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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. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

2. delirium: medical rf
ANF: Na+ retention - disinhib vasoconstriction
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

3. urinary incontinence types
Legal: Cruzan v Hamon
Stress: #1 - functional - urge - overflow
Tx underlying etio - + Kegels - pessary - surgery
Cholinesterase inhib - use: dementia

4. delirium: tx approach
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Injury - neglect - physical/psychosocial - financial - violation of rights
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

5. memantine
Make sure to discuss with patient - some states require reporting
NMDR antagonist - use: dementia
Hypothetical plan - serves as patient's last competent indicated wishes
Cholinesterase inhib - use: dementia

6. What are the risks of uncontrolled ISH?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
^BP -> a-HTN
CVA: stroke - AMI: acute MI - HF
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

7. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
Make sure to discuss with patient - some states require reporting
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

8. What is a mattering map?
5% - underreported
Electrical: change in HR - structural: aortic outflow obstruction
Map of people - perceptions - etc - varies by perspective
30% preventable - of these - 40% serious - of these 40% preventable

9. urge incontinence tx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Hypotension - ^K+
NMDR antagonist - use: dementia
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

10. What are the 4 basic ethical principles?
Isolated systolic HTN
High mortality - esp + Fx - very common in elderly
Respect for autonomy - nonmaleficence - beneficence - justice
P2-metabolite - phase 1 biotx much more affected than phase 2

11. incontinence complication
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
IdioPx - psychiatric: depression - anxiety - somatoform
Isolated systolic HTN
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

12. rivastigmine
Cholinesterase inhib - use: dementia
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

13. How to prevent pressure ulcers?
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Mechanical loading - skin care - avoid friction/shear

14. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Phenytoin
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

15. How does aging impact syncope-preventing reflexes
28% - ADR: 17% - non-compliance 11%
NMDR antagonist - use: dementia
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

16. PEM
Insiduous onset
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Injury - neglect - physical/psychosocial - financial - violation of rights
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

17. which benzodiazepines are most appropriate for elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
BMD (bone mineral density): T-score >2.5 std dev below normal 1
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
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

18. fall sequelae

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19. How does renal nerve prevent syncope?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Temporalis muscle wasting = temporal wasting
#1 patient's last competent indication of wishes - substituted judgment - beneficence
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

20. delirium: Rx that contribute
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
P2-metab: Lorazepam - Trazepam - Oxazepam
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

21. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Figure out a good diet - social aspect - resources - dental/oral comfort
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

22. acute abdomen + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
^SV (diastolic stroke volume)
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

23. BZD + antipsychotic: interaction outcome
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Diagnosis - risk/benefit analysis to choose Rx
Confusion - sedation - falls
^K+

24. how is the CAM used to diagnose delirium?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Parkinsonism -> l-DOPA
Serum Cr: used for Cr clearance equation

25. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

26. BZD + antidepressant: interaction outcome
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
^ANS tone -> ^periph vasoconstriction - ^HR
Confusion - sedation - falls

27. How does aging affect Rx pharmacokinetic distribution?
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
Temporalis muscle wasting = temporal wasting
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Consider responsibilities - drivin

28. MRP: medication related problems
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
80% of hospital admission for syncope for >65yo
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
^morbidity + mortality - -frailest @ greatest risk

29. ADR rf
Delayed absorption - like competitive inhib
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Doctors

30. What are the common causes of lightheadedness?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
IdioPx - psychiatric: depression - anxiety - somatoform
Mechanical loading - skin care - avoid friction/shear
Prescribing - monitoring - patient adherence

31. documenting elderly abuse

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32. refusing intervention
>9 Rx
Legal: Cruzan v Hamon
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Treat underlying disease/lack resources

33. What is the Cockcroft Gault equation?
Hypotension - ^K+
Respect for autonomy - nonmaleficence - beneficence - justice
Used to calculate renal fcn - clearance of Cr adjusted for age
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

34. what normally prevents syncope?
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
3 reflexes: baroreceptor - renal nerve - ANF
Breast cancer + 2o LBP
1/2

35. malignancy + atypical Sx
Breast cancer + 2o LBP
Voice - character - plot - context - time - reader
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
^ANS tone -> ^periph vasoconstriction - ^HR

36. osteoporosis
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Hypothetical plan - serves as patient's last competent indicated wishes
Threats/ terrorizing - isolation - denying food/privileges/liberty

37. metoclopramide may lead to what prescription cascade?
Hyperuricemia -> gout
Parkinsonism -> l-DOPA
Isolated systolic HTN
Treat underlying disease/lack resources

38. how is syncope related to elderly admission to hospital?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
80% of hospital admission for syncope for >65yo

39. What is a PE sign of cachexia?
Temporalis muscle wasting = temporal wasting
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

40. pressure ulcer: staging
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Vertigo - presyncope - disequilibrium - lightheadedness
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

41. What is the bone deterioration cascade?
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
Bone loss -> osteopenia -> osteoporosis -> Fx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Hyperuricemia -> gout

42. galantamine
Cholinesterase inhib - use: dementia
CVA: stroke - AMI: acute MI - HF
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

43. delirium incidence
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Cholinesterase inhib - use: dementia
High mortality - esp + Fx - very common in elderly

44. cachexia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Map of people - perceptions - etc - varies by perspective
5% - underreported
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

45. What are the hazards of elderly hospitalization?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
3 reflexes: baroreceptor - renal nerve - ANF
^morbidity + mortality - -frailest @ greatest risk
Doctors

46. violation of rights
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
>60yo - low abuse risk - ^ monitoring possible
Insiduous onset

47. What is the natural history of syncope?
Determined by Dr for a patient - -> used to determine competency
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Therapy - SSRI

48. How does aging affect pharmacokinetic Rx distribution?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Figure out a good diet - social aspect - resources - dental/oral comfort
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

49. malnutrition
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

50. What are the vascular changes of presyncope?
5% - underreported
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Phenytoin
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)