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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 is polypharmacy
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Phenytoin
Prescribing - monitoring - patient adherence
>9 Rx

2. NSAID may lead to what prescription cascade?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Phenytoin
^BP -> a-HTN

3. How does the aging heart compensate for lower HR to maintain unchanged CO?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Receptors changes: # - sensitivity - counter-regulatory moa
Electrical: change in HR - structural: aortic outflow obstruction
^SV (diastolic stroke volume)

4. violation of rights
Therapy - SSRI
CVA: stroke - AMI: acute MI - HF
Phenytoin
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

5. memantine
NMDR antagonist - use: dementia
Mechanical loading - skin care - avoid friction/shear
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Constipation -> laxatives

6. physical neglect
Therapy - SSRI
Delayed absorption - like competitive inhib
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Treat underlying disease/lack resources

7. vision changes: elderly
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

8. What is a mattering map?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Map of people - perceptions - etc - varies by perspective
Vertigo - presyncope - disequilibrium - lightheadedness

9. incontinence epidemiology
Doctors
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

10. BZD + antidepressant: interaction outcome
Hypothetical plan - serves as patient's last competent indicated wishes
Confusion - sedation - falls
Mechanical loading - skin care - avoid friction/shear
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

11. What are the narrative elements of clinical ethics?
Hypotension - ^K+
Parkinsonism -> l-DOPA
Voice - character - plot - context - time - reader
Temporalis muscle wasting = temporal wasting

12. What are rf for osteoporosis?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Figure out a good diet - social aspect - resources - dental/oral comfort
5% - underreported

13. How does aging affect GI absorption rate of Rx?
^ANS tone -> ^periph vasoconstriction - ^HR
Delayed absorption - like competitive inhib
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

14. which benzodiazepines are most appropriate for elderly?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
P2-metab: Lorazepam - Trazepam - Oxazepam
Phenytoin

15. Presyncope
Make sure to discuss with patient - some states require reporting
CVA: stroke - AMI: acute MI - HF
Beers criteria - medication appropriateness index (12 ?)
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

16. osteoporosis etio
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Electrolyte imbalance - arrhythmia
Parkinsonism -> l-DOPA

17. What are the 4 basic ethical principles?
>60yo - low abuse risk - ^ monitoring possible
Serum Cr: used for Cr clearance equation
Respect for autonomy - nonmaleficence - beneficence - justice
Treat underlying disease/lack resources

18. what Rx are commonly monifoted in elderly for ADR?
Insiduous onset
Therapy - SSRI
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

19. urge incontinence tx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Stress: #1 - functional - urge - overflow
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

20. What is the best approach to malnutrition
Treat underlying disease/lack resources
Confusion - sedation - falls
Threats/ terrorizing - isolation - denying food/privileges/liberty
High mortality - esp + Fx - very common in elderly

21. What are common scenarios of untreated indications in elderly?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
A-blockers - B-blockers - TCA
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Falls - delirium - malnutrition - P ulcers - opportunistic i2

22. What are the rf for caregiver to abuse elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
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

23. delirium: mgmt
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Treat underlying disease/lack resources
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

24. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
^morbidity + mortality - -frailest @ greatest risk
>60yo - low abuse risk - ^ monitoring possible
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

25. opioid tx in elderly
Environment modification: obstacles - mobility - -bladder fcn ok
Begin @25-50% recommended dose - APAP may be dose-limiting
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

26. what normally prevents syncope?
Cachexia - PEM - FTT - obesity
3 reflexes: baroreceptor - renal nerve - ANF
Stress: #1 - functional - urge - overflow
No: fever - leukocytosis - yes: falls - appetite change - low functional status

27. Beers criteria
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Pressure ulcer - fecal impaction - dehydration
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

28. How does aging affect Rx renal elimination?
^ANS tone -> ^periph vasoconstriction - ^HR
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

29. How does renal nerve prevent syncope?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

30. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
CVA: stroke - AMI: acute MI - HF
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
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. tube feeding
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
P2-metab: Lorazepam - Trazepam - Oxazepam
Screen for potentially embarrassing dx - patient/Dr trust
Appointed by court if no substituted judgment -conservator of finance -conservator of person

32. describe the % of ADR considered preventable - and of those serious
5% - underreported
Pressure ulcer - fecal impaction - dehydration
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
30% preventable - of these - 40% serious - of these 40% preventable

33. 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
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Used to calculate renal fcn - clearance of Cr adjusted for age

34. LBW equation
Phenytoin
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

35. How does aging affect pharmacokinetics?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Beers criteria - medication appropriateness index (12 ?)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

36. psychological abuse
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Threats/ terrorizing - isolation - denying food/privileges/liberty
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

37. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
F>M (until 80yo) - stress incontinence #1 - $26B/yr
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
^SV (diastolic stroke volume)

38. What is the STOPP criteria?
P2-metab: Lorazepam - Trazepam - Oxazepam
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
Treat underlying disease/lack resources
Multisystemic vulnerability - -lowered reserves

39. restrain requirements
>60yo - low abuse risk - ^ monitoring possible
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Insiduous onset
#1 patient's last competent indication of wishes - substituted judgment - beneficence

40. What are the rf for elderly abuse?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
^ANS tone -> ^periph vasoconstriction - ^HR
F>M (until 80yo) - stress incontinence #1 - $26B/yr

41. How to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
Used to calculate renal fcn - clearance of Cr adjusted for age
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
>9 Rx

42. driving considerations
>9 Rx
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Make sure to discuss with patient - some states require reporting
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

43. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Screen for potentially embarrassing dx - patient/Dr trust
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

44. what drugs can cause dizziness?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Cholinesterase inhib - use: dementia
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

45. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Legal: Cruzan v Hamon
Stress: #1 - functional - urge - overflow
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

46. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
NMDR antagonist - use: dementia
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Temporalis muscle wasting = temporal wasting

47. using long-acting opioids in elderly
#1 patient's last competent indication of wishes - substituted judgment - beneficence
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Bone loss -> osteopenia -> osteoporosis -> Fx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

48. MRP: medication related problems
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Legal: Cruzan v Hamon
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

49. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Catch-all of unspecified dizziness
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Map of people - perceptions - etc - varies by perspective

50. Aging principles
Serum Cr: used for Cr clearance equation
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Intrinsic: chronic dx - postural: changing position - mediating: risk taking