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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. Disequilibrium
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
^SV (diastolic stroke volume)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

2. Why is abuse underreported?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
^K+
Hyperuricemia -> gout
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

3. what nutritional interventions help underweight?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Worse for cardiac causes v noncardia
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

4. How does renal nerve prevent syncope?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
^ANS tone -> ^periph vasoconstriction - ^HR
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

5. How does aging affect GI absorption of Rx?
P2-metabolite - phase 1 biotx much more affected than phase 2
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Cholinesterase inhib - use: dementia

6. How does aging affect Rx renal elimination?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
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
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Prescribing - monitoring - patient adherence

7. clues of neglect
Prescribing - monitoring - patient adherence
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Mechanical loading - skin care - avoid friction/shear
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

8. which benzodiazepines are most appropriate for elderly?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
P2-metab: Lorazepam - Trazepam - Oxazepam
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

9. delirium incidence
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Serum Cr: used for Cr clearance equation
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

10. delirium: mgmt
Used to calculate renal fcn - clearance of Cr adjusted for age
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

11. stress incontinence tx
Tx underlying etio - + Kegels - pessary - surgery
^BP -> a-HTN
Phenytoin
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

12. using long-acting opioids in elderly
Delayed absorption - like competitive inhib
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

13. Cockcroft Gault equation
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Phenytoin
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
High mortality - esp + Fx - very common in elderly

14. delirium predisposing rf
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
3 reflexes: baroreceptor - renal nerve - ANF
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

15. What is the natural history of syncope?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

16. What are the 4 forms of dizziness?
Determined by Dr for a patient - -> used to determine competency
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Vertigo - presyncope - disequilibrium - lightheadedness

17. osteoporosis
Map of people - perceptions - etc - varies by perspective
BMD (bone mineral density): T-score >2.5 std dev below normal 1
P2-metabolite - phase 1 biotx much more affected than phase 2
Consider responsibilities - drivin

18. falls epidemiology
Used to calculate renal fcn - clearance of Cr adjusted for age
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
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
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

19. documenting elderly abuse

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20. delirium diagnosis
Cachexia - PEM - FTT - obesity
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

21. elderly abuse epidemiology
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
P2-metabolite - phase 1 biotx much more affected than phase 2
CNS suppression -> cholinesterase inhibitors
5% - underreported

22. what mechanical loading helps to prevent pressure ulcers?
CVA: stroke - AMI: acute MI - HF
Constipation -> laxatives
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

23. How does baroreceptor reflex prevent syncope?
IdioPx - psychiatric: depression - anxiety - somatoform
^ANS tone -> ^periph vasoconstriction - ^HR
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Worse for cardiac causes v noncardia

24. How does an 80yo renal fcn compare to that of a 20yo?
1/2
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Figure out a good diet - social aspect - resources - dental/oral comfort
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

25. anticholinergic drugs may lead to what prescription cascade?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
CNS suppression -> cholinesterase inhibitors

26. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
80% of hospital admission for syncope for >65yo
>60yo - low abuse risk - ^ monitoring possible

27. cachexia
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

28. What are the rf for elderly abuse?
Determined by Dr for a patient - -> used to determine competency
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Cholinesterase inhib - use: dementia
Doctors

29. What is sCr?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Serum Cr: used for Cr clearance equation
Receptors changes: # - sensitivity - counter-regulatory moa
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

30. frailty raises vulnerability to...
Constipation -> laxatives
Serum Cr: used for Cr clearance equation
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Hyperuricemia -> gout

31. what Rx are commonly monifoted in elderly for ADR?
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
Stress: #1 - functional - urge - overflow
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

32. fall sequelae

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33. delirium: Rx that contribute
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

34. Aging descriptors
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Voice - character - plot - context - time - reader
Universal - progressive - partially encoded (genetic) - destructive -

35. how is cachexia different from wasting?
5% - underreported
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Confusion - sedation - falls
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

36. rivastigmine
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Legal: Cruzan v Hamon
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Cholinesterase inhib - use: dementia

37. incontinence epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Cachexia - PEM - FTT - obesity
Breast cancer + 2o LBP
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

38. lightheadedness
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Receptors changes: # - sensitivity - counter-regulatory moa
Catch-all of unspecified dizziness
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

39. How does aging affect Rx pharmacokinetic metabolism?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Mechanical loading - skin care - avoid friction/shear
CVA: stroke - AMI: acute MI - HF
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

40. What is the Cockcroft Gault equation?
Worse for cardiac causes v noncardia
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
80% of hospital admission for syncope for >65yo
Used to calculate renal fcn - clearance of Cr adjusted for age

41. How does aging affect GI absorption rate of Rx?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
P2-metab: Lorazepam - Trazepam - Oxazepam
Delayed absorption - like competitive inhib
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

42. how is syncope related to elderly admission to hospital?
Beers criteria - medication appropriateness index (12 ?)
Serum Cr: used for Cr clearance equation
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
80% of hospital admission for syncope for >65yo

43. What are the pharmacodynamic changes associated with aging?
Receptors changes: # - sensitivity - counter-regulatory moa
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Cachexia - PEM - FTT - obesity

44. lipid-soluble Rx
Treat underlying disease/lack resources
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
NMDR antagonist - use: dementia

45. Aging principles
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Consider responsibilities - drivin

46. What is ISH?
Voice - character - plot - context - time - reader
^BP -> a-HTN
Isolated systolic HTN
Insiduous onset

47. How does aging affect pharmacokinetic protein binding?
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
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

48. MI + atypical Sx
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Worse for cardiac causes v noncardia
Determined by Dr for a patient - -> used to determine competency
No: chest pain - yes: fatigue - nausea - low functional status - SOB

49. who is a good candidate for opioid tx?
Bone loss -> osteopenia -> osteoporosis -> Fx
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
>60yo - low abuse risk - ^ monitoring possible
Make sure to discuss with patient - some states require reporting

50. What is capacity?
Determined by Dr for a patient - -> used to determine competency
Worse for cardiac causes v noncardia
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Hypothetical plan - serves as patient's last competent indicated wishes