptor - renal nerve - ANF

47. How does renal nerve prevent syncope?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Make sure to discuss with patient - some states require reporting
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
^SV (diastolic stroke volume)

48. What are the 3 stages of ADRs?
Prescribing - monitoring - patient adherence
1/2
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
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

49. i2 + atypical Sx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
No: fever - leukocytosis - yes: falls - appetite change - low functional status
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

50. How does aging affect pharmacokinetic Rx distribution?
Receptors changes: # - sensitivity - counter-regulatory moa
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Universal - progressive - partially encoded (genetic) - destructive -