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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. malignancy + atypical Sx
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Breast cancer + 2o LBP

2. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
5% - underreported
P2-metabolite - phase 1 biotx much more affected than phase 2
No: fever - leukocytosis - yes: falls - appetite change - low functional status

3. osteoporosis
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Bone loss -> osteopenia -> osteoporosis -> Fx
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Figure out a good diet - social aspect - resources - dental/oral comfort

4. What are the 3 sentinel events for LT care?
80% of hospital admission for syncope for >65yo
Pressure ulcer - fecal impaction - dehydration
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Worse for cardiac causes v noncardia

5. acute abdomen + atypical Sx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

6. fall causes
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
28% - ADR: 17% - non-compliance 11%
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

7. Aging principles
Catch-all of unspecified dizziness
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Therapy - SSRI
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

8. surrogate decision making heirarchy

9. incontinence epidemiology
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

10. What are the vascular changes of presyncope?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
IdioPx - psychiatric: depression - anxiety - somatoform

11. Aging features
Cachexia - PEM - FTT - obesity
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Diagnosis - risk/benefit analysis to choose Rx
Universal - progressive - partially encoded (genetic) - destructive -

12. What is the preferred depression treatment in elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Therapy - SSRI
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

13. What is the best approach to malnutrition
Prescribing - monitoring - patient adherence
Universal - progressive - partially encoded (genetic) - destructive -
Treat underlying disease/lack resources
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

14. rivastigmine
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Threats/ terrorizing - isolation - denying food/privileges/liberty
Worse for cardiac causes v noncardia
Cholinesterase inhib - use: dementia

15. What is sCr?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Parkinsonism -> l-DOPA
Serum Cr: used for Cr clearance equation
Confusion - sedation - falls

16. What are the common causes of lightheadedness?
Confusion - sedation - falls
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
IdioPx - psychiatric: depression - anxiety - somatoform
Catch-all of unspecified dizziness

17. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
80% of hospital admission for syncope for >65yo
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Map of people - perceptions - etc - varies by perspective

18. What are the 3 stages of ADRs?
^K+
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Prescribing - monitoring - patient adherence
^SV (diastolic stroke volume)

19. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
CVA: stroke - AMI: acute MI - HF
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Consider responsibilities - drivin

20. How does aging affect pharmacokinetic Rx distribution?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
^K+
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

21. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
High mortality - esp + Fx - very common in elderly
Figure out a good diet - social aspect - resources - dental/oral comfort
Screen for potentially embarrassing dx - patient/Dr trust

22. how is cachexia different from wasting?
Delayed absorption - like competitive inhib
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Electrical: change in HR - structural: aortic outflow obstruction

23. incontinence complication
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
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

24. nutrition syndromes
Cachexia - PEM - FTT - obesity
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

25. PEM
F>M (until 80yo) - stress incontinence #1 - $26B/yr
CVA: stroke - AMI: acute MI - HF
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Determined by Dr for a patient - -> used to determine competency

26. What are common physical abuse Sx in elderly?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Consider responsibilities - drivin
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Screen for potentially embarrassing dx - patient/Dr trust

27. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Insiduous onset
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Therapy - SSRI

28. refusing intervention
CVA: stroke - AMI: acute MI - HF
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
A-blockers - B-blockers - TCA
Legal: Cruzan v Hamon

29. delirium incidence
^ANS tone -> ^periph vasoconstriction - ^HR
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

30. What is ISH?
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
Isolated systolic HTN
Hyperuricemia -> gout
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

31. LBW equation
Diagnosis - risk/benefit analysis to choose Rx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

32. what % of hospitalizations of elderly are due to ADR + noncompliance?
Electrical: change in HR - structural: aortic outflow obstruction
28% - ADR: 17% - non-compliance 11%
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

33. what drugs can cause dizziness?
Consider responsibilities - drivin
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

34. falls epidemiology
^morbidity + mortality - -frailest @ greatest risk
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

35. How does baroreceptor reflex prevent syncope?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
^K+
^ANS tone -> ^periph vasoconstriction - ^HR
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

36. What are rf for osteoporosis?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
No: fever - leukocytosis - yes: falls - appetite change - low functional status

37. delirium diagnosis
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Make sure to discuss with patient - some states require reporting

38. MRP: medication related problems
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
5% - underreported
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
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

39. How to prevent pressure ulcers?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Mechanical loading - skin care - avoid friction/shear
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% preventable - of these - 40% serious - of these 40% preventable

40. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Hypothetical plan - serves as patient's last competent indicated wishes
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

41. What are the narrative elements of clinical ethics?
^SV (diastolic stroke volume)
Voice - character - plot - context - time - reader
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
Begin @25-50% recommended dose - APAP may be dose-limiting

42. How does aging affect pharmacokinetic protein binding?
Therapy - SSRI
Insiduous onset
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: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

43. advanced directive/care plan

44. How does renal nerve prevent syncope?
Doctors
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

45. How does aging affect Rx renal elimination?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Diagnosis - risk/benefit analysis to choose Rx
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Respect for autonomy - nonmaleficence - beneficence - justice

46. frailty raises vulnerability to...
Bone loss -> osteopenia -> osteoporosis -> Fx
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

47. Alb-bound Rx
Multisystemic vulnerability - -lowered reserves
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Phenytoin
CVA: stroke - AMI: acute MI - HF

48. What is polypharmacy
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Electrolyte imbalance - arrhythmia
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
>9 Rx

49. How does aging affect pharmacokinetics?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
30% preventable - of these - 40% serious - of these 40% preventable
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

50. How does sliding scale glycemic control relate to elderly?
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Tx underlying etio - + Kegels - pessary - surgery
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead