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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. malignancy + atypical Sx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Confusion - sedation - falls
Breast cancer + 2o LBP
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

2. What is a mattering map?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Cholinesterase inhib - use: dementia
Catch-all of unspecified dizziness
Map of people - perceptions - etc - varies by perspective

3. osteoporosis
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

4. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
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
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

5. What is polypharmacy
>9 Rx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Hypothetical plan - serves as patient's last competent indicated wishes
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

6. describe the % of ADR considered preventable - and of those serious
High mortality - esp + Fx - very common in elderly
30% preventable - of these - 40% serious - of these 40% preventable
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
CVA: stroke - AMI: acute MI - HF

7. BZD + antidepressant: interaction outcome
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Confusion - sedation - falls
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

8. NSAID may lead to what prescription cascade?
^BP -> a-HTN
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Consider responsibilities - drivin
Cholinesterase inhib - use: dementia

9. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Figure out a good diet - social aspect - resources - dental/oral comfort
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

10. elderly abuse epidemiology
Hypothetical plan - serves as patient's last competent indicated wishes
5% - underreported
^ANS tone -> ^periph vasoconstriction - ^HR
Delayed absorption - like competitive inhib

11. anticholinergic drugs may lead to what prescription cascade?
Figure out a good diet - social aspect - resources - dental/oral comfort
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
CNS suppression -> cholinesterase inhibitors
Determined by Dr for a patient - -> used to determine competency

12. frailty raises vulnerability to...
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Falls - delirium - malnutrition - P ulcers - opportunistic i2
30% preventable - of these - 40% serious - of these 40% preventable
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

13. BZD + antipsychotic: interaction outcome
Vertigo - presyncope - disequilibrium - lightheadedness
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Confusion - sedation - falls
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

14. tube feeding
^ANS tone -> ^periph vasoconstriction - ^HR
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

15. PEM
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Bone loss -> osteopenia -> osteoporosis -> Fx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

16. Approach to idioPx - recurrent syncope
Insiduous onset
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Cachexia - PEM - FTT - obesity
Consider responsibilities - drivin

17. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
F>M (until 80yo) - stress incontinence #1 - $26B/yr
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

18. lightheadedness
Catch-all of unspecified dizziness
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
Phenytoin
Bone loss -> osteopenia -> osteoporosis -> Fx

19. how may hypertension compensate for aging?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

20. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

21. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Cachexia - PEM - FTT - obesity
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

22. Presyncope
3 reflexes: baroreceptor - renal nerve - ANF
Screen for potentially embarrassing dx - patient/Dr trust
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

23. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
Hypothetical plan - serves as patient's last competent indicated wishes
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

24. delirium: medical rf
Stress: #1 - functional - urge - overflow
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Voice - character - plot - context - time - reader

25. What are common physical abuse Sx in elderly?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
NMDR antagonist - use: dementia
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

26. How does aging affect pharmacokinetic protein binding?
ANF: Na+ retention - disinhib vasoconstriction
Threats/ terrorizing - isolation - denying food/privileges/liberty
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Consider responsibilities - drivin

27. overflow incontinence tx
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
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Begin @25-50% recommended dose - APAP may be dose-limiting

28. How does aging affect GI absorption of Rx?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
CNS suppression -> cholinesterase inhibitors
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

29. MRP: medication related problems
Constipation -> laxatives
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

30. malnutrition
Vertigo - presyncope - disequilibrium - lightheadedness
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Hypotension - ^K+

31. red flags for further inquiry
Therapy - SSRI
Treat underlying disease/lack resources
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

32. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Hypothetical plan - serves as patient's last competent indicated wishes

33. which benzodiazepines are most appropriate for elderly?
Make sure to discuss with patient - some states require reporting
Universal - progressive - partially encoded (genetic) - destructive -
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
P2-metab: Lorazepam - Trazepam - Oxazepam

34. violation of rights
Consider responsibilities - drivin
Tx underlying etio - + Kegels - pessary - surgery
Cholinesterase inhib - use: dementia
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

35. What are the common types of elder mistreatment?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Hyperuricemia -> gout
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

36. What are the common causes of lightheadedness?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
IdioPx - psychiatric: depression - anxiety - somatoform
BMD (bone mineral density): T-score >2.5 std dev below normal 1

37. narcotics may lead to what prescription cascade?
Constipation -> laxatives
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Threats/ terrorizing - isolation - denying food/privileges/liberty

38. Alb-bound Rx
^BP -> a-HTN
Phenytoin
Multisystemic vulnerability - -lowered reserves
Receptors changes: # - sensitivity - counter-regulatory moa

39. osteoporosis epidemiology
Catch-all of unspecified dizziness
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
High mortality - esp + Fx - very common in elderly
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

40. What is START criteria?
>60yo - low abuse risk - ^ monitoring possible
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
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

41. 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
NMDR antagonist - use: dementia
Isolated systolic HTN
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

42. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
^BP -> a-HTN
^SV (diastolic stroke volume)
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

43. ADR rf
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Beers criteria - medication appropriateness index (12 ?)
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

44. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
P2-metab: Lorazepam - Trazepam - Oxazepam

45. What are rf for osteoporosis?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Make sure to discuss with patient - some states require reporting
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

46. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

47. What are the vascular changes of presyncope?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

48. refusing intervention
Tx underlying etio - + Kegels - pessary - surgery
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Legal: Cruzan v Hamon
>60yo - low abuse risk - ^ monitoring possible

49. using long-acting opioids in elderly
3 reflexes: baroreceptor - renal nerve - ANF
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

50. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Hypotension - ^K+
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope