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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 3 sentinel events for LT care?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Mechanical loading - skin care - avoid friction/shear
Pressure ulcer - fecal impaction - dehydration
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

2. How does aging affect pharmacokinetic Rx distribution?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
IdioPx - psychiatric: depression - anxiety - somatoform
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

3. Disequilibrium
Prescribing - monitoring - patient adherence
Legal: Cruzan v Hamon
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

4. What is a mattering map?
Figure out a good diet - social aspect - resources - dental/oral comfort
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Map of people - perceptions - etc - varies by perspective

5. What are the risks of uncontrolled ISH?
3 reflexes: baroreceptor - renal nerve - ANF
CVA: stroke - AMI: acute MI - HF
Phenytoin
Map of people - perceptions - etc - varies by perspective

6. who is a good candidate for opioid tx?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
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
>60yo - low abuse risk - ^ monitoring possible

7. How does ANF prevent syncope?
ANF: Na+ retention - disinhib vasoconstriction
Catch-all of unspecified dizziness
Diagnosis - risk/benefit analysis to choose Rx
>9 Rx

8. rivastigmine
Cholinesterase inhib - use: dementia
Beers criteria - medication appropriateness index (12 ?)
Parkinsonism -> l-DOPA
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

9. ACE inhib + diuretic: interaction outcome
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
Hypotension - ^K+
Confusion - sedation - falls
Cachexia - PEM - FTT - obesity

10. when selecting an P1-metabolite or P2-metabolite safer in elderly?
28% - ADR: 17% - non-compliance 11%
P2-metabolite - phase 1 biotx much more affected than phase 2
Treat underlying disease/lack resources
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

11. what ADR are common in elderly patient?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Treat underlying disease/lack resources
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

12. What is the best approach to malnutrition
Treat underlying disease/lack resources
Map of people - perceptions - etc - varies by perspective
Confusion - sedation - falls
#1 patient's last competent indication of wishes - substituted judgment - beneficence

13. What drugs can contribute to syncope?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
No: fever - leukocytosis - yes: falls - appetite change - low functional status
A-blockers - B-blockers - TCA

14. What are the hazards of elderly hospitalization?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
^morbidity + mortality - -frailest @ greatest risk
IdioPx - psychiatric: depression - anxiety - somatoform
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

15. delirium diagnosis
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

16. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
P2-metabolite - phase 1 biotx much more affected than phase 2
Voice - character - plot - context - time - reader
P2-metab: Lorazepam - Trazepam - Oxazepam

17. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
CVA: stroke - AMI: acute MI - HF
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

18. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Injury - neglect - physical/psychosocial - financial - violation of rights
Parkinsonism -> l-DOPA

19. how is the CAM used to diagnose delirium?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
^K+
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

20. i2 + atypical Sx
^ANS tone -> ^periph vasoconstriction - ^HR
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Determined by Dr for a patient - -> used to determine competency

21. delirium incidence
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Diagnosis - risk/benefit analysis to choose Rx
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

22. acute abdomen + atypical Sx
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
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Stress: #1 - functional - urge - overflow

23. fall sequelae

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24. falls epidemiology
5% - underreported
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

25. What are rf for osteoporosis?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Cholinesterase inhib - use: dementia
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Diagnosis - risk/benefit analysis to choose Rx

26. Alb-bound Rx
Diagnosis - risk/benefit analysis to choose Rx
Phenytoin
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
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

27. functional incontinence tx
Receptors changes: # - sensitivity - counter-regulatory moa
Environment modification: obstacles - mobility - -bladder fcn ok
28% - ADR: 17% - non-compliance 11%
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

28. which benzodiazepines are most appropriate for elderly?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
P2-metab: Lorazepam - Trazepam - Oxazepam
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

29. LBW equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Hyperuricemia -> gout
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Delayed absorption - like competitive inhib

30. how may hypertension compensate for aging?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Determined by Dr for a patient - -> used to determine competency
>60yo - low abuse risk - ^ monitoring possible

31. osteoporosis etio
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

32. antiarrhythmic + diuretic: interaction outcome
^K+
Electrolyte imbalance - arrhythmia
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

33. what receptors increase sensitivity with aging?
Electrolyte imbalance - arrhythmia
28% - ADR: 17% - non-compliance 11%
Bone loss -> osteopenia -> osteoporosis -> Fx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

34. What are the common causes of lightheadedness?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
IdioPx - psychiatric: depression - anxiety - somatoform
^morbidity + mortality - -frailest @ greatest risk
80% of hospital admission for syncope for >65yo

35. delirium predisposing rf
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
P2-metabolite - phase 1 biotx much more affected than phase 2
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

36. malignancy + atypical Sx
P2-metabolite - phase 1 biotx much more affected than phase 2
Breast cancer + 2o LBP
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
>60yo - low abuse risk - ^ monitoring possible

37. preventing malnutrition
3 reflexes: baroreceptor - renal nerve - ANF
Breast cancer + 2o LBP
P2-metabolite - phase 1 biotx much more affected than phase 2
Figure out a good diet - social aspect - resources - dental/oral comfort

38. lipid-soluble Rx
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Vertigo - presyncope - disequilibrium - lightheadedness
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

39. fall causes
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
CNS suppression -> cholinesterase inhibitors
80% of hospital admission for syncope for >65yo
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

40. what receptors decrease sensitivity with aging?
Used to calculate renal fcn - clearance of Cr adjusted for age
Cholinesterase inhib - use: dementia
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

41. conservator
Appointed by court if no substituted judgment -conservator of finance -conservator of person
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
Universal - progressive - partially encoded (genetic) - destructive -
Prescribing - monitoring - patient adherence

42. frailty
Multisystemic vulnerability - -lowered reserves
Voice - character - plot - context - time - reader
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Vertigo - presyncope - disequilibrium - lightheadedness

43. donepezil
^BP -> a-HTN
Confusion - sedation - falls
Cholinesterase inhib - use: dementia
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

44. delirium: mgmt
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Breast cancer + 2o LBP
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

45. How does renal nerve prevent syncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Bone loss -> osteopenia -> osteoporosis -> Fx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
^BP -> a-HTN

46. stress incontinence tx
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
NMDR antagonist - use: dementia
Tx underlying etio - + Kegels - pessary - surgery
Isolated systolic HTN

47. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/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
Hypotension - ^K+
3 reflexes: baroreceptor - renal nerve - ANF

48. refusing intervention
Legal: Cruzan v Hamon
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Make sure to discuss with patient - some states require reporting
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

49. psychological abuse
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Threats/ terrorizing - isolation - denying food/privileges/liberty
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

50. What is START criteria?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin