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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. NSAID may lead to what prescription cascade?
>60yo - low abuse risk - ^ monitoring possible
Multisystemic vulnerability - -lowered reserves
^BP -> a-HTN
Make sure to discuss with patient - some states require reporting

2. LBW equation
^ANS tone -> ^periph vasoconstriction - ^HR
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Delayed absorption - like competitive inhib
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

3. depression + atypical Sx
Begin @25-50% recommended dose - APAP may be dose-limiting
Cholinesterase inhib - use: dementia
BMD (bone mineral density): T-score >2.5 std dev below normal 1
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

4. What are the key points of safe prescription for elderly - lecture
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
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
Diagnosis - risk/benefit analysis to choose Rx
Consider responsibilities - drivin

5. How does aging increase incontinence?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
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
Injury - neglect - physical/psychosocial - financial - violation of rights
Environment modification: obstacles - mobility - -bladder fcn ok

6. elderly abuse epidemiology
5% - underreported
Stress: #1 - functional - urge - overflow
30% preventable - of these - 40% serious - of these 40% preventable
Consider responsibilities - drivin

7. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Appointed by court if no substituted judgment -conservator of finance -conservator of person

8. How does baroreceptor reflex prevent syncope?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Confusion - sedation - falls
^ANS tone -> ^periph vasoconstriction - ^HR

9. substituted judgment
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Cholinesterase inhib - use: dementia
Confusion - sedation - falls

10. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
#1 patient's last competent indication of wishes - substituted judgment - beneficence
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

11. How does aging impact syncope-preventing reflexes
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Consider responsibilities - drivin

12. MI + atypical Sx
Begin @25-50% recommended dose - APAP may be dose-limiting
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
No: chest pain - yes: fatigue - nausea - low functional status - SOB

13. what professional is least likely to report abuse?
Receptors changes: # - sensitivity - counter-regulatory moa
Pressure ulcer - fecal impaction - dehydration
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Doctors

14. How does aging affect Rx pharmacokinetic distribution?
Bone loss -> osteopenia -> osteoporosis -> Fx
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
Map of people - perceptions - etc - varies by perspective
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

15. preventing malnutrition
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Figure out a good diet - social aspect - resources - dental/oral comfort
Respect for autonomy - nonmaleficence - beneficence - justice
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

16. physical neglect
Appointed by court if no substituted judgment -conservator of finance -conservator of person
80% of hospital admission for syncope for >65yo
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

17. PEM
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Used to calculate renal fcn - clearance of Cr adjusted for age
Vertigo - presyncope - disequilibrium - lightheadedness
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

18. narcotics may lead to what prescription cascade?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Constipation -> laxatives
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
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

19. what illnesses are underreported in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
^BP -> a-HTN
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

20. Presyncope
^ANS tone -> ^periph vasoconstriction - ^HR
Universal - progressive - partially encoded (genetic) - destructive -
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

21. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

22. What are the narrative elements of clinical ethics?
Voice - character - plot - context - time - reader
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

23. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Breast cancer + 2o LBP
Bone loss -> osteopenia -> osteoporosis -> Fx

24. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

25. conservator
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
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Appointed by court if no substituted judgment -conservator of finance -conservator of person

26. Alb-bound Rx
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Phenytoin
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
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

27. frailty signs
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Tx underlying etio - + Kegels - pessary - surgery
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
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. i2 + atypical Sx
Hyperuricemia -> gout
No: fever - leukocytosis - yes: falls - appetite change - low functional status
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Electrical: change in HR - structural: aortic outflow obstruction

29. incontinence epidemiology
Diagnosis - risk/benefit analysis to choose Rx
Phenytoin
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Make sure to discuss with patient - some states require reporting

30. How to prevent pressure ulcers?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cholinesterase inhib - use: dementia
^ANS tone -> ^periph vasoconstriction - ^HR
Mechanical loading - skin care - avoid friction/shear

31. tube feeding
Threats/ terrorizing - isolation - denying food/privileges/liberty
Multisystemic vulnerability - -lowered reserves
Mechanical loading - skin care - avoid friction/shear
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

32. thyroid dx + atypical Sx
Cholinesterase inhib - use: dementia
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

33. What is the best approach to malnutrition
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Treat underlying disease/lack resources
Phenytoin

34. What is capacity?
Phenytoin
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Determined by Dr for a patient - -> used to determine competency
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

35. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
No: fever - leukocytosis - yes: falls - appetite change - low functional status
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

36. What are the 3 stages of ADRs?
Prescribing - monitoring - patient adherence
NMDR antagonist - use: dementia
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

37. what % of hospitalizations of elderly are due to ADR + noncompliance?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
28% - ADR: 17% - non-compliance 11%
^K+

38. how may hypertension compensate for aging?
3 reflexes: baroreceptor - renal nerve - ANF
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

39. What is sCr?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
3 reflexes: baroreceptor - renal nerve - ANF
Serum Cr: used for Cr clearance equation
Beers criteria - medication appropriateness index (12 ?)

40. What are the pharmacodynamic changes associated with aging?
Mechanical loading - skin care - avoid friction/shear
Receptors changes: # - sensitivity - counter-regulatory moa
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Stress: #1 - functional - urge - overflow

41. galantamine
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Cholinesterase inhib - use: dementia
^ANS tone -> ^periph vasoconstriction - ^HR
>9 Rx

42. cachexia
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Breast cancer + 2o LBP

43. anticholinergic drugs may lead to what prescription cascade?
Hypothetical plan - serves as patient's last competent indicated wishes
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
CNS suppression -> cholinesterase inhibitors
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

44. driving considerations
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
Make sure to discuss with patient - some states require reporting
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

45. urinary incontinence types
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Stress: #1 - functional - urge - overflow
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
CVA: stroke - AMI: acute MI - HF

46. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Receptors changes: # - sensitivity - counter-regulatory moa
ANF: Na+ retention - disinhib vasoconstriction
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

47. What is polypharmacy
Determined by Dr for a patient - -> used to determine competency
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Electrical: change in HR - structural: aortic outflow obstruction
>9 Rx

48. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Constipation -> laxatives
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
ANF: Na+ retention - disinhib vasoconstriction

49. antiarrhythmic + diuretic: interaction outcome
28% - ADR: 17% - non-compliance 11%
>9 Rx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Electrolyte imbalance - arrhythmia

50. lightheadedness
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
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Catch-all of unspecified dizziness
Electrical: change in HR - structural: aortic outflow obstruction