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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. red flags for further inquiry
Insiduous onset
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

2. anticholinergic drugs may lead to what prescription cascade?
Insiduous onset
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Beers criteria - medication appropriateness index (12 ?)
CNS suppression -> cholinesterase inhibitors

3. What is ISH?
Treat underlying disease/lack resources
Isolated systolic HTN
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Insiduous onset

4. ACE inhib + K+: interaction outcome
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
CNS suppression -> cholinesterase inhibitors
^K+

5. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Respect for autonomy - nonmaleficence - beneficence - justice
Universal - progressive - partially encoded (genetic) - destructive -

6. psychological abuse
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Screen for potentially embarrassing dx - patient/Dr trust
Threats/ terrorizing - isolation - denying food/privileges/liberty
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

7. functional incontinence tx
Hypothetical plan - serves as patient's last competent indicated wishes
Used to calculate renal fcn - clearance of Cr adjusted for age
Environment modification: obstacles - mobility - -bladder fcn ok
Falls - delirium - malnutrition - P ulcers - opportunistic i2

8. nutrition syndromes
Constipation -> laxatives
Cachexia - PEM - FTT - obesity
Respect for autonomy - nonmaleficence - beneficence - justice
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

9. what receptors decrease sensitivity with aging?
Voice - character - plot - context - time - reader
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

10. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

11. what ADR are common in elderly patient?
Confusion - sedation - falls
Vertigo - presyncope - disequilibrium - lightheadedness
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

12. 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
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Prescribing - monitoring - patient adherence
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

13. Aging principles
Hyperuricemia -> gout
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Constipation -> laxatives
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

14. frailty raises vulnerability to...
CNS suppression -> cholinesterase inhibitors
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Vertigo - presyncope - disequilibrium - lightheadedness
Falls - delirium - malnutrition - P ulcers - opportunistic i2

15. What are the rf for elderly abuse?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Cholinesterase inhib - use: dementia
Treat underlying disease/lack resources

16. What drugs can contribute to syncope?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
A-blockers - B-blockers - TCA
Falls - delirium - malnutrition - P ulcers - opportunistic i2

17. How does an 80yo renal fcn compare to that of a 20yo?
CVA: stroke - AMI: acute MI - HF
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Respect for autonomy - nonmaleficence - beneficence - justice
1/2

18. delirium diagnosis
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Mechanical loading - skin care - avoid friction/shear
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

19. physical neglect
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Falls - delirium - malnutrition - P ulcers - opportunistic i2

20. what normally prevents syncope?
Diagnosis - risk/benefit analysis to choose Rx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
3 reflexes: baroreceptor - renal nerve - ANF
Appointed by court if no substituted judgment -conservator of finance -conservator of person

21. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Confusion - sedation - falls
Electrical: change in HR - structural: aortic outflow obstruction
Therapy - SSRI

22. osteoporosis
Mechanical loading - skin care - avoid friction/shear
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

23. What are the 4 forms of dizziness?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Respect for autonomy - nonmaleficence - beneficence - justice
ANF: Na+ retention - disinhib vasoconstriction
Vertigo - presyncope - disequilibrium - lightheadedness

24. What are common physical abuse Sx in elderly?
Cholinesterase inhib - use: dementia
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

25. What are the hazards of elderly hospitalization?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
^morbidity + mortality - -frailest @ greatest risk
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

26. conservator
Hyperuricemia -> gout
Breast cancer + 2o LBP
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Beers criteria - medication appropriateness index (12 ?)

27. i2 + atypical Sx
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

28. delirium predisposing rf
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

29. What is the preferred depression treatment in elderly?
Tx underlying etio - + Kegels - pessary - surgery
Therapy - SSRI
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

30. refusing intervention
Legal: Cruzan v Hamon
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
30% preventable - of these - 40% serious - of these 40% preventable
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

31. osteoporosis etio
30% preventable - of these - 40% serious - of these 40% preventable
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
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

32. How does sliding scale glycemic control relate to elderly?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

33. what professional is least likely to report abuse?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
NMDR antagonist - use: dementia
Tx underlying etio - + Kegels - pessary - surgery
Doctors

34. advanced directive/care plan

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35. How does aging affect pharmacokinetics?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Consider responsibilities - drivin
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

36. vertigo
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Prescribing - monitoring - patient adherence
Cholinesterase inhib - use: dementia

37. Beers criteria
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
Pressure ulcer - fecal impaction - dehydration
High mortality - esp + Fx - very common in elderly
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

38. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Universal - progressive - partially encoded (genetic) - destructive -
Pressure ulcer - fecal impaction - dehydration
P2-metabolite - phase 1 biotx much more affected than phase 2
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

39. dementia tx
Diagnosis - risk/benefit analysis to choose Rx
Insiduous onset
Universal - progressive - partially encoded (genetic) - destructive -
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

40. What are the 4 basic ethical principles?
P2-metabolite - phase 1 biotx much more affected than phase 2
Respect for autonomy - nonmaleficence - beneficence - justice
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

41. narcotics may lead to what prescription cascade?
Constipation -> laxatives
Doctors
Environment modification: obstacles - mobility - -bladder fcn ok
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

42. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
NMDR antagonist - use: dementia
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
A-blockers - B-blockers - TCA

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
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Threats/ terrorizing - isolation - denying food/privileges/liberty
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

44. What are the key points of safe prescription for elderly - lecture
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Stress: #1 - functional - urge - overflow
Diagnosis - risk/benefit analysis to choose Rx
Cachexia - PEM - FTT - obesity

45. What are the rf for caregiver to abuse 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
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
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

46. What is a mattering map?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Map of people - perceptions - etc - varies by perspective
Treat underlying disease/lack resources

47. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Determined by Dr for a patient - -> used to determine competency

48. How does aging affect Rx pharmacokinetic metabolism?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
ANF: Na+ retention - disinhib vasoconstriction
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
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

49. MRP: medication related problems
P2-metab: Lorazepam - Trazepam - Oxazepam
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Hyperuricemia -> gout
Injury - neglect - physical/psychosocial - financial - violation of rights

50. malignancy + atypical Sx
Injury - neglect - physical/psychosocial - financial - violation of rights
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Cholinesterase inhib - use: dementia
Breast cancer + 2o LBP