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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. using long-acting opioids in elderly
Screen for potentially embarrassing dx - patient/Dr trust
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

2. NSAID may lead to what prescription cascade?
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
^BP -> a-HTN
A-blockers - B-blockers - TCA

3. What is the STOPP criteria?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
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

4. how is cachexia different from wasting?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Doctors
P2-metab: Lorazepam - Trazepam - Oxazepam
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

5. Cockcroft Gault equation
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Doctors
IdioPx - psychiatric: depression - anxiety - somatoform

6. What are common medical causes of syncope?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Receptors changes: # - sensitivity - counter-regulatory moa
^morbidity + mortality - -frailest @ greatest risk
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

7. ADR rf
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Pressure ulcer - fecal impaction - dehydration

8. What is the best approach to malnutrition
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Treat underlying disease/lack resources
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

9. What is capacity?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Determined by Dr for a patient - -> used to determine competency
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

10. What drugs can contribute to syncope?
Hypothetical plan - serves as patient's last competent indicated wishes
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
A-blockers - B-blockers - TCA

11. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
^K+
Breast cancer + 2o LBP
^BP -> a-HTN

12. How does aging affect Rx pharmacokinetic metabolism?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Begin @25-50% recommended dose - APAP may be dose-limiting
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

13. malignancy + atypical Sx
Breast cancer + 2o LBP
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Temporalis muscle wasting = temporal wasting
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

14. What are the common types of elder mistreatment?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
A-blockers - B-blockers - TCA
Environment modification: obstacles - mobility - -bladder fcn ok

15. What is polypharmacy
>9 Rx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

16. conservator
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
>9 Rx
Appointed by court if no substituted judgment -conservator of finance -conservator of person

17. who is a good candidate for opioid tx?
Delayed absorption - like competitive inhib
>60yo - low abuse risk - ^ monitoring possible
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

18. how can you determine whether Rx is appropriate to use in elderly patient?
30% preventable - of these - 40% serious - of these 40% preventable
80% of hospital admission for syncope for >65yo
Beers criteria - medication appropriateness index (12 ?)
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

19. refusing intervention
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Legal: Cruzan v Hamon

20. What is START criteria?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
^K+
Breast cancer + 2o LBP

21. Beers criteria: what 10 Rx should elderly avoid or use + caution?
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+
Pressure ulcer - fecal impaction - dehydration
Constipation -> laxatives

22. what can enhance reporting in elderly?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Screen for potentially embarrassing dx - patient/Dr trust
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Hypothetical plan - serves as patient's last competent indicated wishes

23. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Bone loss -> osteopenia -> osteoporosis -> Fx
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
ANF: Na+ retention - disinhib vasoconstriction

24. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Temporalis muscle wasting = temporal wasting

25. red flags for further inquiry
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

26. what Rx are commonly monifoted in elderly for ADR?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
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
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

27. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Therapy - SSRI
CVA: stroke - AMI: acute MI - HF

28. Aging features
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
NMDR antagonist - use: dementia
Legal: Cruzan v Hamon
Universal - progressive - partially encoded (genetic) - destructive -

29. How does ANF prevent syncope?
ANF: Na+ retention - disinhib vasoconstriction
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Therapy - SSRI

30. what receptors decrease sensitivity with aging?
Hyperuricemia -> gout
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

31. osteoporosis
ANF: Na+ retention - disinhib vasoconstriction
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

32. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Multisystemic vulnerability - -lowered reserves
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

33. What is a mattering map?
Vertigo - presyncope - disequilibrium - lightheadedness
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
Temporalis muscle wasting = temporal wasting

34. galantamine
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Cholinesterase inhib - use: dementia
Mechanical loading - skin care - avoid friction/shear

35. What are the pharmacodynamic changes associated with aging?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Consider responsibilities - drivin
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
Receptors changes: # - sensitivity - counter-regulatory moa

36. rule of doable effect
Cholinesterase inhib - use: dementia
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
^ANS tone -> ^periph vasoconstriction - ^HR
BMD (bone mineral density): T-score >2.5 std dev below normal 1

37. What is ISH?
Isolated systolic HTN
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
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
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

38. What are common physical abuse Sx in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Screen for potentially embarrassing dx - patient/Dr trust
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
28% - ADR: 17% - non-compliance 11%

39. How does aging affect GI absorption rate of Rx?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
IdioPx - psychiatric: depression - anxiety - somatoform
Delayed absorption - like competitive inhib
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

40. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Electrolyte imbalance - arrhythmia
Multisystemic vulnerability - -lowered reserves
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

41. osteoporosis epidemiology
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
High mortality - esp + Fx - very common in elderly
Legal: Cruzan v Hamon
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

42. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Receptors changes: # - sensitivity - counter-regulatory moa
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
Legal: Cruzan v Hamon

43. Syncope prognosis based on etio
Begin @25-50% recommended dose - APAP may be dose-limiting
Worse for cardiac causes v noncardia
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

44. incontinence epidemiology
28% - ADR: 17% - non-compliance 11%
NMDR antagonist - use: dementia
F>M (until 80yo) - stress incontinence #1 - $26B/yr
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

45. frailty signs
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

46. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
IdioPx - psychiatric: depression - anxiety - somatoform
Used to calculate renal fcn - clearance of Cr adjusted for age
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

47. physical neglect
Beers criteria - medication appropriateness index (12 ?)
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
>60yo - low abuse risk - ^ monitoring possible
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

48. Approach to idioPx - recurrent syncope
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Consider responsibilities - drivin
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

49. overflow incontinence tx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Map of people - perceptions - etc - varies by perspective
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

50. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Cholinesterase inhib - use: dementia
Constipation -> laxatives
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)