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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. how is syncope related to elderly admission to hospital?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
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
Environment modification: obstacles - mobility - -bladder fcn ok
80% of hospital admission for syncope for >65yo

2. delirium diagnosis
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Environment modification: obstacles - mobility - -bladder fcn ok
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

3. What is abuse?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
^SV (diastolic stroke volume)
Injury - neglect - physical/psychosocial - financial - violation of rights
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

4. ADR rf
A-blockers - B-blockers - TCA
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

5. BZD + antipsychotic: interaction outcome
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Confusion - sedation - falls
Pressure ulcer - fecal impaction - dehydration
Screen for potentially embarrassing dx - patient/Dr trust

6. What are the 4 basic ethical principles?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Electrical: change in HR - structural: aortic outflow obstruction
Voice - character - plot - context - time - reader
Respect for autonomy - nonmaleficence - beneficence - justice

7. How does aging affect GI absorption rate of Rx?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Delayed absorption - like competitive inhib

8. 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
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
>9 Rx
Used to calculate renal fcn - clearance of Cr adjusted for age

9. NSAID may lead to what prescription cascade?
Therapy - SSRI
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
^BP -> a-HTN

10. BZD + antidepressant: interaction outcome
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Screen for potentially embarrassing dx - patient/Dr trust
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Confusion - sedation - falls

11. malignancy + atypical Sx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Breast cancer + 2o LBP
Electrical: change in HR - structural: aortic outflow obstruction
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

12. ACE inhib + diuretic: interaction outcome
P2-metab: Lorazepam - Trazepam - Oxazepam
Hypotension - ^K+
High mortality - esp + Fx - very common in elderly
Temporalis muscle wasting = temporal wasting

13. What are the rf for elderly abuse?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Parkinsonism -> l-DOPA

14. Beers criteria: what 10 Rx should elderly avoid or use + caution?
P2-metab: Lorazepam - Trazepam - Oxazepam
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
80% of hospital admission for syncope for >65yo

15. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

16. What is the preferred depression treatment in elderly?
Therapy - SSRI
Cholinesterase inhib - use: dementia
IdioPx - psychiatric: depression - anxiety - somatoform
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

17. donepezil
Screen for potentially embarrassing dx - patient/Dr trust
CNS suppression -> cholinesterase inhibitors
NMDR antagonist - use: dementia
Cholinesterase inhib - use: dementia

18. frailty signs
Determined by Dr for a patient - -> used to determine competency
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Pressure ulcer - fecal impaction - dehydration

19. What are the rf for caregiver to abuse elderly?
Mechanical loading - skin care - avoid friction/shear
Used to calculate renal fcn - clearance of Cr adjusted for age
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Hypotension - ^K+

20. What are the common causes of lightheadedness?
Prescribing - monitoring - patient adherence
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
IdioPx - psychiatric: depression - anxiety - somatoform
F>M (until 80yo) - stress incontinence #1 - $26B/yr

21. clues of neglect
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Breast cancer + 2o LBP
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

22. delirium predisposing rf
Legal: Cruzan v Hamon
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Mechanical loading - skin care - avoid friction/shear
Temporalis muscle wasting = temporal wasting

23. conservator
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Appointed by court if no substituted judgment -conservator of finance -conservator of person

24. thiazide diuretic may lead to what prescription cascade?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
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
Hyperuricemia -> gout
Temporalis muscle wasting = temporal wasting

25. red flags for further inquiry
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
Bone loss -> osteopenia -> osteoporosis -> Fx
Pressure ulcer - fecal impaction - dehydration
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

26. What is sCr?
Serum Cr: used for Cr clearance equation
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
28% - ADR: 17% - non-compliance 11%
Voice - character - plot - context - time - reader

27. fall causes
Respect for autonomy - nonmaleficence - beneficence - justice
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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

28. How does aging affect Rx pharmacokinetic metabolism?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Mechanical loading - skin care - avoid friction/shear
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Figure out a good diet - social aspect - resources - dental/oral comfort

29. What is a PE sign of cachexia?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Temporalis muscle wasting = temporal wasting

30. What is the bone deterioration cascade?
^morbidity + mortality - -frailest @ greatest risk
Breast cancer + 2o LBP
Bone loss -> osteopenia -> osteoporosis -> Fx
CNS suppression -> cholinesterase inhibitors

31. Beers criteria
CVA: stroke - AMI: acute MI - HF
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
Confusion - sedation - falls
Pressure ulcer - fecal impaction - dehydration

32. How to prevent pressure ulcers?
1/2
Phenytoin
Tx underlying etio - + Kegels - pessary - surgery
Mechanical loading - skin care - avoid friction/shear

33. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

34. What are the 3 sentinel events for LT care?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Pressure ulcer - fecal impaction - dehydration
IdioPx - psychiatric: depression - anxiety - somatoform
Confusion - sedation - falls

35. What is polypharmacy
>9 Rx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Begin @25-50% recommended dose - APAP may be dose-limiting
Threats/ terrorizing - isolation - denying food/privileges/liberty

36. What are common physical abuse Sx in elderly?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Parkinsonism -> l-DOPA
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
3 reflexes: baroreceptor - renal nerve - ANF

37. ACE inhib + K+: interaction outcome
^K+
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

38. preventing malnutrition
Make sure to discuss with patient - some states require reporting
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Figure out a good diet - social aspect - resources - dental/oral comfort
Therapy - SSRI

39. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Beers criteria - medication appropriateness index (12 ?)
Universal - progressive - partially encoded (genetic) - destructive -

40. vision changes: elderly
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Respect for autonomy - nonmaleficence - beneficence - justice
CVA: stroke - AMI: acute MI - HF
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

41. advanced directive/care plan

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42. pulm edema + atypical Sx
Insiduous onset
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Beers criteria - medication appropriateness index (12 ?)
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

43. delirium: Rx that contribute
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

44. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Confusion - sedation - falls
Delayed absorption - like competitive inhib

45. How does aging impact syncope-preventing reflexes
^morbidity + mortality - -frailest @ greatest risk
Delayed absorption - like competitive inhib
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Worse for cardiac causes v noncardia

46. incontinence epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
High mortality - esp + Fx - very common in elderly
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

47. lipid-soluble Rx
3 reflexes: baroreceptor - renal nerve - ANF
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

48. Aging descriptors
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

49. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
Treat underlying disease/lack resources
Environment modification: obstacles - mobility - -bladder fcn ok
>9 Rx

50. memantine
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
NMDR antagonist - use: dementia
>60yo - low abuse risk - ^ monitoring possible