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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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This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. frailty
Multisystemic vulnerability - -lowered reserves
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

2. What are the 4 basic ethical principles?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Respect for autonomy - nonmaleficence - beneficence - justice

3. What are the key points of safe prescription for elderly - lecture
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
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Diagnosis - risk/benefit analysis to choose Rx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

4. What are the possible cardiac causes of presyncope?
Electrical: change in HR - structural: aortic outflow obstruction
P2-metabolite - phase 1 biotx much more affected than phase 2
Multisystemic vulnerability - -lowered reserves
Pressure ulcer - fecal impaction - dehydration

5. What are rf for osteoporosis?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
>9 Rx
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Mechanical loading - skin care - avoid friction/shear

6. cachexia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Catch-all of unspecified dizziness
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

7. How does ANF prevent syncope?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
ANF: Na+ retention - disinhib vasoconstriction
3 reflexes: baroreceptor - renal nerve - ANF
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

8. How does an 80yo renal fcn compare to that of a 20yo?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
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
1/2
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

9. delirium diagnosis
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

10. when selecting an P1-metabolite or P2-metabolite safer in elderly?
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
P2-metabolite - phase 1 biotx much more affected than phase 2
Hypotension - ^K+

11. fall causes
>60yo - low abuse risk - ^ monitoring possible
Prescribing - monitoring - patient adherence
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

12. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Legal: Cruzan v Hamon

13. fall sequelae

14. thyroid dx + atypical Sx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
High mortality - esp + Fx - very common in elderly
Isolated systolic HTN

15. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Confusion - sedation - falls
Prescribing - monitoring - patient adherence

16. What are the rf for elderly abuse?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Doctors
Beers criteria - medication appropriateness index (12 ?)
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

17. stress incontinence tx
Tx underlying etio - + Kegels - pessary - surgery
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Treat underlying disease/lack resources
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

18. what normally prevents syncope?
Breast cancer + 2o LBP
#1 patient's last competent indication of wishes - substituted judgment - beneficence
3 reflexes: baroreceptor - renal nerve - ANF
Temporalis muscle wasting = temporal wasting

19. surrogate decision making heirarchy

20. osteoporosis etio
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Prescribing - monitoring - patient adherence
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

21. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Receptors changes: # - sensitivity - counter-regulatory moa
Map of people - perceptions - etc - varies by perspective
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

22. anticholinergic drugs may lead to what prescription cascade?
Hyperuricemia -> gout
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
CNS suppression -> cholinesterase inhibitors
Make sure to discuss with patient - some states require reporting

23. What is the bone deterioration cascade?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
No: chest pain - yes: fatigue - nausea - low functional status - SOB
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Bone loss -> osteopenia -> osteoporosis -> Fx

24. How does aging increase incontinence?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
>60yo - low abuse risk - ^ monitoring possible
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
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

25. Disequilibrium
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Respect for autonomy - nonmaleficence - beneficence - justice
1/2

26. Aging features
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Universal - progressive - partially encoded (genetic) - destructive -

27. i2 + atypical Sx
Catch-all of unspecified dizziness
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Mechanical loading - skin care - avoid friction/shear
No: fever - leukocytosis - yes: falls - appetite change - low functional status

28. What is sCr?
Serum Cr: used for Cr clearance equation
IdioPx - psychiatric: depression - anxiety - somatoform
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Diagnosis - risk/benefit analysis to choose Rx

29. what receptors decrease sensitivity with aging?
^K+
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

30. frailty signs
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
80% of hospital admission for syncope for >65yo
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

31. How does the aging heart compensate for lower HR to maintain unchanged CO?
Used to calculate renal fcn - clearance of Cr adjusted for age
^SV (diastolic stroke volume)
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
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

32. What are the common types of elder mistreatment?
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
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

33. What are common physical abuse Sx in elderly?
Legal: Cruzan v Hamon
Diagnosis - risk/benefit analysis to choose Rx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Cholinesterase inhib - use: dementia

34. nutrition syndromes
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Cachexia - PEM - FTT - obesity
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

35. how can you determine whether Rx is appropriate to use in elderly patient?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Beers criteria - medication appropriateness index (12 ?)
Appointed by court if no substituted judgment -conservator of finance -conservator of person
#1 patient's last competent indication of wishes - substituted judgment - beneficence

36. driving considerations
Treat underlying disease/lack resources
Make sure to discuss with patient - some states require reporting
Used to calculate renal fcn - clearance of Cr adjusted for age
Cachexia - PEM - FTT - obesity

37. How does aging impact syncope-preventing reflexes
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Insiduous onset
1/2
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

38. incontinence complication
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Cholinesterase inhib - use: dementia
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

39. galantamine
Insiduous onset
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Cholinesterase inhib - use: dementia
Doctors

40. How does aging affect pharmacokinetics?
Parkinsonism -> l-DOPA
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

41. how may hypertension compensate for aging?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Cholinesterase inhib - use: dementia
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

42. what drugs can cause dizziness?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Threats/ terrorizing - isolation - denying food/privileges/liberty
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
High mortality - esp + Fx - very common in elderly

43. What is polypharmacy
>9 Rx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
^SV (diastolic stroke volume)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

44. how is syncope related to elderly admission to hospital?
Beers criteria - medication appropriateness index (12 ?)
ANF: Na+ retention - disinhib vasoconstriction
80% of hospital admission for syncope for >65yo
NMDR antagonist - use: dementia

45. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
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
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Isolated systolic HTN

46. narcotics may lead to what prescription cascade?
ANF: Na+ retention - disinhib vasoconstriction
Constipation -> laxatives
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

47. red flags for further inquiry
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Threats/ terrorizing - isolation - denying food/privileges/liberty
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

48. How does aging affect GI absorption of Rx?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Consider responsibilities - drivin
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

49. what professional is least likely to report abuse?
30% preventable - of these - 40% serious - of these 40% preventable
Doctors
Worse for cardiac causes v noncardia
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

50. How does aging affect Rx pharmacokinetic distribution?
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
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
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
F>M (until 80yo) - stress incontinence #1 - $26B/yr