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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 are the rf for elderly abuse?
Consider responsibilities - drivin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

2. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
ANF: Na+ retention - disinhib vasoconstriction
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

3. How does aging affect GI absorption rate of Rx?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Delayed absorption - like competitive inhib

4. what drugs can cause dizziness?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Begin @25-50% recommended dose - APAP may be dose-limiting
Constipation -> laxatives

5. What is sCr?
Serum Cr: used for Cr clearance equation
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

6. How does aging affect pharmacokinetics?
Doctors
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

7. how may hypertension compensate for aging?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
ANF: Na+ retention - disinhib vasoconstriction

8. What are the key points of safe prescription for elderly - lecture
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
5% - underreported
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Diagnosis - risk/benefit analysis to choose Rx

9. What are the narrative elements of clinical ethics?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
5% - underreported
Voice - character - plot - context - time - reader
Tx underlying etio - + Kegels - pessary - surgery

10. opioid tx in elderly
Electrolyte imbalance - arrhythmia
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
^BP -> a-HTN
Begin @25-50% recommended dose - APAP may be dose-limiting

11. urinary incontinence types
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Stress: #1 - functional - urge - overflow

12. How does aging affect pharmacokinetic Rx distribution?
Temporalis muscle wasting = temporal wasting
Universal - progressive - partially encoded (genetic) - destructive -
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Respect for autonomy - nonmaleficence - beneficence - justice

13. What are the pharmacodynamic changes associated with aging?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Receptors changes: # - sensitivity - counter-regulatory moa
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

14. which benzodiazepines are most appropriate for elderly?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
P2-metab: Lorazepam - Trazepam - Oxazepam
Treat underlying disease/lack resources
Delayed absorption - like competitive inhib

15. malnutrition
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Receptors changes: # - sensitivity - counter-regulatory moa
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

16. what can enhance reporting in elderly?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Screen for potentially embarrassing dx - patient/Dr trust
Respect for autonomy - nonmaleficence - beneficence - justice
Serum Cr: used for Cr clearance equation

17. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Receptors changes: # - sensitivity - counter-regulatory moa
CVA: stroke - AMI: acute MI - HF
Consider responsibilities - drivin

18. thyroid dx + atypical Sx
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

19. restrain requirements
ANF: Na+ retention - disinhib vasoconstriction
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Catch-all of unspecified dizziness
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

20. delirium: tx approach
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
^K+

21. nutrition syndromes
Make sure to discuss with patient - some states require reporting
Multisystemic vulnerability - -lowered reserves
Cachexia - PEM - FTT - obesity
Electrolyte imbalance - arrhythmia

22. frailty signs
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Parkinsonism -> l-DOPA
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

23. urge incontinence tx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
^morbidity + mortality - -frailest @ greatest risk

24. documenting elderly abuse

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25. physical neglect
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
^BP -> a-HTN
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

26. incontinence epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

27. What are the common causes of lightheadedness?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
IdioPx - psychiatric: depression - anxiety - somatoform
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Legal: Cruzan v Hamon

28. What are common scenarios of untreated indications in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Delayed absorption - like competitive inhib

29. fall causes
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
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

30. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Map of people - perceptions - etc - varies by perspective

31. delirium: Rx that contribute
Bone loss -> osteopenia -> osteoporosis -> Fx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Treat underlying disease/lack resources

32. MI + atypical Sx
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Hypothetical plan - serves as patient's last competent indicated wishes

33. Disequilibrium
Delayed absorption - like competitive inhib
Voice - character - plot - context - time - reader
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

34. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
P2-metabolite - phase 1 biotx much more affected than phase 2
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

35. PEM
Electrolyte imbalance - arrhythmia
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

36. donepezil
5% - underreported
Universal - progressive - partially encoded (genetic) - destructive -
80% of hospital admission for syncope for >65yo
Cholinesterase inhib - use: dementia

37. driving considerations
Electrolyte imbalance - arrhythmia
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Make sure to discuss with patient - some states require reporting
Worse for cardiac causes v noncardia

38. what normally prevents syncope?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
3 reflexes: baroreceptor - renal nerve - ANF
Legal: Cruzan v Hamon

39. narcotics may lead to what prescription cascade?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Constipation -> laxatives
Confusion - sedation - falls
Tx underlying etio - + Kegels - pessary - surgery

40. What is a PE sign of cachexia?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Electrolyte imbalance - arrhythmia
Temporalis muscle wasting = temporal wasting

41. what illnesses are underreported in elderly?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

42. How does aging affect Rx pharmacokinetic metabolism?
Phenytoin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

43. How does aging affect pharmacokinetic protein binding?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^ANS tone -> ^periph vasoconstriction - ^HR
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

44. refusing intervention
Electrolyte imbalance - arrhythmia
Legal: Cruzan v Hamon
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

45. frailty raises vulnerability to...
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Breast cancer + 2o LBP

46. What is a mattering map?
CVA: stroke - AMI: acute MI - HF
Legal: Cruzan v Hamon
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Map of people - perceptions - etc - varies by perspective

47. tube feeding
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
A-blockers - B-blockers - TCA
30% preventable - of these - 40% serious - of these 40% preventable

48. elderly abuse epidemiology
5% - underreported
Serum Cr: used for Cr clearance equation
Legal: Cruzan v Hamon
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

49. osteoporosis epidemiology
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
High mortality - esp + Fx - very common in elderly
Respect for autonomy - nonmaleficence - beneficence - justice

50. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
>9 Rx
Hypotension - ^K+