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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. restrain requirements
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Must be signed by attending daily -medical necessity/patient liberty -as minimal as 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
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

2. lightheadedness
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Cholinesterase inhib - use: dementia
Catch-all of unspecified dizziness

3. What are the hazards of elderly hospitalization?
^morbidity + mortality - -frailest @ greatest risk
^K+
P2-metabolite - phase 1 biotx much more affected than phase 2
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

4. LBW equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Hypothetical plan - serves as patient's last competent indicated wishes
Multisystemic vulnerability - -lowered reserves
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

5. galantamine
Serum Cr: used for Cr clearance equation
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Cholinesterase inhib - use: dementia
Stress: #1 - functional - urge - overflow

6. MRP: medication related problems
Cholinesterase inhib - use: dementia
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Screen for potentially embarrassing dx - patient/Dr trust
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

7. delirium: Rx that contribute
3 reflexes: baroreceptor - renal nerve - ANF
Determined by Dr for a patient - -> used to determine competency
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

8. How does aging affect Rx pharmacokinetic distribution?
Catch-all of unspecified dizziness
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
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

9. tube feeding
Stress: #1 - functional - urge - overflow
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Cholinesterase inhib - use: dementia

10. What are the key points of safe prescription for elderly - lecture
Diagnosis - risk/benefit analysis to choose Rx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

11. Syncope prognosis based on etio
Delayed absorption - like competitive inhib
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Phenytoin
Worse for cardiac causes v noncardia

12. What are the possible cardiac causes of presyncope?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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
Pressure ulcer - fecal impaction - dehydration
Electrical: change in HR - structural: aortic outflow obstruction

13. dementia tx
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
Hypotension - ^K+
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Serum Cr: used for Cr clearance equation

14. urge incontinence tx
Respect for autonomy - nonmaleficence - beneficence - justice
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

15. elderly abuse epidemiology
5% - underreported
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Doctors

16. What is a PE sign of cachexia?
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
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Temporalis muscle wasting = temporal wasting
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

17. who is a good candidate for opioid tx?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
3 reflexes: baroreceptor - renal nerve - ANF
>60yo - low abuse risk - ^ monitoring possible
Receptors changes: # - sensitivity - counter-regulatory moa

18. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
>60yo - low abuse risk - ^ monitoring possible
Multisystemic vulnerability - -lowered reserves

19. frailty
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Multisystemic vulnerability - -lowered reserves
>9 Rx
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

20. Why is abuse underreported?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

21. driving considerations
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Injury - neglect - physical/psychosocial - financial - violation of rights
Make sure to discuss with patient - some states require reporting
CNS suppression -> cholinesterase inhibitors

22. ADR rf
Cholinesterase inhib - use: dementia
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

23. What are the common types of elder mistreatment?
CNS suppression -> cholinesterase inhibitors
5% - underreported
Catch-all of unspecified dizziness
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

24. refusing intervention
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
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
Legal: Cruzan v Hamon

25. conservator
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Cachexia - PEM - FTT - obesity
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

26. surrogate decision making heirarchy

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27. fall causes
Receptors changes: # - sensitivity - counter-regulatory moa
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Cholinesterase inhib - use: dementia

28. what drugs can cause dizziness?
Hypotension - ^K+
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

29. What are the 4 basic ethical principles?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Respect for autonomy - nonmaleficence - beneficence - justice
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

30. Beers criteria
Consider responsibilities - drivin
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Figure out a good diet - social aspect - resources - dental/oral comfort
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

31. Alb-bound Rx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Catch-all of unspecified dizziness
Phenytoin
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

32. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Cachexia - PEM - FTT - obesity

33. delirium predisposing rf
Temporalis muscle wasting = temporal wasting
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

34. advanced directive/care plan

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35. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
30% preventable - of these - 40% serious - of these 40% preventable
Prescribing - monitoring - patient adherence

36. delirium: tx approach
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
^morbidity + mortality - -frailest @ greatest risk
Insiduous onset
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

37. violation of rights
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Treat underlying disease/lack resources
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

38. Cockcroft Gault equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Treat underlying disease/lack resources

39. overflow incontinence tx
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
Receptors changes: # - sensitivity - counter-regulatory moa
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Consider responsibilities - drivin

40. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

41. rule of doable effect
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
CNS suppression -> cholinesterase inhibitors
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

42. Approach to idioPx - recurrent syncope
Consider responsibilities - drivin
28% - ADR: 17% - non-compliance 11%
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Temporalis muscle wasting = temporal wasting

43. what % of hospitalizations of elderly are due to ADR + noncompliance?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Therapy - SSRI
28% - ADR: 17% - non-compliance 11%
5% - underreported

44. What is the Cockcroft Gault equation?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Make sure to discuss with patient - some states require reporting
Delayed absorption - like competitive inhib
Used to calculate renal fcn - clearance of Cr adjusted for age

45. 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
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
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
#1 patient's last competent indication of wishes - substituted judgment - beneficence

46. malnutrition
Cachexia - PEM - FTT - obesity
F>M (until 80yo) - stress incontinence #1 - $26B/yr
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
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

47. What is the preferred depression treatment in elderly?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
>60yo - low abuse risk - ^ monitoring possible
Therapy - SSRI

48. How does aging impact syncope-preventing reflexes
ANF: Na+ retention - disinhib vasoconstriction
Delayed absorption - like competitive inhib
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Parkinsonism -> l-DOPA

49. acute abdomen + atypical Sx
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

50. What are rf for osteoporosis?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Electrical: change in HR - structural: aortic outflow obstruction