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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 are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Cholinesterase inhib - use: dementia
A-blockers - B-blockers - TCA

2. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Figure out a good diet - social aspect - resources - dental/oral comfort
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

3. frailty
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Multisystemic vulnerability - -lowered reserves
Screen for potentially embarrassing dx - patient/Dr trust
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

4. MRP: medication related problems
Catch-all of unspecified dizziness
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

5. osteopenia
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Breast cancer + 2o LBP

6. what % of hospitalizations of elderly are due to ADR + noncompliance?
^K+
28% - ADR: 17% - non-compliance 11%
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
Vertigo - presyncope - disequilibrium - lightheadedness

7. clues of neglect
Electrolyte imbalance - arrhythmia
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
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
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

8. What are the common types of elder mistreatment?
Make sure to discuss with patient - some states require reporting
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

9. How does ANF prevent syncope?
^K+
ANF: Na+ retention - disinhib vasoconstriction
Diagnosis - risk/benefit analysis to choose Rx
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

10. What are the common causes of lightheadedness?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
IdioPx - psychiatric: depression - anxiety - somatoform
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

11. What are rf for osteoporosis?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

12. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
^morbidity + mortality - -frailest @ greatest risk

13. preventing malnutrition
Falls - delirium - malnutrition - P ulcers - opportunistic i2
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
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Figure out a good diet - social aspect - resources - dental/oral comfort

14. rivastigmine
Cholinesterase inhib - use: dementia
Map of people - perceptions - etc - varies by perspective
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Isolated systolic HTN

15. when selecting an P1-metabolite or P2-metabolite safer in elderly?
1/2
Confusion - sedation - falls
P2-metabolite - phase 1 biotx much more affected than phase 2
Prescribing - monitoring - patient adherence

16. what mechanical loading helps to prevent pressure ulcers?
Diagnosis - risk/benefit analysis to choose Rx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

17. What is the preferred depression treatment in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
30% preventable - of these - 40% serious - of these 40% preventable
Therapy - SSRI

18. What is a mattering map?
Respect for autonomy - nonmaleficence - beneficence - justice
Map of people - perceptions - etc - varies by perspective
30% preventable - of these - 40% serious - of these 40% preventable
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

19. narcotics may lead to what prescription cascade?
IdioPx - psychiatric: depression - anxiety - somatoform
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Constipation -> laxatives
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

20. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Confusion - sedation - falls

21. What are the pharmacodynamic changes associated with aging?
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Receptors changes: # - sensitivity - counter-regulatory moa
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

22. BZD + antidepressant: interaction outcome
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
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
Confusion - sedation - falls

23. antiarrhythmic + diuretic: interaction outcome
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Electrolyte imbalance - arrhythmia
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Confusion - sedation - falls

24. How does renal nerve prevent syncope?
>60yo - low abuse risk - ^ monitoring possible
Cachexia - PEM - FTT - obesity
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

25. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
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
Hypotension - ^K+

26. lightheadedness
Electrolyte imbalance - arrhythmia
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Catch-all of unspecified dizziness
BMD (bone mineral density): T-score >2.5 std dev below normal 1

27. galantamine
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Hyperuricemia -> gout
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Cholinesterase inhib - use: dementia

28. What is the best approach to malnutrition
Treat underlying disease/lack resources
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
NMDR antagonist - use: dementia

29. ACE inhib + K+: interaction outcome
Environment modification: obstacles - mobility - -bladder fcn ok
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
^K+
28% - ADR: 17% - non-compliance 11%

30. Aging features
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
Universal - progressive - partially encoded (genetic) - destructive -
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
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

31. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
NMDR antagonist - use: dementia
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
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

32. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Beers criteria - medication appropriateness index (12 ?)
Hyperuricemia -> gout

33. PEM
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Serum Cr: used for Cr clearance equation
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Pressure ulcer - fecal impaction - dehydration

34. nutrition syndromes
Cachexia - PEM - FTT - obesity
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
ANF: Na+ retention - disinhib vasoconstriction
Cholinesterase inhib - use: dementia

35. thyroid dx + atypical Sx
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Determined by Dr for a patient - -> used to determine competency
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

36. BZD + antipsychotic: interaction outcome
Beers criteria - medication appropriateness index (12 ?)
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Confusion - sedation - falls

37. How does aging affect Rx pharmacokinetic metabolism?
Multisystemic vulnerability - -lowered reserves
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

38. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Determined by Dr for a patient - -> used to determine competency
Confusion - sedation - falls

39. opioid tx in elderly
F>M (until 80yo) - stress incontinence #1 - $26B/yr
P2-metabolite - phase 1 biotx much more affected than phase 2
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Begin @25-50% recommended dose - APAP may be dose-limiting

40. malnutrition
Mechanical loading - skin care - avoid friction/shear
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
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

41. delirium: mgmt
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
IdioPx - psychiatric: depression - anxiety - somatoform
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

42. osteoporosis epidemiology
NMDR antagonist - use: dementia
High mortality - esp + Fx - very common in elderly
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

43. How does an 80yo renal fcn compare to that of a 20yo?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
ANF: Na+ retention - disinhib vasoconstriction
1/2
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

44. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
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
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

45. What is sCr?
Serum Cr: used for Cr clearance equation
Cachexia - PEM - FTT - obesity
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Isolated systolic HTN

46. osteoporosis
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Worse for cardiac causes v noncardia
BMD (bone mineral density): T-score >2.5 std dev below normal 1
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

47. delirium: Rx that contribute
>9 Rx
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Therapy - SSRI

48. vertigo
Worse for cardiac causes v noncardia
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Voice - character - plot - context - time - reader
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

49. Presyncope
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
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
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
#1 patient's last competent indication of wishes - substituted judgment - beneficence

50. What are the vascular changes of presyncope?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Determined by Dr for a patient - -> used to determine competency
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
No: fever - leukocytosis - yes: falls - appetite change - low functional status