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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 ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cachexia - PEM - FTT - obesity
Determined by Dr for a patient - -> used to determine competency
P2-metab: Lorazepam - Trazepam - Oxazepam

2. substituted judgment
5% - underreported
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

3. malnutrition
5% - underreported
High mortality - esp + Fx - very common in elderly
Cholinesterase inhib - use: dementia
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

4. What is the preferred depression treatment in elderly?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Therapy - SSRI
^BP -> a-HTN

5. how can you determine whether Rx is appropriate to use in elderly patient?
IdioPx - psychiatric: depression - anxiety - somatoform
Beers criteria - medication appropriateness index (12 ?)
Determined by Dr for a patient - -> used to determine competency
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

6. how may hypertension compensate for aging?
Injury - neglect - physical/psychosocial - financial - violation of rights
Universal - progressive - partially encoded (genetic) - destructive -
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Falls - delirium - malnutrition - P ulcers - opportunistic i2

7. LBW equation
Make sure to discuss with patient - some states require reporting
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Map of people - perceptions - etc - varies by perspective

8. what receptors increase sensitivity with aging?
Cholinesterase inhib - use: dementia
>60yo - low abuse risk - ^ monitoring possible
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

9. What are common scenarios of untreated indications in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
^SV (diastolic stroke volume)
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Serum Cr: used for Cr clearance equation

10. frailty raises vulnerability to...
Screen for potentially embarrassing dx - patient/Dr trust
Falls - delirium - malnutrition - P ulcers - opportunistic i2
>60yo - low abuse risk - ^ monitoring possible
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

11. thyroid dx + atypical Sx
Doctors
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

12. What are common medical causes of syncope?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Consider responsibilities - drivin

13. frailty
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Voice - character - plot - context - time - reader
Multisystemic vulnerability - -lowered reserves

14. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
^SV (diastolic stroke volume)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
No: chest pain - yes: fatigue - nausea - low functional status - SOB

15. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
Bone loss -> osteopenia -> osteoporosis -> Fx
Figure out a good diet - social aspect - resources - dental/oral comfort
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

16. psychological abuse
^SV (diastolic stroke volume)
Cholinesterase inhib - use: dementia
Threats/ terrorizing - isolation - denying food/privileges/liberty
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

17. What is a PE sign of cachexia?
Cholinesterase inhib - use: dementia
Hypothetical plan - serves as patient's last competent indicated wishes
Worse for cardiac causes v noncardia
Temporalis muscle wasting = temporal wasting

18. How does the aging heart compensate for lower HR to maintain unchanged CO?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
^SV (diastolic stroke volume)

19. MRP: medication related problems
^morbidity + mortality - -frailest @ greatest risk
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
BMD (bone mineral density): T-score >2.5 std dev below normal 1

20. What are the hazards of elderly hospitalization?
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
Treat underlying disease/lack resources
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
^morbidity + mortality - -frailest @ greatest risk

21. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
30% preventable - of these - 40% serious - of these 40% preventable
Temporalis muscle wasting = temporal wasting
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

22. What are the pharmacodynamic changes associated with aging?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Receptors changes: # - sensitivity - counter-regulatory moa
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Catch-all of unspecified dizziness

23. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

24. using long-acting opioids in elderly
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Breast cancer + 2o LBP

25. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

26. What is ISH?
High mortality - esp + Fx - very common in elderly
Isolated systolic HTN
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
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

27. donepezil
Doctors
NMDR antagonist - use: dementia
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Cholinesterase inhib - use: dementia

28. memantine
Tx underlying etio - + Kegels - pessary - surgery
Electrical: change in HR - structural: aortic outflow obstruction
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
NMDR antagonist - use: dementia

29. How does an 80yo renal fcn compare to that of a 20yo?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
1/2
Figure out a good diet - social aspect - resources - dental/oral comfort
Screen for potentially embarrassing dx - patient/Dr trust

30. ACE inhib + diuretic: interaction outcome
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Hypotension - ^K+
Cholinesterase inhib - use: dementia
Breast cancer + 2o LBP

31. malignancy + atypical Sx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Breast cancer + 2o LBP
28% - ADR: 17% - non-compliance 11%

32. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
^SV (diastolic stroke volume)
IdioPx - psychiatric: depression - anxiety - somatoform

33. preventing malnutrition
Cachexia - PEM - FTT - obesity
Figure out a good diet - social aspect - resources - dental/oral comfort
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
No: chest pain - yes: fatigue - nausea - low functional status - SOB

34. describe the % of ADR considered preventable - and of those serious
Determined by Dr for a patient - -> used to determine competency
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
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
30% preventable - of these - 40% serious - of these 40% preventable

35. what can enhance reporting in elderly?
Delayed absorption - like competitive inhib
Screen for potentially embarrassing dx - patient/Dr trust
Beers criteria - medication appropriateness index (12 ?)
Phenytoin

36. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Make sure to discuss with patient - some states require reporting
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
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
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

37. What are the possible cardiac causes of presyncope?
28% - ADR: 17% - non-compliance 11%
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Electrical: change in HR - structural: aortic outflow obstruction
Pressure ulcer - fecal impaction - dehydration

38. What are the common types of elder mistreatment?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Electrical: change in HR - structural: aortic outflow obstruction

39. Cockcroft Gault equation
Figure out a good diet - social aspect - resources - dental/oral comfort
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
#1 patient's last competent indication of wishes - substituted judgment - beneficence

40. narcotics may lead to what prescription cascade?
Electrolyte imbalance - arrhythmia
Constipation -> laxatives
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

41. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Serum Cr: used for Cr clearance equation

42. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
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

43. What are the 3 stages of ADRs?
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
A-blockers - B-blockers - TCA
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Prescribing - monitoring - patient adherence

44. which benzodiazepines are most appropriate for elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

45. Why is abuse underreported?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Universal - progressive - partially encoded (genetic) - destructive -
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

46. BZD + antipsychotic: interaction outcome
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Confusion - sedation - falls
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

47. thiazide diuretic may lead to what prescription cascade?
Hyperuricemia -> gout
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
80% of hospital admission for syncope for >65yo
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

48. NSAID may lead to what prescription cascade?
^BP -> a-HTN
Screen for potentially embarrassing dx - patient/Dr trust
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Cachexia - PEM - FTT - obesity

49. pulm edema + atypical Sx
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Insiduous onset

50. what professional is least likely to report abuse?
Confusion - sedation - falls
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
IdioPx - psychiatric: depression - anxiety - somatoform
Doctors