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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. MI + atypical Sx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Multisystemic vulnerability - -lowered reserves
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

2. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Doctors
Injury - neglect - physical/psychosocial - financial - violation of rights
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

3. nutrition syndromes
Cachexia - PEM - FTT - obesity
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Cholinesterase inhib - use: dementia

4. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Determined by Dr for a patient - -> used to determine competency
^morbidity + mortality - -frailest @ greatest risk
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

5. documenting elderly abuse

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6. Syncope prognosis based on etio
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Stress: #1 - functional - urge - overflow
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Worse for cardiac causes v noncardia

7. ACE inhib + diuretic: interaction outcome
Delayed absorption - like competitive inhib
Insiduous onset
Hypotension - ^K+
ANF: Na+ retention - disinhib vasoconstriction

8. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Used to calculate renal fcn - clearance of Cr adjusted for age
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

9. delirium: tx approach
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Hypotension - ^K+
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
80% of hospital admission for syncope for >65yo

10. What is the STOPP criteria?
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
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
BMD (bone mineral density): T-score >2.5 std dev below normal 1
28% - ADR: 17% - non-compliance 11%

11. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Legal: Cruzan v Hamon
Isolated systolic HTN
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

12. red flags for further inquiry
Map of people - perceptions - etc - varies by perspective
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
1/2
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

13. How does aging affect pharmacokinetic protein binding?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Legal: Cruzan v Hamon

14. tube feeding
>60yo - low abuse risk - ^ monitoring possible
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Treat underlying disease/lack resources
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

15. anticholinergic drugs may lead to what prescription cascade?
Determined by Dr for a patient - -> used to determine competency
CNS suppression -> cholinesterase inhibitors
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Treat underlying disease/lack resources

16. i2 + atypical Sx
Bone loss -> osteopenia -> osteoporosis -> Fx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Legal: Cruzan v Hamon

17. What is abuse?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Injury - neglect - physical/psychosocial - financial - violation of rights

18. How does aging affect GI absorption of Rx?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

19. how is cachexia different from wasting?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
ANF: Na+ retention - disinhib vasoconstriction
Doctors
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

20. acute abdomen + atypical Sx
Confusion - sedation - falls
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

21. ACE inhib + K+: interaction outcome
Diagnosis - risk/benefit analysis to choose Rx
#1 patient's last competent indication of wishes - substituted judgment - beneficence
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
^K+

22. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
P2-metabolite - phase 1 biotx much more affected than phase 2
Beers criteria - medication appropriateness index (12 ?)
Cholinesterase inhib - use: dementia

23. what ADR are common in elderly patient?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

24. How does an 80yo renal fcn compare to that of a 20yo?
1/2
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Electrical: change in HR - structural: aortic outflow obstruction
^ANS tone -> ^periph vasoconstriction - ^HR

25. What is polypharmacy
Vertigo - presyncope - disequilibrium - lightheadedness
>9 Rx
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
28% - ADR: 17% - non-compliance 11%

26. opioid tx in elderly
Vertigo - presyncope - disequilibrium - lightheadedness
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Begin @25-50% recommended dose - APAP may be dose-limiting
Determined by Dr for a patient - -> used to determine competency

27. metoclopramide may lead to what prescription cascade?
Universal - progressive - partially encoded (genetic) - destructive -
Respect for autonomy - nonmaleficence - beneficence - justice
Parkinsonism -> l-DOPA
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

28. conservator
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
A-blockers - B-blockers - TCA
Appointed by court if no substituted judgment -conservator of finance -conservator of person

29. elderly abuse epidemiology
5% - underreported
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Treat underlying disease/lack resources

30. stress incontinence tx
Begin @25-50% recommended dose - APAP may be dose-limiting
^SV (diastolic stroke volume)
Tx underlying etio - + Kegels - pessary - surgery
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

31. surrogate decision making heirarchy

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32. dementia tx
NMDR antagonist - use: dementia
^morbidity + mortality - -frailest @ greatest risk
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Environment modification: obstacles - mobility - -bladder fcn ok

33. NSAID 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
^BP -> a-HTN
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Hypotension - ^K+

34. What are rf for osteoporosis?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
CNS suppression -> cholinesterase inhibitors
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Treat underlying disease/lack resources

35. frailty
Multisystemic vulnerability - -lowered reserves
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
BMD (bone mineral density): T-score >2.5 std dev below normal 1

36. Disequilibrium
^SV (diastolic stroke volume)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Confusion - sedation - falls

37. How does sliding scale glycemic control relate to elderly?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Vertigo - presyncope - disequilibrium - lightheadedness
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

38. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Electrical: change in HR - structural: aortic outflow obstruction
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
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

39. thyroid dx + atypical Sx
Determined by Dr for a patient - -> used to determine competency
Cholinesterase inhib - use: dementia
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
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

40. cachexia
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
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

41. How does aging affect Rx pharmacokinetic distribution?
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
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
Insiduous onset

42. delirium: medical rf
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
CNS suppression -> cholinesterase inhibitors
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

43. pulm edema + atypical Sx
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Insiduous onset
CNS suppression -> cholinesterase inhibitors
Falls - delirium - malnutrition - P ulcers - opportunistic i2

44. What is the Cockcroft Gault equation?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Used to calculate renal fcn - clearance of Cr adjusted for age
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

45. What are common physical abuse Sx in elderly?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Beers criteria - medication appropriateness index (12 ?)
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

46. malignancy + atypical Sx
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
IdioPx - psychiatric: depression - anxiety - somatoform
Breast cancer + 2o LBP
Cholinesterase inhib - use: dementia

47. rivastigmine
Treat underlying disease/lack resources
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Cholinesterase inhib - use: dementia
Environment modification: obstacles - mobility - -bladder fcn ok

48. LBW equation
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

49. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Voice - character - plot - context - time - reader
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

50. rule of doable effect
1/2
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear