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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. thiazide diuretic may lead to what prescription cascade?
Doctors
Hypotension - ^K+
Hyperuricemia -> gout
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

2. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Catch-all of unspecified dizziness
Electrical: change in HR - structural: aortic outflow obstruction

3. functional incontinence tx
Therapy - SSRI
Environment modification: obstacles - mobility - -bladder fcn ok
ANF: Na+ retention - disinhib vasoconstriction
No: fever - leukocytosis - yes: falls - appetite change - low functional status

4. delirium: Rx that contribute
High mortality - esp + Fx - very common in elderly
Delayed absorption - like competitive inhib
Falls - delirium - malnutrition - P ulcers - opportunistic i2
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

5. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Receptors changes: # - sensitivity - counter-regulatory moa
Confusion - sedation - falls

6. delirium predisposing rf
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

7. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Multisystemic vulnerability - -lowered reserves
Cachexia - PEM - FTT - obesity

8. what normally prevents syncope?
30% preventable - of these - 40% serious - of these 40% preventable
Multisystemic vulnerability - -lowered reserves
3 reflexes: baroreceptor - renal nerve - ANF
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

9. What are the common causes of lightheadedness?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Confusion - sedation - falls
BMD (bone mineral density): T-score >2.5 std dev below normal 1
IdioPx - psychiatric: depression - anxiety - somatoform

10. delirium incidence
Begin @25-50% recommended dose - APAP may be dose-limiting
High mortality - esp + Fx - very common in elderly
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

11. malnutrition
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Parkinsonism -> l-DOPA

12. substituted judgment
P2-metabolite - phase 1 biotx much more affected than phase 2
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
ANF: Na+ retention - disinhib vasoconstriction
Map of people - perceptions - etc - varies by perspective

13. delirium diagnosis
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Treat underlying disease/lack resources

14. opioid tx in elderly
CVA: stroke - AMI: acute MI - HF
Catch-all of unspecified dizziness
Parkinsonism -> l-DOPA
Begin @25-50% recommended dose - APAP may be dose-limiting

15. conservator
^ANS tone -> ^periph vasoconstriction - ^HR
Begin @25-50% recommended dose - APAP may be dose-limiting
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

16. clues of neglect
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Cholinesterase inhib - use: dementia
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

17. Beers criteria: what 10 Rx should elderly avoid or use + caution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Respect for autonomy - nonmaleficence - beneficence - justice
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Confusion - sedation - falls

18. What is the best approach to malnutrition
Treat underlying disease/lack resources
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
>9 Rx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

19. what Rx are commonly monifoted in elderly for ADR?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Confusion - sedation - falls

20. incontinence epidemiology
Hypotension - ^K+
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

21. what mechanical loading helps to prevent pressure ulcers?
CNS suppression -> cholinesterase inhibitors
Delayed absorption - like competitive inhib
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

22. documenting elderly abuse

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23. osteopenia
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
30% preventable - of these - 40% serious - of these 40% preventable
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
28% - ADR: 17% - non-compliance 11%

24. What are the 4 forms of dizziness?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Electrical: change in HR - structural: aortic outflow obstruction
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Vertigo - presyncope - disequilibrium - lightheadedness

25. BZD + antidepressant: interaction outcome
Hyperuricemia -> gout
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Mechanical loading - skin care - avoid friction/shear
Confusion - sedation - falls

26. donepezil
Electrical: change in HR - structural: aortic outflow obstruction
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Cholinesterase inhib - use: dementia

27. urge incontinence tx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Hypothetical plan - serves as patient's last competent indicated wishes
Consider responsibilities - drivin
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

28. ACE inhib + diuretic: interaction outcome
Insiduous onset
CVA: stroke - AMI: acute MI - HF
Hypotension - ^K+
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

29. MRP: medication related problems
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Constipation -> laxatives
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

30. malignancy + atypical Sx
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Breast cancer + 2o LBP
Universal - progressive - partially encoded (genetic) - destructive -
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

31. What are the hazards of elderly hospitalization?
ANF: Na+ retention - disinhib vasoconstriction
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
^morbidity + mortality - -frailest @ greatest risk
80% of hospital admission for syncope for >65yo

32. What is the STOPP criteria?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
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
Catch-all of unspecified dizziness
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

33. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Figure out a good diet - social aspect - resources - dental/oral comfort
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

34. What is the epidemiology of dizziness?
Cholinesterase inhib - use: dementia
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Mechanical loading - skin care - avoid friction/shear

35. how can you determine whether Rx is appropriate to use in elderly patient?
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
Beers criteria - medication appropriateness index (12 ?)
Legal: Cruzan v Hamon
Bone loss -> osteopenia -> osteoporosis -> Fx

36. Beers criteria
Cholinesterase inhib - use: dementia
Constipation -> laxatives
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
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

37. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Pressure ulcer - fecal impaction - dehydration
Therapy - SSRI
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

38. physical neglect
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Confusion - sedation - falls
NMDR antagonist - use: dementia

39. who is a good candidate for opioid tx?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Confusion - sedation - falls
>60yo - low abuse risk - ^ monitoring possible

40. frailty
IdioPx - psychiatric: depression - anxiety - somatoform
Electrolyte imbalance - arrhythmia
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Multisystemic vulnerability - -lowered reserves

41. How does aging increase incontinence?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
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
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

42. What is START criteria?
^BP -> a-HTN
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
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

43. refusing intervention
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Legal: Cruzan v Hamon

44. how is the CAM used to diagnose delirium?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
No: chest pain - yes: fatigue - nausea - low functional status - SOB
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

45. How does aging affect GI absorption of Rx?
Respect for autonomy - nonmaleficence - beneficence - justice
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Universal - progressive - partially encoded (genetic) - destructive -

46. delirium: mgmt
Vertigo - presyncope - disequilibrium - lightheadedness
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

47. Aging features
Receptors changes: # - sensitivity - counter-regulatory moa
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Universal - progressive - partially encoded (genetic) - destructive -
NMDR antagonist - use: dementia

48. rivastigmine
Cholinesterase inhib - use: dementia
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Bone loss -> osteopenia -> osteoporosis -> Fx

49. What are the 3 sentinel events for LT care?
Diagnosis - risk/benefit analysis to choose Rx
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Pressure ulcer - fecal impaction - dehydration
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

50. fall sequelae

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