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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. lightheadedness
80% of hospital admission for syncope for >65yo
Map of people - perceptions - etc - varies by perspective
Catch-all of unspecified dizziness
Hypothetical plan - serves as patient's last competent indicated wishes

2. How does aging affect GI absorption rate of Rx?
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
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Pressure ulcer - fecal impaction - dehydration
Delayed absorption - like competitive inhib

3. What are the rf for caregiver to abuse elderly?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Used to calculate renal fcn - clearance of Cr adjusted for age

4. BZD + antidepressant: interaction outcome
P2-metabolite - phase 1 biotx much more affected than phase 2
Confusion - sedation - falls
Cachexia - PEM - FTT - obesity
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

5. What are the pharmacodynamic changes associated with aging?
Receptors changes: # - sensitivity - counter-regulatory moa
Cholinesterase inhib - use: dementia
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Hypothetical plan - serves as patient's last competent indicated wishes

6. What is capacity?
Determined by Dr for a patient - -> used to determine competency
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Universal - progressive - partially encoded (genetic) - destructive -

7. Approach to idioPx - recurrent syncope
Electrical: change in HR - structural: aortic outflow obstruction
Make sure to discuss with patient - some states require reporting
Cholinesterase inhib - use: dementia
Consider responsibilities - drivin

8. what ADR are common in elderly patient?
1/2
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
5% - underreported

9. surrogate decision making heirarchy

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10. What are the common types of elder mistreatment?
Phenytoin
Isolated systolic HTN
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

11. ACE inhib + K+: interaction outcome
Figure out a good diet - social aspect - resources - dental/oral comfort
Pressure ulcer - fecal impaction - dehydration
Screen for potentially embarrassing dx - patient/Dr trust
^K+

12. How does aging affect Rx renal elimination?
Respect for autonomy - nonmaleficence - beneficence - justice
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
^morbidity + mortality - -frailest @ greatest risk
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

13. vision changes: elderly
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Screen for potentially embarrassing dx - patient/Dr trust

14. PEM
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
A-blockers - B-blockers - TCA

15. What is abuse?
Injury - neglect - physical/psychosocial - financial - violation of rights
CVA: stroke - AMI: acute MI - HF
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Therapy - SSRI

16. What is the best approach to malnutrition
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Treat underlying disease/lack resources
Doctors

17. How does aging affect Rx pharmacokinetic metabolism?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
>9 Rx
Isolated systolic HTN
Cholinesterase inhib - use: dementia

18. What are the 3 stages of ADRs?
NMDR antagonist - use: dementia
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Delayed absorption - like competitive inhib
Prescribing - monitoring - patient adherence

19. BZD + antipsychotic: interaction outcome
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Confusion - sedation - falls

20. Beers criteria
Voice - character - plot - context - time - reader
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
NMDR antagonist - use: dementia

21. anticholinergic drugs may lead to what prescription cascade?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Vertigo - presyncope - disequilibrium - lightheadedness
Threats/ terrorizing - isolation - denying food/privileges/liberty
CNS suppression -> cholinesterase inhibitors

22. donepezil
Respect for autonomy - nonmaleficence - beneficence - justice
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
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

23. delirium: mgmt
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

24. frailty raises vulnerability to...
CNS suppression -> cholinesterase inhibitors
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

25. advanced directive/care plan

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26. urinary incontinence types
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Stress: #1 - functional - urge - overflow
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

27. What is a mattering map?
3 reflexes: baroreceptor - renal nerve - ANF
Map of people - perceptions - etc - varies by perspective
Serum Cr: used for Cr clearance equation
Electrical: change in HR - structural: aortic outflow obstruction

28. What are the rf for elderly abuse?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
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
Used to calculate renal fcn - clearance of Cr adjusted for age
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

29. How does aging affect GI absorption of Rx?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
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
P2-metab: Lorazepam - Trazepam - Oxazepam

30. what nutritional interventions help underweight?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Threats/ terrorizing - isolation - denying food/privileges/liberty
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

31. lipid-soluble Rx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
CVA: stroke - AMI: acute MI - HF
BMD (bone mineral density): T-score >2.5 std dev below normal 1

32. what receptors decrease sensitivity with aging?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
A-blockers - B-blockers - TCA
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

33. fall sequelae

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34. how is syncope related to elderly admission to hospital?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
80% of hospital admission for syncope for >65yo
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
IdioPx - psychiatric: depression - anxiety - somatoform

35. restrain requirements
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
1/2
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

36. How does sliding scale glycemic control relate to elderly?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

37. What is START criteria?
Doctors
Cholinesterase inhib - use: dementia
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

38. acute abdomen + atypical Sx
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Make sure to discuss with patient - some states require reporting
Figure out a good diet - social aspect - resources - dental/oral comfort

39. how may hypertension compensate for aging?
Environment modification: obstacles - mobility - -bladder fcn ok
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Bone loss -> osteopenia -> osteoporosis -> Fx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

40. MRP: medication related problems
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
^SV (diastolic stroke volume)

41. ACE inhib + diuretic: interaction outcome
Phenytoin
Hypotension - ^K+
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
CVA: stroke - AMI: acute MI - HF

42. What are common medical causes of syncope?
^ANS tone -> ^periph vasoconstriction - ^HR
Diagnosis - risk/benefit analysis to choose Rx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Catch-all of unspecified dizziness

43. pressure ulcer: staging
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
80% of hospital admission for syncope for >65yo
Temporalis muscle wasting = temporal wasting
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

44. What is the bone deterioration cascade?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Bone loss -> osteopenia -> osteoporosis -> Fx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

45. what receptors increase sensitivity with aging?
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
>60yo - low abuse risk - ^ monitoring possible

46. 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
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Cholinesterase inhib - use: dementia

47. What are the risks of uncontrolled ISH?
>60yo - low abuse risk - ^ monitoring possible
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
CVA: stroke - AMI: acute MI - HF

48. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
^K+
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

49. What is sCr?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Serum Cr: used for Cr clearance equation
>60yo - low abuse risk - ^ monitoring possible
Vertigo - presyncope - disequilibrium - lightheadedness

50. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Beers criteria - medication appropriateness index (12 ?)
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