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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. BZD + antidepressant: interaction outcome
Catch-all of unspecified dizziness
Begin @25-50% recommended dose - APAP may be dose-limiting
Confusion - sedation - falls
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

2. lightheadedness
Catch-all of unspecified dizziness
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

3. anticholinergic drugs may lead to what prescription cascade?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
CNS suppression -> cholinesterase inhibitors
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
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

4. How does the aging heart compensate for lower HR to maintain unchanged CO?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
^SV (diastolic stroke volume)
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

5. How does aging affect Rx pharmacokinetic metabolism?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Beers criteria - medication appropriateness index (12 ?)
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

6. What is the STOPP criteria?
^BP -> a-HTN
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
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

7. Syncope prognosis based on etio
Worse for cardiac causes v noncardia
Used to calculate renal fcn - clearance of Cr adjusted for age
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

8. What is abuse?
Isolated systolic HTN
Voice - character - plot - context - time - reader
Injury - neglect - physical/psychosocial - financial - violation of rights
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

9. What is the Cockcroft Gault equation?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Prescribing - monitoring - patient adherence
Used to calculate renal fcn - clearance of Cr adjusted for age

10. How does aging increase incontinence?
Receptors changes: # - sensitivity - counter-regulatory moa
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
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
>60yo - low abuse risk - ^ monitoring possible

11. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Parkinsonism -> l-DOPA
No: chest pain - yes: fatigue - nausea - low functional status - SOB

12. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Pressure ulcer - fecal impaction - dehydration
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep

13. when selecting an P1-metabolite or P2-metabolite safer in elderly?
ANF: Na+ retention - disinhib vasoconstriction
P2-metabolite - phase 1 biotx much more affected than phase 2
^BP -> a-HTN
>9 Rx

14. thiazide diuretic may lead to what prescription cascade?
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Cachexia - PEM - FTT - obesity
Hyperuricemia -> gout
Receptors changes: # - sensitivity - counter-regulatory moa

15. frailty signs
^SV (diastolic stroke volume)
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
P2-metabolite - phase 1 biotx much more affected than phase 2

16. 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
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
^morbidity + mortality - -frailest @ greatest risk
Confusion - sedation - falls

17. pulm edema + atypical Sx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
5% - underreported
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Insiduous onset

18. How does sliding scale glycemic control relate to elderly?
#1 patient's last competent indication of wishes - substituted judgment - beneficence
^ANS tone -> ^periph vasoconstriction - ^HR
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

19. acute abdomen + atypical Sx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

20. What are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
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. frailty raises vulnerability to...
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Confusion - sedation - falls
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

22. Alb-bound Rx
Multisystemic vulnerability - -lowered reserves
Screen for potentially embarrassing dx - patient/Dr trust
Phenytoin
Bone loss -> osteopenia -> osteoporosis -> Fx

23. What are the common causes of lightheadedness?
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
CVA: stroke - AMI: acute MI - HF
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
IdioPx - psychiatric: depression - anxiety - somatoform

24. what Rx are commonly monifoted in elderly for ADR?
Catch-all of unspecified dizziness
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

25. What are the 3 stages of ADRs?
Cachexia - PEM - FTT - obesity
Prescribing - monitoring - patient adherence
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Injury - neglect - physical/psychosocial - financial - violation of rights

26. what normally prevents syncope?
Stress: #1 - functional - urge - overflow
3 reflexes: baroreceptor - renal nerve - ANF
Phenytoin
Injury - neglect - physical/psychosocial - financial - violation of rights

27. how may hypertension compensate for aging?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Catch-all of unspecified dizziness
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

28. dementia tx
Hyperuricemia -> gout
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
3 reflexes: baroreceptor - renal nerve - ANF

29. refusing intervention
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Legal: Cruzan v Hamon
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

30. opioid tx in elderly
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Begin @25-50% recommended dose - APAP may be dose-limiting
Breast cancer + 2o LBP
Legal: Cruzan v Hamon

31. delirium incidence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Hyperuricemia -> gout
Vertigo - presyncope - disequilibrium - lightheadedness
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

32. What are the possible cardiac causes of presyncope?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Cholinesterase inhib - use: dementia
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Electrical: change in HR - structural: aortic outflow obstruction

33. What are the 3 sentinel events for LT care?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Pressure ulcer - fecal impaction - dehydration
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

34. substituted judgment
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Injury - neglect - physical/psychosocial - financial - violation of rights
Cholinesterase inhib - use: dementia

35. incontinence complication
Confusion - sedation - falls
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Temporalis muscle wasting = temporal wasting
^SV (diastolic stroke volume)

36. Presyncope
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Tx underlying etio - + Kegels - pessary - surgery
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

37. how can you determine whether Rx is appropriate to use in elderly patient?
^SV (diastolic stroke volume)
P2-metabolite - phase 1 biotx much more affected than phase 2
Beers criteria - medication appropriateness index (12 ?)
Temporalis muscle wasting = temporal wasting

38. LBW equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Insiduous onset
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

39. narcotics may lead to what prescription cascade?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Constipation -> laxatives
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

40. What are the pharmacodynamic changes associated with aging?
^K+
Receptors changes: # - sensitivity - counter-regulatory moa
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

41. What are the 4 forms of dizziness?
Breast cancer + 2o LBP
Vertigo - presyncope - disequilibrium - lightheadedness
Confusion - sedation - falls
Therapy - SSRI

42. galantamine
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Cholinesterase inhib - use: dementia
^morbidity + mortality - -frailest @ greatest risk

43. what ADR are common in elderly patient?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

44. How does aging affect pharmacokinetic Rx distribution?
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
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
Constipation -> laxatives
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

45. BZD + antipsychotic: interaction outcome
P2-metabolite - phase 1 biotx much more affected than phase 2
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Confusion - sedation - falls

46. ADR rf
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
^K+
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
A-blockers - B-blockers - TCA

47. incontinence epidemiology
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
F>M (until 80yo) - stress incontinence #1 - $26B/yr
>9 Rx
Cholinesterase inhib - use: dementia

48. How does aging affect GI absorption of Rx?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Map of people - perceptions - etc - varies by perspective

49. What are the vascular changes of presyncope?
Used to calculate renal fcn - clearance of Cr adjusted for age
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
IdioPx - psychiatric: depression - anxiety - somatoform
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

50. delirium: medical rf
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Make sure to discuss with patient - some states require reporting
Voice - character - plot - context - time - reader
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction