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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 is the epidemiology of dizziness?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

2. What are the rf for elderly abuse?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Stress: #1 - functional - urge - overflow

3. functional incontinence tx
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
28% - ADR: 17% - non-compliance 11%
Screen for potentially embarrassing dx - patient/Dr trust
Environment modification: obstacles - mobility - -bladder fcn ok

4. cachexia
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
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
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

5. what professional is least likely to report abuse?
Diagnosis - risk/benefit analysis to choose Rx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Hyperuricemia -> gout
Doctors

6. osteopenia
^morbidity + mortality - -frailest @ greatest risk
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

7. driving considerations
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
^morbidity + mortality - -frailest @ greatest risk
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Make sure to discuss with patient - some states require reporting

8. acute abdomen + atypical Sx
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Constipation -> laxatives
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

9. What are rf for osteoporosis?
Diagnosis - risk/benefit analysis to choose Rx
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Figure out a good diet - social aspect - resources - dental/oral comfort
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

10. who is a good candidate for opioid tx?
Catch-all of unspecified dizziness
High mortality - esp + Fx - very common in elderly
>60yo - low abuse risk - ^ monitoring possible
Delayed absorption - like competitive inhib

11. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
>60yo - low abuse risk - ^ monitoring possible

12. psychological abuse
>9 Rx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Threats/ terrorizing - isolation - denying food/privileges/liberty
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

13. How does the aging heart compensate for lower HR to maintain unchanged CO?
Hypotension - ^K+
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^SV (diastolic stroke volume)
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

14. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
>60yo - low abuse risk - ^ monitoring possible
Therapy - SSRI
5% - underreported

15. How does aging impact syncope-preventing reflexes
Tx underlying etio - + Kegels - pessary - surgery
80% of hospital admission for syncope for >65yo
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

16. fall sequelae

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17. physical neglect
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Hypotension - ^K+
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

18. What are the hazards of elderly hospitalization?
Hypotension - ^K+
30% preventable - of these - 40% serious - of these 40% preventable
^morbidity + mortality - -frailest @ greatest risk
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

19. What is the STOPP criteria?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
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

20. What are the 3 sentinel events for LT care?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
NMDR antagonist - use: dementia
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Pressure ulcer - fecal impaction - dehydration

21. Cockcroft Gault equation
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
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
F>M (until 80yo) - stress incontinence #1 - $26B/yr
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

22. falls epidemiology
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Map of people - perceptions - etc - varies by perspective

23. anticholinergic drugs may lead to what prescription cascade?
Pressure ulcer - fecal impaction - dehydration
CNS suppression -> cholinesterase inhibitors
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
No: fever - leukocytosis - yes: falls - appetite change - low functional status

24. urge incontinence tx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Figure out a good diet - social aspect - resources - dental/oral comfort
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

25. restrain requirements
Environment modification: obstacles - mobility - -bladder fcn ok
Therapy - SSRI
Confusion - sedation - falls
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

26. MRP: medication related problems
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

27. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
28% - ADR: 17% - non-compliance 11%
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

28. NSAID may lead to what prescription cascade?
^BP -> a-HTN
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Map of people - perceptions - etc - varies by perspective

29. What are the 4 basic ethical principles?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Stress: #1 - functional - urge - overflow
Figure out a good diet - social aspect - resources - dental/oral comfort
Respect for autonomy - nonmaleficence - beneficence - justice

30. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Used to calculate renal fcn - clearance of Cr adjusted for age
Constipation -> laxatives

31. What are the common types of elder mistreatment?
1/2
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Confusion - sedation - falls
CNS suppression -> cholinesterase inhibitors

32. How does aging affect pharmacokinetics?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Mechanical loading - skin care - avoid friction/shear
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
F>M (until 80yo) - stress incontinence #1 - $26B/yr

33. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

34. What are the risks of uncontrolled ISH?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Vertigo - presyncope - disequilibrium - lightheadedness
CVA: stroke - AMI: acute MI - HF
Cachexia - PEM - FTT - obesity

35. PEM
No: chest pain - yes: fatigue - nausea - low functional status - SOB
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

36. incontinence epidemiology
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
30% preventable - of these - 40% serious - of these 40% preventable
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
F>M (until 80yo) - stress incontinence #1 - $26B/yr

37. osteoporosis
Used to calculate renal fcn - clearance of Cr adjusted for age
5% - underreported
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
BMD (bone mineral density): T-score >2.5 std dev below normal 1

38. What are the vascular changes of presyncope?
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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

39. Why is abuse underreported?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

40. opioid tx in elderly
Beers criteria - medication appropriateness index (12 ?)
Begin @25-50% recommended dose - APAP may be dose-limiting
Catch-all of unspecified dizziness
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

41. Disequilibrium
^BP -> a-HTN
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

42. What is polypharmacy
Mechanical loading - skin care - avoid friction/shear
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
>9 Rx
Respect for autonomy - nonmaleficence - beneficence - justice

43. How does aging affect GI absorption of Rx?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
30% preventable - of these - 40% serious - of these 40% preventable
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
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

44. What is a PE sign of cachexia?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Bone loss -> osteopenia -> osteoporosis -> Fx
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
Temporalis muscle wasting = temporal wasting

45. How does ANF prevent syncope?
ANF: Na+ retention - disinhib vasoconstriction
P2-metab: Lorazepam - Trazepam - Oxazepam
>9 Rx
Insiduous onset

46. How to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
28% - ADR: 17% - non-compliance 11%

47. MI + atypical Sx
Hypotension - ^K+
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Serum Cr: used for Cr clearance equation
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

48. what can enhance reporting in elderly?
Receptors changes: # - sensitivity - counter-regulatory moa
Threats/ terrorizing - isolation - denying food/privileges/liberty
Screen for potentially embarrassing dx - patient/Dr trust
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. How does aging affect Rx pharmacokinetic distribution?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
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
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
Multisystemic vulnerability - -lowered reserves

50. what mechanical loading helps to prevent pressure ulcers?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Cholinesterase inhib - use: dementia