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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. Disequilibrium
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Begin @25-50% recommended dose - APAP may be dose-limiting
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

2. antiarrhythmic + diuretic: interaction outcome
^K+
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Electrolyte imbalance - arrhythmia
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

3. What is abuse?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Injury - neglect - physical/psychosocial - financial - violation of rights
Hyperuricemia -> gout
P2-metab: Lorazepam - Trazepam - Oxazepam

4. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Consider responsibilities - drivin
Cholinesterase inhib - use: dementia

5. osteoporosis etio
Cachexia - PEM - FTT - obesity
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

6. pulm edema + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Insiduous onset
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

7. Aging descriptors
Breast cancer + 2o LBP
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

8. dementia tx
5% - underreported
30% preventable - of these - 40% serious - of these 40% preventable
Used to calculate renal fcn - clearance of Cr adjusted for age
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

9. What are the rf for caregiver to abuse elderly?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Therapy - SSRI
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

10. What are the rf for elderly abuse?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
BMD (bone mineral density): T-score >2.5 std dev below normal 1
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

11. functional incontinence tx
Pressure ulcer - fecal impaction - dehydration
Environment modification: obstacles - mobility - -bladder fcn ok
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

12. what nutritional interventions help underweight?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Screen for potentially embarrassing dx - patient/Dr trust
A-blockers - B-blockers - TCA

13. elderly abuse epidemiology
Confusion - sedation - falls
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
5% - underreported

14. fall causes
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Pressure ulcer - fecal impaction - dehydration
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Universal - progressive - partially encoded (genetic) - destructive -

15. How does aging impact syncope-preventing reflexes
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Hypotension - ^K+
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
No: chest pain - yes: fatigue - nausea - low functional status - SOB

16. What are common physical abuse Sx in elderly?
Confusion - sedation - falls
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
28% - ADR: 17% - non-compliance 11%

17. narcotics may lead to what prescription cascade?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
CNS suppression -> cholinesterase inhibitors
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Constipation -> laxatives

18. What is the bone deterioration cascade?
^BP -> a-HTN
Bone loss -> osteopenia -> osteoporosis -> Fx
Prescribing - monitoring - patient adherence
28% - ADR: 17% - non-compliance 11%

19. delirium: tx approach
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Consider responsibilities - drivin
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

20. What are the vascular changes of presyncope?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
IdioPx - psychiatric: depression - anxiety - somatoform
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

21. incontinence epidemiology
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Bone loss -> osteopenia -> osteoporosis -> Fx
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
F>M (until 80yo) - stress incontinence #1 - $26B/yr

22. using long-acting opioids in elderly
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
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
Consider responsibilities - drivin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

23. what illnesses are underreported in elderly?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Threats/ terrorizing - isolation - denying food/privileges/liberty
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

24. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Receptors changes: # - sensitivity - counter-regulatory moa
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

25. Alb-bound Rx
Legal: Cruzan v Hamon
Phenytoin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

26. stress incontinence tx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
3 reflexes: baroreceptor - renal nerve - ANF
28% - ADR: 17% - non-compliance 11%
Tx underlying etio - + Kegels - pessary - surgery

27. incontinence complication
Parkinsonism -> l-DOPA
Multisystemic vulnerability - -lowered reserves
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

28. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
Diagnosis - risk/benefit analysis to choose Rx
Environment modification: obstacles - mobility - -bladder fcn ok
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

29. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Appointed by court if no substituted judgment -conservator of finance -conservator of person
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

30. ACE inhib + K+: interaction outcome
^K+
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Used to calculate renal fcn - clearance of Cr adjusted for age
Figure out a good diet - social aspect - resources - dental/oral comfort

31. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Determined by Dr for a patient - -> used to determine competency
Environment modification: obstacles - mobility - -bladder fcn ok
Receptors changes: # - sensitivity - counter-regulatory moa

32. donepezil
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Cholinesterase inhib - use: dementia

33. What are the common types of elder mistreatment?
P2-metab: Lorazepam - Trazepam - Oxazepam
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

34. How does aging affect pharmacokinetics?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
NMDR antagonist - use: dementia
Cholinesterase inhib - use: dementia

35. What are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
Confusion - sedation - falls
Receptors changes: # - sensitivity - counter-regulatory moa
Constipation -> laxatives

36. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Phenytoin
30% preventable - of these - 40% serious - of these 40% preventable
F>M (until 80yo) - stress incontinence #1 - $26B/yr

37. documenting elderly abuse

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38. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

39. How does aging affect Rx pharmacokinetic distribution?
A-blockers - B-blockers - TCA
No: fever - leukocytosis - yes: falls - appetite change - low functional status
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
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

40. clues of neglect
Hypothetical plan - serves as patient's last competent indicated wishes
Cholinesterase inhib - use: dementia
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Screen for potentially embarrassing dx - patient/Dr trust

41. lipid-soluble Rx
A-blockers - B-blockers - TCA
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

42. thiazide diuretic may lead to what prescription cascade?
80% of hospital admission for syncope for >65yo
Hyperuricemia -> gout
30% preventable - of these - 40% serious - of these 40% preventable
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

43. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Make sure to discuss with patient - some states require reporting
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

44. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Figure out a good diet - social aspect - resources - dental/oral comfort
Injury - neglect - physical/psychosocial - financial - violation of rights
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

45. What is the Cockcroft Gault equation?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Used to calculate renal fcn - clearance of Cr adjusted for age
Hypotension - ^K+
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

46. rule of doable effect
Voice - character - plot - context - time - reader
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Tx underlying etio - + Kegels - pessary - surgery

47. what receptors increase sensitivity with aging?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Falls - delirium - malnutrition - P ulcers - opportunistic i2

48. Cockcroft Gault equation
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Cholinesterase inhib - use: dementia
Beers criteria - medication appropriateness index (12 ?)

49. What is the preferred depression treatment in elderly?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Environment modification: obstacles - mobility - -bladder fcn ok
Therapy - SSRI
F>M (until 80yo) - stress incontinence #1 - $26B/yr

50. ACE inhib + diuretic: interaction outcome
Therapy - SSRI
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Environment modification: obstacles - mobility - -bladder fcn ok
Hypotension - ^K+