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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. functional incontinence tx
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
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
Environment modification: obstacles - mobility - -bladder fcn ok
Temporalis muscle wasting = temporal wasting

2. What are the 3 sentinel events for LT care?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Begin @25-50% recommended dose - APAP may be dose-limiting
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Pressure ulcer - fecal impaction - dehydration

3. What is a mattering map?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Map of people - perceptions - etc - varies by perspective

4. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
^SV (diastolic stroke volume)
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

5. anticholinergic drugs may lead to what prescription cascade?
5% - underreported
CNS suppression -> cholinesterase inhibitors
Used to calculate renal fcn - clearance of Cr adjusted for age
Electrolyte imbalance - arrhythmia

6. thiazide diuretic may lead to what prescription cascade?
Screen for potentially embarrassing dx - patient/Dr trust
Constipation -> laxatives
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Hyperuricemia -> gout

7. What are the common causes of lightheadedness?
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
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
IdioPx - psychiatric: depression - anxiety - somatoform
Falls - delirium - malnutrition - P ulcers - opportunistic i2

8. what drugs can cause dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
>9 Rx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Begin @25-50% recommended dose - APAP may be dose-limiting

9. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Catch-all of unspecified dizziness
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

10. 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
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Cachexia - PEM - FTT - obesity
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

11. what professional is least likely to report abuse?
Doctors
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Injury - neglect - physical/psychosocial - financial - violation of rights
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

12. restrain requirements
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
^SV (diastolic stroke volume)
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

13. What is a PE sign of cachexia?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Temporalis muscle wasting = temporal wasting
Catch-all of unspecified dizziness
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

14. How does aging affect pharmacokinetic protein binding?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Make sure to discuss with patient - some states require reporting
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

15. What is the epidemiology of dizziness?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Parkinsonism -> l-DOPA
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

16. incontinence epidemiology
Hypotension - ^K+
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
BMD (bone mineral density): T-score >2.5 std dev below normal 1

17. What is ISH?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Isolated systolic HTN
Temporalis muscle wasting = temporal wasting
Worse for cardiac causes v noncardia

18. How does aging affect Rx pharmacokinetic distribution?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
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
Mechanical loading - skin care - avoid friction/shear
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

19. Aging principles
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
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
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

20. urge incontinence tx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

21. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Catch-all of unspecified dizziness

22. delirium: tx approach
Electrical: change in HR - structural: aortic outflow obstruction
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

23. How does ANF prevent syncope?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
ANF: Na+ retention - disinhib vasoconstriction

24. clues of neglect
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Used to calculate renal fcn - clearance of Cr adjusted for age

25. opioid tx in elderly
Hyperuricemia -> gout
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Begin @25-50% recommended dose - APAP may be dose-limiting
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

26. 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
Injury - neglect - physical/psychosocial - financial - violation of rights
Used to calculate renal fcn - clearance of Cr adjusted for age
Receptors changes: # - sensitivity - counter-regulatory moa

27. BZD + antipsychotic: interaction outcome
Receptors changes: # - sensitivity - counter-regulatory moa
^morbidity + mortality - -frailest @ greatest risk
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Confusion - sedation - falls

28. What is the natural history 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
^BP -> a-HTN
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

29. What are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
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
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

30. what receptors increase sensitivity with aging?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cachexia - PEM - FTT - obesity
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Pressure ulcer - fecal impaction - dehydration

31. 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
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

32. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

33. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
Constipation -> laxatives
^SV (diastolic stroke volume)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

34. what normally prevents syncope?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
IdioPx - psychiatric: depression - anxiety - somatoform
3 reflexes: baroreceptor - renal nerve - ANF
Cholinesterase inhib - use: dementia

35. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Parkinsonism -> l-DOPA
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

36. How does an 80yo renal fcn compare to that of a 20yo?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Isolated systolic HTN
1/2

37. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Phenytoin
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

38. What are the 3 stages of ADRs?
^ANS tone -> ^periph vasoconstriction - ^HR
Pressure ulcer - fecal impaction - dehydration
Consider responsibilities - drivin
Prescribing - monitoring - patient adherence

39. using long-acting opioids in elderly
Used to calculate renal fcn - clearance of Cr adjusted for age
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Legal: Cruzan v Hamon
1/2

40. What is the preferred depression treatment in elderly?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Bone loss -> osteopenia -> osteoporosis -> Fx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Therapy - SSRI

41. Approach to idioPx - recurrent syncope
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Consider responsibilities - drivin
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

42. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

43. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Respect for autonomy - nonmaleficence - beneficence - justice

44. What are rf for osteoporosis?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
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
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Environment modification: obstacles - mobility - -bladder fcn ok

45. What is abuse?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Injury - neglect - physical/psychosocial - financial - violation of rights
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Cachexia - PEM - FTT - obesity

46. what nutritional interventions help underweight?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

47. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
^BP -> a-HTN
High mortality - esp + Fx - very common in elderly

48. What are the 4 forms of dizziness?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Vertigo - presyncope - disequilibrium - lightheadedness
Cachexia - PEM - FTT - obesity
Diagnosis - risk/benefit analysis to choose Rx

49. What are the narrative elements of clinical ethics?
^ANS tone -> ^periph vasoconstriction - ^HR
Worse for cardiac causes v noncardia
Voice - character - plot - context - time - reader
Doctors

50. ACE inhib + K+: interaction outcome
Screen for potentially embarrassing dx - patient/Dr trust
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Confusion - sedation - falls
^K+