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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 drugs can contribute to syncope?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
1/2
A-blockers - B-blockers - TCA
Hypothetical plan - serves as patient's last competent indicated wishes

2. what can enhance reporting in elderly?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Screen for potentially embarrassing dx - patient/Dr trust
Catch-all of unspecified dizziness
Used to calculate renal fcn - clearance of Cr adjusted for age

3. delirium predisposing rf
Legal: Cruzan v Hamon
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Temporalis muscle wasting = temporal wasting

4. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
1/2
BMD (bone mineral density): T-score >2.5 std dev below normal 1

5. How does aging affect Rx pharmacokinetic metabolism?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
80% of hospital admission for syncope for >65yo
Injury - neglect - physical/psychosocial - financial - violation of rights
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

6. elderly abuse epidemiology
5% - underreported
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
ANF: Na+ retention - disinhib vasoconstriction
Constipation -> laxatives

7. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

8. opioid tx in elderly
A-blockers - B-blockers - TCA
Consider responsibilities - drivin
Universal - progressive - partially encoded (genetic) - destructive -
Begin @25-50% recommended dose - APAP may be dose-limiting

9. incontinence complication
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
^K+

10. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Parkinsonism -> l-DOPA
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

11. frailty signs
Delayed absorption - like competitive inhib
Breast cancer + 2o LBP
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

12. malignancy + atypical Sx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Breast cancer + 2o LBP
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

13. thiazide diuretic may lead to what prescription cascade?
Hyperuricemia -> gout
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

14. PEM
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Beers criteria - medication appropriateness index (12 ?)
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

15. How does renal nerve prevent syncope?
Tx underlying etio - + Kegels - pessary - surgery
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Constipation -> laxatives
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

16. What are the 4 forms of dizziness?
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
Constipation -> laxatives
^SV (diastolic stroke volume)
Vertigo - presyncope - disequilibrium - lightheadedness

17. memantine
Cholinesterase inhib - use: dementia
NMDR antagonist - use: dementia
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

18. nutrition syndromes
3 reflexes: baroreceptor - renal nerve - ANF
Bone loss -> osteopenia -> osteoporosis -> Fx
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Cachexia - PEM - FTT - obesity

19. How does aging affect Rx pharmacokinetic distribution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Confusion - sedation - falls
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
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

20. pressure ulcer: staging
Cachexia - PEM - FTT - obesity
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
3 reflexes: baroreceptor - renal nerve - ANF

21. overflow incontinence tx
1/2
Make sure to discuss with patient - some states require reporting
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

22. conservator
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Appointed by court if no substituted judgment -conservator of finance -conservator of person
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Legal: Cruzan v Hamon

23. tube feeding
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
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
Make sure to discuss with patient - some states require reporting

24. driving considerations
Cholinesterase inhib - use: dementia
Injury - neglect - physical/psychosocial - financial - violation of rights
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Make sure to discuss with patient - some states require reporting

25. vision changes: elderly
3 reflexes: baroreceptor - renal nerve - ANF
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Figure out a good diet - social aspect - resources - dental/oral comfort

26. What are the 3 stages of ADRs?
P2-metab: Lorazepam - Trazepam - Oxazepam
Prescribing - monitoring - patient adherence
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

27. What are the rf for elderly abuse?
Treat underlying disease/lack resources
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
3 reflexes: baroreceptor - renal nerve - ANF
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

28. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
^K+
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
28% - ADR: 17% - non-compliance 11%

29. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
80% of hospital admission for syncope for >65yo
Used to calculate renal fcn - clearance of Cr adjusted for age

30. dementia tx
Serum Cr: used for Cr clearance equation
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
28% - ADR: 17% - non-compliance 11%
>9 Rx

31. what ADR are common in elderly patient?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

32. violation of rights
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Make sure to discuss with patient - some states require reporting
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

33. Alb-bound Rx
^BP -> a-HTN
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
1/2
Phenytoin

34. using long-acting opioids in elderly
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
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Multisystemic vulnerability - -lowered reserves
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

35. restrain requirements
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
CVA: stroke - AMI: acute MI - HF
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. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
^SV (diastolic stroke volume)
Appointed by court if no substituted judgment -conservator of finance -conservator of person

37. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
IdioPx - psychiatric: depression - anxiety - somatoform
P2-metabolite - phase 1 biotx much more affected than phase 2
80% of hospital admission for syncope for >65yo

38. documenting elderly abuse

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39. What is ISH?
Figure out a good diet - social aspect - resources - dental/oral comfort
Cachexia - PEM - FTT - obesity
Isolated systolic HTN
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

40. describe the % of ADR considered preventable - and of those serious
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
30% preventable - of these - 40% serious - of these 40% preventable
High mortality - esp + Fx - very common in elderly
IdioPx - psychiatric: depression - anxiety - somatoform

41. Aging descriptors
Treat underlying disease/lack resources
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Injury - neglect - physical/psychosocial - financial - violation of rights

42. red flags for further inquiry
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
Phenytoin
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

43. What are common medical causes of syncope?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
5% - underreported
Beers criteria - medication appropriateness index (12 ?)
Injury - neglect - physical/psychosocial - financial - violation of rights

44. What are the common causes of lightheadedness?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
IdioPx - psychiatric: depression - anxiety - somatoform

45. What are the risks of uncontrolled ISH?
A-blockers - B-blockers - TCA
CVA: stroke - AMI: acute MI - HF
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Treat underlying disease/lack resources

46. advanced directive/care plan

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47. stress incontinence tx
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Tx underlying etio - + Kegels - pessary - surgery
Map of people - perceptions - etc - varies by perspective
Falls - delirium - malnutrition - P ulcers - opportunistic i2

48. What is a mattering map?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
High mortality - esp + Fx - very common in elderly
Map of people - perceptions - etc - varies by perspective

49. rule of doable effect
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Multisystemic vulnerability - -lowered reserves
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

50. MI + atypical Sx
5% - underreported
No: chest pain - yes: fatigue - nausea - low functional status - SOB
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Map of people - perceptions - etc - varies by perspective