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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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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. physical neglect
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
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

2. osteoporosis
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Injury - neglect - physical/psychosocial - financial - violation of rights
^SV (diastolic stroke volume)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

3. What is the best approach to malnutrition
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Treat underlying disease/lack resources
Used to calculate renal fcn - clearance of Cr adjusted for age
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

4. thyroid dx + atypical Sx
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Hyperuricemia -> gout
1/2
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

5. MRP: medication related problems
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

6. What are common physical abuse Sx in elderly?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Bone loss -> osteopenia -> osteoporosis -> Fx
Treat underlying disease/lack resources
Prescribing - monitoring - patient adherence

7. MI + atypical Sx
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
^morbidity + mortality - -frailest @ greatest risk
IdioPx - psychiatric: depression - anxiety - somatoform
No: chest pain - yes: fatigue - nausea - low functional status - SOB

8. BZD + antidepressant: interaction outcome
Phenytoin
Parkinsonism -> l-DOPA
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Confusion - sedation - falls

9. How does aging affect Rx pharmacokinetic metabolism?
High mortality - esp + Fx - very common in elderly
P2-metab: Lorazepam - Trazepam - Oxazepam
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

10. How does aging affect GI absorption of Rx?
Map of people - perceptions - etc - varies by perspective
Insiduous onset
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
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

11. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
Respect for autonomy - nonmaleficence - beneficence - justice
^BP -> a-HTN
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

12. fall causes
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Temporalis muscle wasting = temporal wasting
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

13. anticholinergic drugs may lead to what prescription cascade?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
CNS suppression -> cholinesterase inhibitors
Map of people - perceptions - etc - varies by perspective
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

14. substituted judgment
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
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
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

15. How does aging affect Rx renal elimination?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Catch-all of unspecified dizziness
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

16. What is capacity?
Determined by Dr for a patient - -> used to determine competency
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Begin @25-50% recommended dose - APAP may be dose-limiting

17. lipid-soluble Rx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Universal - progressive - partially encoded (genetic) - destructive -
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

18. 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
Multisystemic vulnerability - -lowered reserves
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Screen for potentially embarrassing dx - patient/Dr trust

19. What are the common causes of lightheadedness?
Mechanical loading - skin care - avoid friction/shear
IdioPx - psychiatric: depression - anxiety - somatoform
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Appointed by court if no substituted judgment -conservator of finance -conservator of person

20. conservator
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Electrolyte imbalance - arrhythmia
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

21. What are common medical causes of syncope?
Parkinsonism -> l-DOPA
Beers criteria - medication appropriateness index (12 ?)
Hyperuricemia -> gout
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

22. Disequilibrium
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Cholinesterase inhib - use: dementia
Isolated systolic HTN
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

23. restrain requirements
^SV (diastolic stroke volume)
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
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

24. galantamine
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Cholinesterase inhib - use: dementia
Hyperuricemia -> gout
Confusion - sedation - falls

25. delirium incidence
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
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
Threats/ terrorizing - isolation - denying food/privileges/liberty
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

26. What is a PE sign of cachexia?
Delayed absorption - like competitive inhib
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Begin @25-50% recommended dose - APAP may be dose-limiting
Temporalis muscle wasting = temporal wasting

27. how is syncope related to elderly admission to hospital?
28% - ADR: 17% - non-compliance 11%
80% of hospital admission for syncope for >65yo
P2-metab: Lorazepam - Trazepam - Oxazepam
Electrolyte imbalance - arrhythmia

28. rivastigmine
^SV (diastolic stroke volume)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Cholinesterase inhib - use: dementia
BMD (bone mineral density): T-score >2.5 std dev below normal 1

29. What are the pharmacodynamic changes associated with aging?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Receptors changes: # - sensitivity - counter-regulatory moa
Bone loss -> osteopenia -> osteoporosis -> Fx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

30. how can you determine whether Rx is appropriate to use in elderly patient?
Beers criteria - medication appropriateness index (12 ?)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

31. What are the common types of elder mistreatment?
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
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
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
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

32. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
80% of hospital admission for syncope for >65yo
Constipation -> laxatives

33. Syncope prognosis based on etio
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
30% preventable - of these - 40% serious - of these 40% preventable
Worse for cardiac causes v noncardia
High mortality - esp + Fx - very common in elderly

34. urge incontinence tx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

35. memantine
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
NMDR antagonist - use: dementia
Cholinesterase inhib - use: dementia
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

36. violation of rights
Insiduous onset
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
>60yo - low abuse risk - ^ monitoring possible
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

37. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Figure out a good diet - social aspect - resources - dental/oral comfort
#1 patient's last competent indication of wishes - substituted judgment - beneficence
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

38. How does an 80yo renal fcn compare to that of a 20yo?
Consider responsibilities - drivin
1/2
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

39. red flags for further inquiry
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Vertigo - presyncope - disequilibrium - lightheadedness
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

40. vertigo
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
80% of hospital admission for syncope for >65yo
Multisystemic vulnerability - -lowered reserves

41. How does sliding scale glycemic control relate to elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
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
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

42. what can enhance reporting in elderly?
ANF: Na+ retention - disinhib vasoconstriction
No: fever - leukocytosis - yes: falls - appetite change - low functional status
>9 Rx
Screen for potentially embarrassing dx - patient/Dr trust

43. Why is abuse underreported?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Catch-all of unspecified dizziness
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
F>M (until 80yo) - stress incontinence #1 - $26B/yr

44. pulm edema + atypical Sx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Insiduous onset
Confusion - sedation - falls

45. 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
Receptors changes: # - sensitivity - counter-regulatory moa
CNS suppression -> cholinesterase inhibitors

46. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Constipation -> laxatives
Delayed absorption - like competitive inhib

47. what mechanical loading helps to prevent pressure ulcers?
30% preventable - of these - 40% serious - of these 40% preventable
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Doctors

48. refusing intervention
Stress: #1 - functional - urge - overflow
>9 Rx
Legal: Cruzan v Hamon
CVA: stroke - AMI: acute MI - HF

49. elderly abuse epidemiology
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
5% - underreported
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

50. what nutritional interventions help underweight?
Mechanical loading - skin care - avoid friction/shear
Electrolyte imbalance - arrhythmia
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding