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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. Aging descriptors
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Injury - neglect - physical/psychosocial - financial - violation of rights
Doctors
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

2. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Vertigo - presyncope - disequilibrium - lightheadedness
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

3. LBW equation
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

4. dementia tx
Determined by Dr for a patient - -> used to determine competency
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Mechanical loading - skin care - avoid friction/shear
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

5. overflow incontinence tx
Multisystemic vulnerability - -lowered reserves
Cholinesterase inhib - use: dementia
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Cholinesterase inhib - use: dementia

6. How does aging impact syncope-preventing reflexes
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
IdioPx - psychiatric: depression - anxiety - somatoform
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

7. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
1/2
3 reflexes: baroreceptor - renal nerve - ANF
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

8. How does an 80yo renal fcn compare to that of a 20yo?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
1/2
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Bone loss -> osteopenia -> osteoporosis -> Fx

9. What are the common types of elder mistreatment?
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
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Constipation -> laxatives
Serum Cr: used for Cr clearance equation

10. donepezil
Cholinesterase inhib - use: dementia
Consider responsibilities - drivin
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Cachexia - PEM - FTT - obesity

11. ACE inhib + diuretic: interaction outcome
Phenytoin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Hypotension - ^K+
IdioPx - psychiatric: depression - anxiety - somatoform

12. What are the possible cardiac causes of presyncope?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Electrical: change in HR - structural: aortic outflow obstruction
Doctors
^BP -> a-HTN

13. Beers criteria
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
Multisystemic vulnerability - -lowered reserves
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

14. conservator
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Hypotension - ^K+
Cholinesterase inhib - use: dementia
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

15. incontinence epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Begin @25-50% recommended dose - APAP may be dose-limiting
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

16. How does aging affect GI absorption rate of Rx?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Delayed absorption - like competitive inhib
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
5% - underreported

17. malignancy + atypical Sx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Parkinsonism -> l-DOPA
Breast cancer + 2o LBP
1/2

18. depression + atypical Sx
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Treat underlying disease/lack resources
Cholinesterase inhib - use: dementia
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

19. fall causes
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Prescribing - monitoring - patient adherence
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

20. surrogate decision making heirarchy

21. Presyncope
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
BMD (bone mineral density): T-score >2.5 std dev below normal 1

22. What are the 3 stages of ADRs?
Prescribing - monitoring - patient adherence
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
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

23. How does aging affect Rx renal elimination?
3 reflexes: baroreceptor - renal nerve - ANF
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Vertigo - presyncope - disequilibrium - lightheadedness
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

24. advanced directive/care plan

25. What is polypharmacy
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
>9 Rx

26. rivastigmine
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Cholinesterase inhib - use: dementia
^K+
Worse for cardiac causes v noncardia

27. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

28. malnutrition
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
ANF: Na+ retention - disinhib vasoconstriction

29. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Hyperuricemia -> gout

30. How does aging affect pharmacokinetics?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
5% - underreported
Map of people - perceptions - etc - varies by perspective
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

31. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Hypotension - ^K+

32. Disequilibrium
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

33. delirium predisposing rf
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

34. stress incontinence tx
30% preventable - of these - 40% serious - of these 40% preventable
Electrical: change in HR - structural: aortic outflow obstruction
^K+
Tx underlying etio - + Kegels - pessary - surgery

35. What is the preferred depression treatment in elderly?
CNS suppression -> cholinesterase inhibitors
30% preventable - of these - 40% serious - of these 40% preventable
Therapy - SSRI
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

36. What is a mattering map?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Map of people - perceptions - etc - varies by perspective
Treat underlying disease/lack resources
Breast cancer + 2o LBP

37. pulm edema + atypical Sx
Insiduous onset
Constipation -> laxatives
Consider responsibilities - drivin
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

38. osteoporosis etio
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Universal - progressive - partially encoded (genetic) - destructive -

39. memantine
1/2
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Appointed by court if no substituted judgment -conservator of finance -conservator of person
NMDR antagonist - use: dementia

40. osteoporosis
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^K+
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Temporalis muscle wasting = temporal wasting

41. delirium: mgmt
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
1/2
^BP -> a-HTN

42. What is START criteria?
Receptors changes: # - sensitivity - counter-regulatory moa
Treat underlying disease/lack resources
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

43. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
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
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

44. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Legal: Cruzan v Hamon
Multisystemic vulnerability - -lowered reserves
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

45. What is the Cockcroft Gault equation?
Parkinsonism -> l-DOPA
Used to calculate renal fcn - clearance of Cr adjusted for age
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

46. What is the natural history of syncope?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Bone loss -> osteopenia -> osteoporosis -> Fx
Worse for cardiac causes v noncardia

47. MI + atypical Sx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Injury - neglect - physical/psychosocial - financial - violation of rights
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Multisystemic vulnerability - -lowered reserves

48. which benzodiazepines are most appropriate for elderly?
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
P2-metab: Lorazepam - Trazepam - Oxazepam
Voice - character - plot - context - time - reader

49. driving considerations
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Make sure to discuss with patient - some states require reporting
Receptors changes: # - sensitivity - counter-regulatory moa
Begin @25-50% recommended dose - APAP may be dose-limiting

50. Aging principles
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Catch-all of unspecified dizziness
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers