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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. PEM
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

2. How to prevent pressure ulcers?
A-blockers - B-blockers - TCA
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Mechanical loading - skin care - avoid friction/shear
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

3. pressure ulcer: staging
Isolated systolic HTN
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Doctors
Injury - neglect - physical/psychosocial - financial - violation of rights

4. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
5% - underreported
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

5. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Universal - progressive - partially encoded (genetic) - destructive -
1/2
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

6. substituted judgment
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
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
Map of people - perceptions - etc - varies by perspective
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

7. what mechanical loading helps to prevent pressure ulcers?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Environment modification: obstacles - mobility - -bladder fcn ok

8. What is the preferred depression treatment in elderly?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Injury - neglect - physical/psychosocial - financial - violation of rights
Therapy - SSRI

9. what can enhance reporting in elderly?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Screen for potentially embarrassing dx - patient/Dr trust

10. what receptors decrease sensitivity with aging?
30% preventable - of these - 40% serious - of these 40% preventable
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

11. Why is abuse underreported?
Pressure ulcer - fecal impaction - dehydration
3 reflexes: baroreceptor - renal nerve - ANF
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

12. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
IdioPx - psychiatric: depression - anxiety - somatoform
Insiduous onset
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

13. LBW equation
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
#1 patient's last competent indication of wishes - substituted judgment - beneficence
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Constipation -> laxatives

14. i2 + atypical Sx
28% - ADR: 17% - non-compliance 11%
3 reflexes: baroreceptor - renal nerve - ANF
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
No: fever - leukocytosis - yes: falls - appetite change - low functional status

15. narcotics may lead to what prescription cascade?
Constipation -> laxatives
Therapy - SSRI
^morbidity + mortality - -frailest @ greatest risk
Tx underlying etio - + Kegels - pessary - surgery

16. frailty raises vulnerability to...
Therapy - SSRI
Falls - delirium - malnutrition - P ulcers - opportunistic i2
BMD (bone mineral density): T-score >2.5 std dev below normal 1
1/2

17. Approach to idioPx - recurrent syncope
^morbidity + mortality - -frailest @ greatest risk
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Consider responsibilities - drivin
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

18. documenting elderly abuse

19. What are the hazards of elderly hospitalization?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Injury - neglect - physical/psychosocial - financial - violation of rights
^morbidity + mortality - -frailest @ greatest risk
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

20. What is a mattering map?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
^BP -> a-HTN
Map of people - perceptions - etc - varies by perspective
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

21. Beers criteria
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
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
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
5% - underreported

22. osteoporosis
Serum Cr: used for Cr clearance equation
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

23. Cockcroft Gault equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
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
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
3 reflexes: baroreceptor - renal nerve - ANF

24. delirium predisposing rf
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

25. How does aging affect pharmacokinetic protein binding?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
High mortality - esp + Fx - very common in elderly
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

26. What are common physical abuse Sx in elderly?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Electrolyte imbalance - arrhythmia
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

27. driving considerations
Make sure to discuss with patient - some states require reporting
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
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

28. 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
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Legal: Cruzan v Hamon

29. lightheadedness
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Catch-all of unspecified dizziness
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

30. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
>9 Rx
Figure out a good diet - social aspect - resources - dental/oral comfort
Worse for cardiac causes v noncardia

31. Alb-bound Rx
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Hypothetical plan - serves as patient's last competent indicated wishes
Phenytoin

32. lipid-soluble Rx
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Stress: #1 - functional - urge - overflow
Screen for potentially embarrassing dx - patient/Dr trust
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

33. What is a PE sign of cachexia?
Temporalis muscle wasting = temporal wasting
Written doc - don't alter it - pertinent +/- - use patient/caregiver's own words - photos - report: concise - precise - likeliness of abuse: definite/accident/indeterminate - body map for forensic documentation
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

34. How does aging affect Rx renal elimination?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Delayed absorption - like competitive inhib
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
#1 patient's last competent indication of wishes - substituted judgment - beneficence

35. what professional is least likely to report abuse?
5% - underreported
Doctors
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

36. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Confusion - sedation - falls
Multisystemic vulnerability - -lowered reserves
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

37. clues of neglect
Cholinesterase inhib - use: dementia
Beers criteria - medication appropriateness index (12 ?)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

38. thiazide diuretic may lead to what prescription cascade?
30% preventable - of these - 40% serious - of these 40% preventable
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Hyperuricemia -> gout
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

39. How does an 80yo renal fcn compare to that of a 20yo?
Parkinsonism -> l-DOPA
Begin @25-50% recommended dose - APAP may be dose-limiting
1/2
F>M (until 80yo) - stress incontinence #1 - $26B/yr

40. What are the common types of elder mistreatment?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Universal - progressive - partially encoded (genetic) - destructive -
Vertigo - presyncope - disequilibrium - lightheadedness

41. What are common medical causes of syncope?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Mechanical loading - skin care - avoid friction/shear
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
80% of hospital admission for syncope for >65yo

42. rivastigmine
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Cholinesterase inhib - use: dementia
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Hypothetical plan - serves as patient's last competent indicated wishes

43. pulm edema + atypical Sx
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Insiduous onset
High mortality - esp + Fx - very common in elderly
Breast cancer + 2o LBP

44. What are the possible cardiac causes of presyncope?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Electrical: change in HR - structural: aortic outflow obstruction

45. What are the narrative elements of clinical ethics?
Voice - character - plot - context - time - reader
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Multisystemic vulnerability - -lowered reserves
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

46. who is a good candidate for opioid tx?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
>60yo - low abuse risk - ^ monitoring possible

47. how is syncope related to elderly admission to hospital?
Prescribing - monitoring - patient adherence
Consider responsibilities - drivin
Tx underlying etio - + Kegels - pessary - surgery
80% of hospital admission for syncope for >65yo

48. What is the bone deterioration cascade?
Hyperuricemia -> gout
Bone loss -> osteopenia -> osteoporosis -> Fx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Threats/ terrorizing - isolation - denying food/privileges/liberty

49. falls epidemiology
Insiduous onset
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

50. galantamine
28% - ADR: 17% - non-compliance 11%
Cholinesterase inhib - use: dementia
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Universal - progressive - partially encoded (genetic) - destructive -