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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. How does an 80yo renal fcn compare to that of a 20yo?
Prescribing - monitoring - patient adherence
1/2
^morbidity + mortality - -frailest @ greatest risk
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

2. violation of rights
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Consider responsibilities - drivin
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

3. How does aging affect Rx pharmacokinetic metabolism?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

4. frailty signs
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Serum Cr: used for Cr clearance equation

5. How to prevent pressure ulcers?
^morbidity + mortality - -frailest @ greatest risk
Confusion - sedation - falls
Mechanical loading - skin care - avoid friction/shear
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

6. How does baroreceptor reflex prevent syncope?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
^ANS tone -> ^periph vasoconstriction - ^HR
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Cholinesterase inhib - use: dementia

7. physical neglect
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

8. What are the 4 forms of dizziness?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Vertigo - presyncope - disequilibrium - lightheadedness

9. PEM
80% of hospital admission for syncope for >65yo
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Map of people - perceptions - etc - varies by perspective

10. What are the key points of safe prescription for elderly - lecture
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Worse for cardiac causes v noncardia
Diagnosis - risk/benefit analysis to choose Rx

11. antiarrhythmic + diuretic: interaction outcome
>60yo - low abuse risk - ^ monitoring possible
Electrolyte imbalance - arrhythmia
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

12. opioid tx in elderly
Treat underlying disease/lack resources
Begin @25-50% recommended dose - APAP may be dose-limiting
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
3 reflexes: baroreceptor - renal nerve - ANF

13. thiazide diuretic may lead to what prescription cascade?
Hyperuricemia -> gout
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Injury - neglect - physical/psychosocial - financial - violation of rights

14. What are the possible cardiac causes of presyncope?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Treat underlying disease/lack resources
Electrical: change in HR - structural: aortic outflow obstruction

15. What are the rf for elderly abuse?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Confusion - sedation - falls

16. What are the hazards of elderly hospitalization?
Threats/ terrorizing - isolation - denying food/privileges/liberty
^morbidity + mortality - -frailest @ greatest risk
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

17. depression + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Stress: #1 - functional - urge - overflow
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Insiduous onset

18. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Receptors changes: # - sensitivity - counter-regulatory moa
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

19. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Doctors
Falls - delirium - malnutrition - P ulcers - opportunistic i2

20. what can enhance reporting in elderly?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Screen for potentially embarrassing dx - patient/Dr trust
28% - ADR: 17% - non-compliance 11%
Constipation -> laxatives

21. documenting elderly abuse

22. pressure ulcer: staging
P2-metab: Lorazepam - Trazepam - Oxazepam
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Serum Cr: used for Cr clearance equation
No: fever - leukocytosis - yes: falls - appetite change - low functional status

23. driving considerations
Make sure to discuss with patient - some states require reporting
Delayed absorption - like competitive inhib
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Pressure ulcer - fecal impaction - dehydration

24. What is a PE sign of cachexia?
28% - ADR: 17% - non-compliance 11%
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Screen for potentially embarrassing dx - patient/Dr trust
Temporalis muscle wasting = temporal wasting

25. 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
Mechanical loading - skin care - avoid friction/shear
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

26. What is the epidemiology of dizziness?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Bone loss -> osteopenia -> osteoporosis -> Fx

27. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Phenytoin
^ANS tone -> ^periph vasoconstriction - ^HR

28. malnutrition
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Worse for cardiac causes v noncardia
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

29. incontinence complication
>60yo - low abuse risk - ^ monitoring possible
Prescribing - monitoring - patient adherence
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Therapy - SSRI

30. What is the natural history of syncope?
>60yo - low abuse risk - ^ monitoring possible
Diagnosis - risk/benefit analysis to choose Rx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

31. nutrition syndromes
Cachexia - PEM - FTT - obesity
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Diagnosis - risk/benefit analysis to choose Rx

32. memantine
Temporalis muscle wasting = temporal wasting
P2-metabolite - phase 1 biotx much more affected than phase 2
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
NMDR antagonist - use: dementia

33. refusing intervention
Legal: Cruzan v Hamon
Consider responsibilities - drivin
Delayed absorption - like competitive inhib
Make sure to discuss with patient - some states require reporting

34. How does the aging heart compensate for lower HR to maintain unchanged CO?
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
Diagnosis - risk/benefit analysis to choose Rx
Injury - neglect - physical/psychosocial - financial - violation of rights
^SV (diastolic stroke volume)

35. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Therapy - SSRI

36. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Confusion - sedation - falls
Breast cancer + 2o LBP
NMDR antagonist - use: dementia

37. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Serum Cr: used for Cr clearance equation
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

38. What are the common types of elder mistreatment?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

39. what % of hospitalizations of elderly are due to ADR + noncompliance?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
28% - ADR: 17% - non-compliance 11%

40. urinary incontinence types
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Mechanical loading - skin care - avoid friction/shear
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Stress: #1 - functional - urge - overflow

41. metoclopramide may lead to what prescription cascade?
Confusion - sedation - falls
Therapy - SSRI
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Parkinsonism -> l-DOPA

42. narcotics may lead to what prescription cascade?
Constipation -> laxatives
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
ANF: Na+ retention - disinhib vasoconstriction
1/2

43. What is the Cockcroft Gault equation?
Screen for potentially embarrassing dx - patient/Dr trust
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Used to calculate renal fcn - clearance of Cr adjusted for age

44. what receptors decrease sensitivity with aging?
Diagnosis - risk/benefit analysis to choose Rx
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
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

45. donepezil
P2-metab: Lorazepam - Trazepam - Oxazepam
Cholinesterase inhib - use: dementia
Hypotension - ^K+
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

46. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
Confusion - sedation - falls
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

47. describe the % of ADR considered preventable - and of those serious
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
30% preventable - of these - 40% serious - of these 40% preventable

48. MI + atypical Sx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
No: chest pain - yes: fatigue - nausea - low functional status - SOB

49. lightheadedness
^K+
Voice - character - plot - context - time - reader
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Catch-all of unspecified dizziness

50. MRP: medication related problems
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Hypothetical plan - serves as patient's last competent indicated wishes
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease