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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. What are the rf for caregiver to abuse elderly?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Doctors
Map of people - perceptions - etc - varies by perspective
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

2. What are common medical causes of syncope?
Electrolyte imbalance - arrhythmia
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
Cholinesterase inhib - use: dementia

3. osteoporosis epidemiology
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Phenytoin
High mortality - esp + Fx - very common in elderly

4. What is a PE sign of cachexia?
Tx underlying etio - + Kegels - pessary - surgery
Temporalis muscle wasting = temporal wasting
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

5. preventing malnutrition
Electrical: change in HR - structural: aortic outflow obstruction
Figure out a good diet - social aspect - resources - dental/oral comfort
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Parkinsonism -> l-DOPA

6. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Multisystemic vulnerability - -lowered reserves
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
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

7. How does aging affect pharmacokinetics?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Screen for potentially embarrassing dx - patient/Dr trust
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

8. falls epidemiology
Confusion - sedation - falls
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
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
Cachexia - PEM - FTT - obesity

9. violation of rights
Delayed absorption - like competitive inhib
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
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
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

10. who is a good candidate for opioid tx?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Vertigo - presyncope - disequilibrium - lightheadedness
NMDR antagonist - use: dementia
>60yo - low abuse risk - ^ monitoring possible

11. Approach to idioPx - recurrent syncope
Hyperuricemia -> gout
Consider responsibilities - drivin
Electrical: change in HR - structural: aortic outflow obstruction
High mortality - esp + Fx - very common in elderly

12. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
28% - ADR: 17% - non-compliance 11%
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Respect for autonomy - nonmaleficence - beneficence - justice

13. urinary incontinence types
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Stress: #1 - functional - urge - overflow
Serum Cr: used for Cr clearance equation

14. What are the key points of safe prescription for elderly - lecture
1/2
Breast cancer + 2o LBP
Diagnosis - risk/benefit analysis to choose Rx
Injury - neglect - physical/psychosocial - financial - violation of rights

15. functional incontinence tx
Used to calculate renal fcn - clearance of Cr adjusted for age
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Environment modification: obstacles - mobility - -bladder fcn ok
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

16. cachexia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Cholinesterase inhib - use: dementia

17. What are the common types of elder mistreatment?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
5% - underreported
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

18. osteoporosis
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Appointed by court if no substituted judgment -conservator of finance -conservator of person
A-blockers - B-blockers - TCA
BMD (bone mineral density): T-score >2.5 std dev below normal 1

19. How does aging affect Rx pharmacokinetic metabolism?
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
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
80% of hospital admission for syncope for >65yo

20. what % of hospitalizations of elderly are due to ADR + noncompliance?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
28% - ADR: 17% - non-compliance 11%
1/2
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

21. What are the hazards of elderly hospitalization?
Isolated systolic HTN
^morbidity + mortality - -frailest @ greatest risk
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
No: chest pain - yes: fatigue - nausea - low functional status - SOB

22. rivastigmine
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Cholinesterase inhib - use: dementia
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

23. Beers criteria
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
1/2
F>M (until 80yo) - stress incontinence #1 - $26B/yr
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

24. How does aging increase incontinence?
Therapy - SSRI
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
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
Insiduous onset

25. What are the risks of uncontrolled ISH?
^K+
CVA: stroke - AMI: acute MI - HF
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Bone loss -> osteopenia -> osteoporosis -> Fx

26. ADR rf
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

27. what drugs can cause dizziness?
1/2
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

28. What is START criteria?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Mechanical loading - skin care - avoid friction/shear
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

29. PEM
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

30. conservator
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Injury - neglect - physical/psychosocial - financial - violation of rights
Cachexia - PEM - FTT - obesity
Appointed by court if no substituted judgment -conservator of finance -conservator of person

31. How does aging affect GI absorption rate of Rx?
Delayed absorption - like competitive inhib
>60yo - low abuse risk - ^ monitoring possible
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Hyperuricemia -> gout

32. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Screen for potentially embarrassing dx - patient/Dr trust
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

33. substituted judgment
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
3 reflexes: baroreceptor - renal nerve - ANF
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

34. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Receptors changes: # - sensitivity - counter-regulatory moa
Electrical: change in HR - structural: aortic outflow obstruction
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

35. incontinence complication
Prescribing - monitoring - patient adherence
1/2
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Confusion - sedation - falls

36. dementia tx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Breast cancer + 2o LBP

37. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Treat underlying disease/lack resources
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

38. clues of neglect
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

39. What are the possible cardiac causes of presyncope?
Electrical: change in HR - structural: aortic outflow obstruction
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

40. How does renal nerve prevent syncope?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

41. osteopenia
BMD (bone mineral density): T-score >2.5 std dev below normal 1
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
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

42. which benzodiazepines are most appropriate for elderly?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
P2-metab: Lorazepam - Trazepam - Oxazepam
Make sure to discuss with patient - some states require reporting
ANF: Na+ retention - disinhib vasoconstriction

43. narcotics may lead to what prescription cascade?
^ANS tone -> ^periph vasoconstriction - ^HR
Constipation -> laxatives
30% preventable - of these - 40% serious - of these 40% preventable
Injury - neglect - physical/psychosocial - financial - violation of rights

44. What are the 4 forms of dizziness?
Stress: #1 - functional - urge - overflow
>9 Rx
Begin @25-50% recommended dose - APAP may be dose-limiting
Vertigo - presyncope - disequilibrium - lightheadedness

45. stress incontinence tx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
P2-metab: Lorazepam - Trazepam - Oxazepam
Tx underlying etio - + Kegels - pessary - surgery

46. refusing intervention
^morbidity + mortality - -frailest @ greatest risk
Legal: Cruzan v Hamon
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
^SV (diastolic stroke volume)

47. delirium: mgmt
1/2
Screen for potentially embarrassing dx - patient/Dr trust
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Pressure ulcer - fecal impaction - dehydration

48. memantine
Beers criteria - medication appropriateness index (12 ?)
NMDR antagonist - use: dementia
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

49. red flags for further inquiry
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
No: chest pain - yes: fatigue - nausea - low functional status - SOB
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Threats/ terrorizing - isolation - denying food/privileges/liberty

50. depression + atypical Sx
Threats/ terrorizing - isolation - denying food/privileges/liberty
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
ANF: Na+ retention - disinhib vasoconstriction
^K+