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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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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. lipid-soluble Rx
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
3 reflexes: baroreceptor - renal nerve - ANF
^BP -> a-HTN

2. i2 + atypical Sx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

3. thyroid dx + atypical Sx
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

4. What drugs can contribute to syncope?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Stress: #1 - functional - urge - overflow
A-blockers - B-blockers - TCA
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

5. What are the rf for elderly abuse?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
30% preventable - of these - 40% serious - of these 40% preventable
Isolated systolic HTN

6. what drugs can cause dizziness?
Insiduous onset
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

7. ACE inhib + diuretic: interaction outcome
Therapy - SSRI
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Hypotension - ^K+
Isolated systolic HTN

8. What are common physical abuse Sx in elderly?
Electrical: change in HR - structural: aortic outflow obstruction
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

9. What is ISH?
Isolated systolic HTN
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

10. BZD + antipsychotic: 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
^SV (diastolic stroke volume)
Respect for autonomy - nonmaleficence - beneficence - justice
Confusion - sedation - falls

11. What are the hazards of elderly hospitalization?
Diagnosis - risk/benefit analysis to choose Rx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
^morbidity + mortality - -frailest @ greatest risk
Treat underlying disease/lack resources

12. malignancy + atypical Sx
30% preventable - of these - 40% serious - of these 40% preventable
Breast cancer + 2o LBP
CVA: stroke - AMI: acute MI - HF
Insiduous onset

13. what receptors decrease sensitivity with aging?
Parkinsonism -> l-DOPA
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Constipation -> laxatives

14. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Electrolyte imbalance - arrhythmia
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

15. fall causes
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

16. What are common scenarios of untreated indications in elderly?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

17. What is START criteria?
Used to calculate renal fcn - clearance of Cr adjusted for age
Hypotension - ^K+
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

18. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
3 reflexes: baroreceptor - renal nerve - ANF
Cachexia - PEM - FTT - obesity
BMD (bone mineral density): T-score >2.5 std dev below normal 1

19. What is a PE sign of cachexia?
Temporalis muscle wasting = temporal wasting
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Tx underlying etio - + Kegels - pessary - surgery
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

20. memantine
Prescribing - monitoring - patient adherence
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Consider responsibilities - drivin
NMDR antagonist - use: dementia

21. galantamine
Cholinesterase inhib - use: dementia
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

22. functional incontinence tx
Tx underlying etio - + Kegels - pessary - surgery
Environment modification: obstacles - mobility - -bladder fcn ok
30% preventable - of these - 40% serious - of these 40% preventable
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

23. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Beers criteria - medication appropriateness index (12 ?)
Threats/ terrorizing - isolation - denying food/privileges/liberty
Prescribing - monitoring - patient adherence

24. donepezil
Hyperuricemia -> gout
Cholinesterase inhib - use: dementia
3 reflexes: baroreceptor - renal nerve - ANF
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

25. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Make sure to discuss with patient - some states require reporting
Environment modification: obstacles - mobility - -bladder fcn ok
Tx underlying etio - + Kegels - pessary - surgery

26. What is the preferred depression treatment in elderly?
Therapy - SSRI
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

27. delirium: tx approach
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

28. frailty signs
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

29. how can you determine whether Rx is appropriate to use in elderly patient?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Beers criteria - medication appropriateness index (12 ?)
Electrical: change in HR - structural: aortic outflow obstruction
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

30. What are the possible cardiac causes of presyncope?
Temporalis muscle wasting = temporal wasting
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
Electrical: change in HR - structural: aortic outflow obstruction
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

31. What are the pharmacodynamic changes associated with aging?
Prescribing - monitoring - patient adherence
Receptors changes: # - sensitivity - counter-regulatory moa
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Treat underlying disease/lack resources

32. overflow incontinence tx
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
1/2
Worse for cardiac causes v noncardia

33. How does ANF prevent syncope?
^morbidity + mortality - -frailest @ greatest risk
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
ANF: Na+ retention - disinhib vasoconstriction
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

34. What are the vascular changes of presyncope?
Prescribing - monitoring - patient adherence
Hypotension - ^K+
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

35. What are the common types of elder mistreatment?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

36. Presyncope
NMDR antagonist - use: dementia
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
High mortality - esp + Fx - very common in elderly
Hypothetical plan - serves as patient's last competent indicated wishes

37. What are the narrative elements of clinical ethics?
Voice - character - plot - context - time - reader
Phenytoin
CVA: stroke - AMI: acute MI - HF
Figure out a good diet - social aspect - resources - dental/oral comfort

38. vision changes: elderly
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Confusion - sedation - falls
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Consider responsibilities - drivin

39. delirium predisposing rf
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Confusion - sedation - falls

40. What are the rf for caregiver to abuse elderly?
Hyperuricemia -> gout
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

41. incontinence epidemiology
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Cholinesterase inhib - use: dementia
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
F>M (until 80yo) - stress incontinence #1 - $26B/yr

42. frailty raises vulnerability to...
Multisystemic vulnerability - -lowered reserves
Falls - delirium - malnutrition - P ulcers - opportunistic i2
^SV (diastolic stroke volume)
Worse for cardiac causes v noncardia

43. describe the % of ADR considered preventable - and of those serious
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
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
30% preventable - of these - 40% serious - of these 40% preventable

44. LBW equation
P2-metabolite - phase 1 biotx much more affected than phase 2
Electrical: change in HR - structural: aortic outflow obstruction
Diagnosis - risk/benefit analysis to choose Rx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

45. What are the 3 stages of ADRs?
Prescribing - monitoring - patient adherence
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
Delayed absorption - like competitive inhib
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

46. what professional is least likely to report abuse?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Doctors
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
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

47. What is the STOPP criteria?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Make sure to discuss with patient - some states require reporting
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
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

48. Aging features
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Electrical: change in HR - structural: aortic outflow obstruction
Universal - progressive - partially encoded (genetic) - destructive -
Prescribing - monitoring - patient adherence

49. What is the best approach to malnutrition
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Treat underlying disease/lack resources
Insiduous onset

50. How does aging increase incontinence?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
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
Insiduous onset