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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. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
5% - underreported
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Beers criteria - medication appropriateness index (12 ?)

2. Approach to idioPx - recurrent syncope
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Vertigo - presyncope - disequilibrium - lightheadedness
Consider responsibilities - drivin
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

3. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
Screen for potentially embarrassing dx - patient/Dr trust
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Cachexia - PEM - FTT - obesity

4. pulm edema + atypical Sx
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
Insiduous onset
^morbidity + mortality - -frailest @ greatest risk
Injury - neglect - physical/psychosocial - financial - violation of rights

5. driving considerations
Used to calculate renal fcn - clearance of Cr adjusted for age
Make sure to discuss with patient - some states require reporting
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Mechanical loading - skin care - avoid friction/shear

6. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Confusion - sedation - falls
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

7. What is the bone deterioration cascade?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
>60yo - low abuse risk - ^ monitoring possible
Bone loss -> osteopenia -> osteoporosis -> Fx
Legal: Cruzan v Hamon

8. What is the preferred depression treatment in elderly?
Therapy - SSRI
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
^BP -> a-HTN

9. What is the epidemiology of dizziness?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Cholinesterase inhib - use: dementia
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

10. delirium: tx approach
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
ANF: Na+ retention - disinhib vasoconstriction
^SV (diastolic stroke volume)

11. frailty
A-blockers - B-blockers - TCA
Confusion - sedation - falls
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Multisystemic vulnerability - -lowered reserves

12. NSAID may lead to what prescription cascade?
^BP -> a-HTN
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
Multisystemic vulnerability - -lowered reserves
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

13. frailty signs
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
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
80% of hospital admission for syncope for >65yo

14. tube feeding
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Hypotension - ^K+
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

15. fall causes
Phenytoin
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

16. conservator
28% - ADR: 17% - non-compliance 11%
^K+
Appointed by court if no substituted judgment -conservator of finance -conservator of person
30% preventable - of these - 40% serious - of these 40% preventable

17. What are rf for osteoporosis?
>60yo - low abuse risk - ^ monitoring possible
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

18. incontinence complication
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
>9 Rx
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

19. MI + atypical Sx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

20. Alb-bound Rx
Diagnosis - risk/benefit analysis to choose Rx
Phenytoin
Cachexia - PEM - FTT - obesity
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

21. What is the best approach to malnutrition
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Treat underlying disease/lack resources
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Legal: Cruzan v Hamon

22. preventing malnutrition
^ANS tone -> ^periph vasoconstriction - ^HR
Confusion - sedation - falls
Threats/ terrorizing - isolation - denying food/privileges/liberty
Figure out a good diet - social aspect - resources - dental/oral comfort

23. How does aging affect pharmacokinetic protein binding?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

24. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Receptors changes: # - sensitivity - counter-regulatory moa

25. Disequilibrium
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Screen for potentially embarrassing dx - patient/Dr trust
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

26. How does aging affect Rx pharmacokinetic distribution?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
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

27. How does sliding scale glycemic control relate to elderly?
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
Hypotension - ^K+
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

28. substituted judgment
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
>60yo - low abuse risk - ^ monitoring possible
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

29. frailty raises vulnerability to...
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Falls - delirium - malnutrition - P ulcers - opportunistic i2
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

30. thiazide diuretic may lead to what prescription cascade?
Hyperuricemia -> gout
Parkinsonism -> l-DOPA
Cholinesterase inhib - use: dementia
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

31. What is ISH?
Legal: Cruzan v Hamon
Isolated systolic HTN
Injury - neglect - physical/psychosocial - financial - violation of rights
NMDR antagonist - use: dementia

32. what drugs can cause dizziness?
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
Confusion - sedation - falls
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

33. Beers criteria
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
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
^morbidity + mortality - -frailest @ greatest risk

34. what receptors decrease sensitivity with aging?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Make sure to discuss with patient - some states require reporting
Treat underlying disease/lack resources
Cachexia - PEM - FTT - obesity

35. How does ANF prevent syncope?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
ANF: Na+ retention - disinhib vasoconstriction
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Hypotension - ^K+

36. how can you determine whether Rx is appropriate to use in elderly patient?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Injury - neglect - physical/psychosocial - financial - violation of rights
Beers criteria - medication appropriateness index (12 ?)

37. How to prevent pressure ulcers?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
F>M (until 80yo) - stress incontinence #1 - $26B/yr
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Mechanical loading - skin care - avoid friction/shear

38. What are the common types of elder mistreatment?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Tx underlying etio - + Kegels - pessary - surgery
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

39. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Make sure to discuss with patient - some states require reporting
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

40. BZD + antidepressant: interaction outcome
Consider responsibilities - drivin
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
^ANS tone -> ^periph vasoconstriction - ^HR
Confusion - sedation - falls

41. How does aging increase incontinence?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cholinesterase inhib - use: dementia
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

42. What are common physical abuse Sx in elderly?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^K+
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

43. who is a good candidate for opioid tx?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
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
>60yo - low abuse risk - ^ monitoring possible

44. physical neglect
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Therapy - SSRI
Beers criteria - medication appropriateness index (12 ?)

45. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
^BP -> a-HTN
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
CNS suppression -> cholinesterase inhibitors

46. what normally prevents syncope?
3 reflexes: baroreceptor - renal nerve - ANF
Beers criteria - medication appropriateness index (12 ?)
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Screen for potentially embarrassing dx - patient/Dr trust

47. delirium incidence
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cholinesterase inhib - use: dementia
Prescribing - monitoring - patient adherence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

48. What are the 4 basic ethical principles?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
5% - underreported
Respect for autonomy - nonmaleficence - beneficence - justice
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

49. delirium diagnosis
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

50. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
Figure out a good diet - social aspect - resources - dental/oral comfort
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx