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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 are the pharmacodynamic changes associated with aging?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Hypothetical plan - serves as patient's last competent indicated wishes
Parkinsonism -> l-DOPA
Receptors changes: # - sensitivity - counter-regulatory moa

2. frailty raises vulnerability to...
Breast cancer + 2o LBP
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Appointed by court if no substituted judgment -conservator of finance -conservator of person

3. What are the 3 sentinel events for LT care?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Breast cancer + 2o LBP
Pressure ulcer - fecal impaction - dehydration

4. fall sequelae

5. What are common scenarios of untreated indications in elderly?
3 reflexes: baroreceptor - renal nerve - ANF
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

6. antiarrhythmic + diuretic: interaction outcome
5% - underreported
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Electrolyte imbalance - arrhythmia

7. violation of rights
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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

8. delirium predisposing rf
Worse for cardiac causes v noncardia
Figure out a good diet - social aspect - resources - dental/oral comfort
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

9. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Diagnosis - risk/benefit analysis to choose Rx
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

10. How does aging affect Rx renal elimination?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Figure out a good diet - social aspect - resources - dental/oral comfort
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Appointed by court if no substituted judgment -conservator of finance -conservator of person

11. Beers criteria
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Hypothetical plan - serves as patient's last competent indicated wishes
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
Hyperuricemia -> gout

12. lipid-soluble Rx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

13. advanced directive/care plan

14. elderly abuse epidemiology
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
5% - underreported
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

15. memantine
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
NMDR antagonist - use: dementia
Mechanical loading - skin care - avoid friction/shear
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

16. What is a mattering map?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Map of people - perceptions - etc - varies by perspective
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

17. red flags for further inquiry
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

18. What is sCr?
Map of people - perceptions - etc - varies by perspective
Serum Cr: used for Cr clearance equation
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Doctors

19. 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
Beers criteria - medication appropriateness index (12 ?)
5% - underreported
High mortality - esp + Fx - very common in elderly

20. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

21. frailty signs
P2-metab: Lorazepam - Trazepam - Oxazepam
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Screen for potentially embarrassing dx - patient/Dr trust
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

22. what mechanical loading helps to prevent pressure ulcers?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

23. what ADR are common in elderly patient?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
80% of hospital admission for syncope for >65yo
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

24. MI + atypical Sx
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Used to calculate renal fcn - clearance of Cr adjusted for age

25. restrain requirements
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
CNS suppression -> cholinesterase inhibitors
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

26. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Threats/ terrorizing - isolation - denying food/privileges/liberty
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^SV (diastolic stroke volume)

27. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
30% preventable - of these - 40% serious - of these 40% preventable
Delayed absorption - like competitive inhib
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

28. What is the Cockcroft Gault equation?
Constipation -> laxatives
Catch-all of unspecified dizziness
Used to calculate renal fcn - clearance of Cr adjusted for age
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

29. osteoporosis etio
CVA: stroke - AMI: acute MI - HF
Worse for cardiac causes v noncardia
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Therapy - SSRI

30. What are the rf for elderly abuse?
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Hypothetical plan - serves as patient's last competent indicated wishes

31. frailty
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Multisystemic vulnerability - -lowered reserves
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

32. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Isolated systolic HTN
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
P2-metabolite - phase 1 biotx much more affected than phase 2
Map of people - perceptions - etc - varies by perspective

33. malnutrition
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Phenytoin
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

34. donepezil
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Figure out a good diet - social aspect - resources - dental/oral comfort
Cholinesterase inhib - use: dementia

35. LBW equation
Serum Cr: used for Cr clearance equation
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

36. PEM
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Pressure ulcer - fecal impaction - dehydration

37. What are common medical causes of syncope?
Breast cancer + 2o LBP
Receptors changes: # - sensitivity - counter-regulatory moa
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

38. falls epidemiology
Begin @25-50% recommended dose - APAP may be dose-limiting
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Multisystemic vulnerability - -lowered reserves
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

39. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
CVA: stroke - AMI: acute MI - HF
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

40. rivastigmine
Electrolyte imbalance - arrhythmia
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
Voice - character - plot - context - time - reader
Cholinesterase inhib - use: dementia

41. ACE inhib + K+: interaction outcome
^K+
Tx underlying etio - + Kegels - pessary - surgery
Cholinesterase inhib - use: dementia
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

42. stress incontinence tx
Used to calculate renal fcn - clearance of Cr adjusted for age
Tx underlying etio - + Kegels - pessary - surgery
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
F>M (until 80yo) - stress incontinence #1 - $26B/yr

43. tube feeding
High mortality - esp + Fx - very common in elderly
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Receptors changes: # - sensitivity - counter-regulatory moa

44. pressure ulcer: staging
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Treat underlying disease/lack resources
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

45. psychological abuse
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Legal: Cruzan v Hamon
Threats/ terrorizing - isolation - denying food/privileges/liberty
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

46. substituted judgment
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Vertigo - presyncope - disequilibrium - lightheadedness
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

47. What is polypharmacy
Hypothetical plan - serves as patient's last competent indicated wishes
Universal - progressive - partially encoded (genetic) - destructive -
IdioPx - psychiatric: depression - anxiety - somatoform
>9 Rx

48. How does an 80yo renal fcn compare to that of a 20yo?
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
1/2
Injury - neglect - physical/psychosocial - financial - violation of rights
Make sure to discuss with patient - some states require reporting

49. what professional is least likely to report abuse?
Doctors
IdioPx - psychiatric: depression - anxiety - somatoform
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Environment modification: obstacles - mobility - -bladder fcn ok

50. what can enhance reporting in elderly?
Screen for potentially embarrassing dx - patient/Dr trust
Determined by Dr for a patient - -> used to determine competency
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear