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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 is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
CVA: stroke - AMI: acute MI - HF
Confusion - sedation - falls
3 reflexes: baroreceptor - renal nerve - ANF

2. acute abdomen + atypical Sx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

3. pulm edema + atypical Sx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Insiduous onset

4. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Mechanical loading - skin care - avoid friction/shear
Serum Cr: used for Cr clearance equation

5. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
NMDR antagonist - use: dementia
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

6. NSAID may lead to what prescription cascade?
Consider responsibilities - drivin
^BP -> a-HTN
IdioPx - psychiatric: depression - anxiety - somatoform
Cholinesterase inhib - use: dementia

7. clues of neglect
Isolated systolic HTN
Make sure to discuss with patient - some states require reporting
A-blockers - B-blockers - TCA
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

8. Approach to idioPx - recurrent syncope
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Consider responsibilities - drivin
CNS suppression -> cholinesterase inhibitors
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

9. What are common physical abuse Sx in elderly?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
30% preventable - of these - 40% serious - of these 40% preventable
No: fever - leukocytosis - yes: falls - appetite change - low functional status
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

10. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
F>M (until 80yo) - stress incontinence #1 - $26B/yr
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

11. galantamine
Cholinesterase inhib - use: dementia
Stress: #1 - functional - urge - overflow
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
^morbidity + mortality - -frailest @ greatest risk

12. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
80% of hospital admission for syncope for >65yo
Map of people - perceptions - etc - varies by perspective
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

13. What are the common types of elder mistreatment?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
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
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
3 reflexes: baroreceptor - renal nerve - ANF

14. How does baroreceptor reflex prevent syncope?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
^ANS tone -> ^periph vasoconstriction - ^HR
Electrical: change in HR - structural: aortic outflow obstruction
Phenytoin

15. who is a good candidate for opioid tx?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
>60yo - low abuse risk - ^ monitoring possible
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

16. What are rf for osteoporosis?
Phenytoin
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Hypotension - ^K+
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

17. delirium: tx approach
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Mechanical loading - skin care - avoid friction/shear

18. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
IdioPx - psychiatric: depression - anxiety - somatoform
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
^SV (diastolic stroke volume)

19. How does aging affect Rx pharmacokinetic distribution?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Serum Cr: used for Cr clearance equation
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
ANF: Na+ retention - disinhib vasoconstriction

20. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
P2-metab: Lorazepam - Trazepam - Oxazepam
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Cholinesterase inhib - use: dementia

21. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Threats/ terrorizing - isolation - denying food/privileges/liberty

22. How does aging affect pharmacokinetic Rx distribution?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
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
Hypothetical plan - serves as patient's last competent indicated wishes
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

23. Syncope prognosis based on etio
Worse for cardiac causes v noncardia
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Pressure ulcer - fecal impaction - dehydration

24. frailty signs
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
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^ANS tone -> ^periph vasoconstriction - ^HR
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

25. What are the risks of uncontrolled ISH?
High mortality - esp + Fx - very common in elderly
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
CVA: stroke - AMI: acute MI - HF

26. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Consider responsibilities - drivin
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

27. What is a mattering map?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Tx underlying etio - + Kegels - pessary - surgery
Map of people - perceptions - etc - varies by perspective
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

28. vision changes: elderly
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

29. red flags for further inquiry
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Hypotension - ^K+

30. How does an 80yo renal fcn compare to that of a 20yo?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
1/2
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
Multisystemic vulnerability - -lowered reserves

31. rule of doable effect
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
80% of hospital admission for syncope for >65yo
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

32. frailty
5% - underreported
1/2
Multisystemic vulnerability - -lowered reserves
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

33. Disequilibrium
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

34. what illnesses are underreported in elderly?
Breast cancer + 2o LBP
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

35. frailty raises vulnerability to...
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Cholinesterase inhib - use: dementia
Voice - character - plot - context - time - reader
Falls - delirium - malnutrition - P ulcers - opportunistic i2

36. 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
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
CVA: stroke - AMI: acute MI - HF
Hyperuricemia -> gout

37. What are the pharmacodynamic changes associated with aging?
Tx underlying etio - + Kegels - pessary - surgery
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Receptors changes: # - sensitivity - counter-regulatory moa
Catch-all of unspecified dizziness

38. incontinence complication
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
3 reflexes: baroreceptor - renal nerve - ANF
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

39. depression + atypical Sx
High mortality - esp + Fx - very common in elderly
Respect for autonomy - nonmaleficence - beneficence - justice
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
30% preventable - of these - 40% serious - of these 40% preventable

40. malignancy + atypical Sx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
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
Breast cancer + 2o LBP
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

41. stress incontinence tx
Appointed by court if no substituted judgment -conservator of finance -conservator of person
80% of hospital admission for syncope for >65yo
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Tx underlying etio - + Kegels - pessary - surgery

42. surrogate decision making heirarchy

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43. How does aging increase incontinence?
High mortality - esp + Fx - very common in elderly
Stress: #1 - functional - urge - overflow
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
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

44. physical neglect
ANF: Na+ retention - disinhib vasoconstriction
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Bone loss -> osteopenia -> osteoporosis -> Fx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

45. using long-acting opioids in elderly
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Legal: Cruzan v Hamon

46. what ADR are common in elderly patient?
>60yo - low abuse risk - ^ monitoring possible
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Doctors
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

47. fall sequelae

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48. Aging features
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Universal - progressive - partially encoded (genetic) - destructive -
^ANS tone -> ^periph vasoconstriction - ^HR
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

49. How does aging impact syncope-preventing reflexes
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Electrolyte imbalance - arrhythmia
Legal: Cruzan v Hamon

50. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Threats/ terrorizing - isolation - denying food/privileges/liberty
^BP -> a-HTN