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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. how may hypertension compensate for aging?
Used to calculate renal fcn - clearance of Cr adjusted for age
Stress: #1 - functional - urge - overflow
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
High mortality - esp + Fx - very common in elderly

2. what illnesses are underreported in elderly?
Isolated systolic HTN
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
>9 Rx

3. What is polypharmacy
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
>9 Rx
IdioPx - psychiatric: depression - anxiety - somatoform

4. LBW equation
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
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Prescribing - monitoring - patient adherence

5. what normally prevents syncope?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
3 reflexes: baroreceptor - renal nerve - ANF
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

6. NSAID may lead to what prescription cascade?
Phenytoin
No: chest pain - yes: fatigue - nausea - low functional status - SOB
^BP -> a-HTN
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

7. What is a mattering map?
Screen for potentially embarrassing dx - patient/Dr trust
Map of people - perceptions - etc - varies by perspective
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Prescribing - monitoring - patient adherence

8. What is the natural history of syncope?
>9 Rx
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
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

9. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

10. thiazide diuretic may lead to what prescription cascade?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Hyperuricemia -> gout
NMDR antagonist - use: dementia

11. How does aging impact syncope-preventing reflexes
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Doctors
Worse for cardiac causes v noncardia
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

12. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Confusion - sedation - falls

13. MI + atypical Sx
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
Mechanical loading - skin care - avoid friction/shear
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

14. delirium: Rx that contribute
^SV (diastolic stroke volume)
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

15. lipid-soluble Rx
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)
CNS suppression -> cholinesterase inhibitors
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

16. violation of rights
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Electrical: change in HR - structural: aortic outflow obstruction

17. fall sequelae

18. What is START criteria?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Mechanical loading - skin care - avoid friction/shear
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Insiduous onset

19. What are common physical abuse Sx in elderly?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

20. driving considerations
Make sure to discuss with patient - some states require reporting
5% - underreported
P2-metabolite - phase 1 biotx much more affected than phase 2
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

21. which benzodiazepines are most appropriate for elderly?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
P2-metab: Lorazepam - Trazepam - Oxazepam
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

22. BZD + antidepressant: interaction outcome
5% - underreported
Confusion - sedation - falls
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
P2-metabolite - phase 1 biotx much more affected than phase 2

23. metoclopramide may lead to what prescription cascade?
Used to calculate renal fcn - clearance of Cr adjusted for age
Parkinsonism -> l-DOPA
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
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

24. How does aging affect GI absorption of Rx?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

25. What is the Cockcroft Gault equation?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Insiduous onset
Used to calculate renal fcn - clearance of Cr adjusted for age
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

26. Beers criteria
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
Legal: Cruzan v Hamon
A-blockers - B-blockers - TCA
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

27. What is capacity?
Determined by Dr for a patient - -> used to determine competency
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Cachexia - PEM - FTT - obesity
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

28. using long-acting opioids in elderly
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
30% preventable - of these - 40% serious - of these 40% preventable
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Used to calculate renal fcn - clearance of Cr adjusted for age

29. How does aging affect Rx pharmacokinetic metabolism?
Electrical: change in HR - structural: aortic outflow obstruction
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Phenytoin
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

30. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
Screen for potentially embarrassing dx - patient/Dr trust
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

31. urinary incontinence types
Stress: #1 - functional - urge - overflow
Cholinesterase inhib - use: dementia
1/2
28% - ADR: 17% - non-compliance 11%

32. What are the key points of safe prescription for elderly - lecture
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Map of people - perceptions - etc - varies by perspective
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Diagnosis - risk/benefit analysis to choose Rx

33. frailty signs
5% - underreported
P2-metab: Lorazepam - Trazepam - Oxazepam
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
>60yo - low abuse risk - ^ monitoring possible

34. What is the epidemiology of dizziness?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
30% preventable - of these - 40% serious - of these 40% preventable
Begin @25-50% recommended dose - APAP may be dose-limiting

35. nutrition syndromes
Vertigo - presyncope - disequilibrium - lightheadedness
Serum Cr: used for Cr clearance equation
Cachexia - PEM - FTT - obesity
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

36. osteoporosis epidemiology
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
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
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
High mortality - esp + Fx - very common in elderly

37. urge incontinence tx
3 reflexes: baroreceptor - renal nerve - ANF
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

38. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Begin @25-50% recommended dose - APAP may be dose-limiting
Insiduous onset
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

39. what % of hospitalizations of elderly are due to ADR + noncompliance?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
28% - ADR: 17% - non-compliance 11%
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

40. depression + atypical Sx
Confusion - sedation - falls
Electrical: change in HR - structural: aortic outflow obstruction
>60yo - low abuse risk - ^ monitoring possible
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

41. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
NMDR antagonist - use: dementia
F>M (until 80yo) - stress incontinence #1 - $26B/yr

42. physical neglect
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Temporalis muscle wasting = temporal wasting
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

43. vertigo
Insiduous onset
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Mechanical loading - skin care - avoid friction/shear
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

44. How does aging increase incontinence?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Mechanical loading - skin care - avoid friction/shear
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
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

45. preventing malnutrition
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
5% - underreported
Prescribing - monitoring - patient adherence
Figure out a good diet - social aspect - resources - dental/oral comfort

46. i2 + atypical Sx
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
>9 Rx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
No: fever - leukocytosis - yes: falls - appetite change - low functional status

47. what Rx are commonly monifoted in elderly for ADR?
Cholinesterase inhib - use: dementia
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
P2-metabolite - phase 1 biotx much more affected than phase 2

48. galantamine
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Cholinesterase inhib - use: dementia
Constipation -> laxatives
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

49. how is the CAM used to diagnose delirium?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Map of people - perceptions - etc - varies by perspective
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

50. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
^ANS tone -> ^periph vasoconstriction - ^HR
Vertigo - presyncope - disequilibrium - lightheadedness
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV