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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 common causes of lightheadedness?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Map of people - perceptions - etc - varies by perspective
IdioPx - psychiatric: depression - anxiety - somatoform
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

2. describe the % of ADR considered preventable - and of those serious
30% preventable - of these - 40% serious - of these 40% preventable
Worse for cardiac causes v noncardia
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Constipation -> laxatives

3. What are common scenarios of untreated indications in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

4. What are the 4 basic ethical principles?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Respect for autonomy - nonmaleficence - beneficence - justice
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

5. incontinence complication
1/2
^morbidity + mortality - -frailest @ greatest risk
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

6. delirium predisposing rf
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Breast cancer + 2o LBP
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

7. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Breast cancer + 2o LBP

8. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Therapy - SSRI

9. What is the Cockcroft Gault equation?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Used to calculate renal fcn - clearance of Cr adjusted for age
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

10. What are common physical abuse Sx in elderly?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Injury - neglect - physical/psychosocial - financial - violation of rights
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

11. How does aging affect pharmacokinetics?
>9 Rx
Cholinesterase inhib - use: dementia
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

12. BZD + antipsychotic: interaction outcome
Threats/ terrorizing - isolation - denying food/privileges/liberty
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
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

13. How does aging affect Rx pharmacokinetic distribution?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Beers criteria - medication appropriateness index (12 ?)
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. overflow incontinence tx
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
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

15. What is capacity?
Make sure to discuss with patient - some states require reporting
1/2
Insiduous onset
Determined by Dr for a patient - -> used to determine competency

16. delirium: Rx that contribute
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
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
#1 patient's last competent indication of wishes - substituted judgment - beneficence

17. substituted judgment
Hypotension - ^K+
^morbidity + mortality - -frailest @ greatest risk
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

18. advanced directive/care plan

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19. delirium: tx approach
Screen for potentially embarrassing dx - patient/Dr trust
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Environment modification: obstacles - mobility - -bladder fcn ok

20. How does aging affect GI absorption rate of Rx?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Delayed absorption - like competitive inhib
F>M (until 80yo) - stress incontinence #1 - $26B/yr

21. falls epidemiology
Figure out a good diet - social aspect - resources - dental/oral comfort
NMDR antagonist - use: dementia
#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

22. malignancy + atypical Sx
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Breast cancer + 2o LBP
>9 Rx
28% - ADR: 17% - non-compliance 11%

23. psychological abuse
3 reflexes: baroreceptor - renal nerve - ANF
Threats/ terrorizing - isolation - denying food/privileges/liberty
Parkinsonism -> l-DOPA
BMD (bone mineral density): T-score >2.5 std dev below normal 1

24. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
30% preventable - of these - 40% serious - of these 40% preventable
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Temporalis muscle wasting = temporal wasting

25. How does the aging heart compensate for lower HR to maintain unchanged CO?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
^SV (diastolic stroke volume)
5% - underreported
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

26. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
1/2
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

27. What is abuse?
Injury - neglect - physical/psychosocial - financial - violation of rights
Treat underlying disease/lack resources
Map of people - perceptions - etc - varies by perspective
Constipation -> laxatives

28. What are the hazards of elderly hospitalization?
Catch-all of unspecified dizziness
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
^K+
^morbidity + mortality - -frailest @ greatest risk

29. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Constipation -> laxatives
Used to calculate renal fcn - clearance of Cr adjusted for age
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

30. What are the pharmacodynamic changes associated with aging?
Doctors
CNS suppression -> cholinesterase inhibitors
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Receptors changes: # - sensitivity - counter-regulatory moa

31. delirium: mgmt
P2-metabolite - phase 1 biotx much more affected than phase 2
Isolated systolic HTN
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

32. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Prescribing - monitoring - patient adherence
Respect for autonomy - nonmaleficence - beneficence - justice
Breast cancer + 2o LBP

33. using long-acting opioids in elderly
Cholinesterase inhib - use: dementia
ANF: Na+ retention - disinhib vasoconstriction
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
1/2

34. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Hyperuricemia -> gout

35. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
IdioPx - psychiatric: depression - anxiety - somatoform
Falls - delirium - malnutrition - P ulcers - opportunistic i2

36. incontinence epidemiology
Figure out a good diet - social aspect - resources - dental/oral comfort
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
>9 Rx

37. conservator
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

38. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Make sure to discuss with patient - some states require reporting

39. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Figure out a good diet - social aspect - resources - dental/oral comfort
28% - ADR: 17% - non-compliance 11%

40. How to prevent pressure ulcers?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Begin @25-50% recommended dose - APAP may be dose-limiting
Mechanical loading - skin care - avoid friction/shear
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

41. Presyncope
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Injury - neglect - physical/psychosocial - financial - violation of rights

42. How does aging affect Rx pharmacokinetic metabolism?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
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
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Appointed by court if no substituted judgment -conservator of finance -conservator of person

43. What is sCr?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Serum Cr: used for Cr clearance equation
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Hyperuricemia -> gout

44. How does aging affect GI absorption of Rx?
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
1/2
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

45. which benzodiazepines are most appropriate for elderly?
>60yo - low abuse risk - ^ monitoring possible
5% - underreported
P2-metab: Lorazepam - Trazepam - Oxazepam
P2-metabolite - phase 1 biotx much more affected than phase 2

46. How does aging affect pharmacokinetic protein binding?
Cachexia - PEM - FTT - obesity
Make sure to discuss with patient - some states require reporting
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
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

47. what Rx are commonly monifoted in elderly for ADR?
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Electrolyte imbalance - arrhythmia

48. How does sliding scale glycemic control relate to elderly?
High mortality - esp + Fx - very common in elderly
Make sure to discuss with patient - some states require reporting
Injury - neglect - physical/psychosocial - financial - violation of rights
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

49. What are common medical causes of syncope?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Voice - character - plot - context - time - reader
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

50. How does aging affect Rx renal elimination?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
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: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health