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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. vertigo
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
P2-metabolite - phase 1 biotx much more affected than phase 2
Cholinesterase inhib - use: dementia
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

2. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
>9 Rx
Threats/ terrorizing - isolation - denying food/privileges/liberty

3. What are the key points of safe prescription for elderly - lecture
Cholinesterase inhib - use: dementia
Diagnosis - risk/benefit analysis to choose Rx
Map of people - perceptions - etc - varies by perspective
Respect for autonomy - nonmaleficence - beneficence - justice

4. What is the epidemiology of dizziness?
5% - underreported
CNS suppression -> cholinesterase inhibitors
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
^K+

5. ACE inhib + K+: interaction outcome
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
^K+
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

6. what professional is least likely to report abuse?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Doctors

7. who is a good candidate for opioid tx?
Beers criteria - medication appropriateness index (12 ?)
30% preventable - of these - 40% serious - of these 40% preventable
>9 Rx
>60yo - low abuse risk - ^ monitoring possible

8. how is the CAM used to diagnose delirium?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
No: fever - leukocytosis - yes: falls - appetite change - low functional status
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

9. Aging descriptors
Hyperuricemia -> gout
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

10. how can you determine whether Rx is appropriate to use in elderly patient?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Beers criteria - medication appropriateness index (12 ?)
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Therapy - SSRI

11. fall sequelae

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12. galantamine
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
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
Cholinesterase inhib - use: dementia
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

13. How does aging impact syncope-preventing reflexes
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Consider responsibilities - drivin
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

14. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Receptors changes: # - sensitivity - counter-regulatory moa
Parkinsonism -> l-DOPA
P2-metab: Lorazepam - Trazepam - Oxazepam

15. How to prevent pressure ulcers?
Pressure ulcer - fecal impaction - dehydration
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
P2-metabolite - phase 1 biotx much more affected than phase 2
Mechanical loading - skin care - avoid friction/shear

16. what Rx are commonly monifoted in elderly for ADR?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
^K+
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Phenytoin

17. documenting elderly abuse

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18. How does an 80yo renal fcn compare to that of a 20yo?
Mechanical loading - skin care - avoid friction/shear
1/2
Vertigo - presyncope - disequilibrium - lightheadedness
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

19. What drugs can contribute to syncope?
Hypotension - ^K+
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
A-blockers - B-blockers - TCA
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

20. How does ANF prevent syncope?
ANF: Na+ retention - disinhib vasoconstriction
Isolated systolic HTN
Mechanical loading - skin care - avoid friction/shear
Voice - character - plot - context - time - reader

21. What are the pharmacodynamic changes associated with aging?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Consider responsibilities - drivin
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Receptors changes: # - sensitivity - counter-regulatory moa

22. fall causes
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Electrolyte imbalance - arrhythmia
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

23. Why is abuse underreported?
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Stress: #1 - functional - urge - overflow

24. refusing intervention
Breast cancer + 2o LBP
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Treat underlying disease/lack resources
Legal: Cruzan v Hamon

25. malignancy + atypical Sx
Breast cancer + 2o LBP
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

26. red flags for further inquiry
Respect for autonomy - nonmaleficence - beneficence - justice
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

27. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Respect for autonomy - nonmaleficence - beneficence - justice
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

28. What are the vascular changes of presyncope?
>9 Rx
Figure out a good diet - social aspect - resources - dental/oral comfort
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Parkinsonism -> l-DOPA

29. What is the best approach to malnutrition
Treat underlying disease/lack resources
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Environment modification: obstacles - mobility - -bladder fcn ok
Screen for potentially embarrassing dx - patient/Dr trust

30. depression + atypical Sx
Begin @25-50% recommended dose - APAP may be dose-limiting
Phenytoin
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Treat underlying disease/lack resources

31. How does renal nerve prevent syncope?
Voice - character - plot - context - time - reader
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
^morbidity + mortality - -frailest @ greatest risk
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

32. What are common medical causes of syncope?
Tx underlying etio - + Kegels - pessary - surgery
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

33. Aging features
Threats/ terrorizing - isolation - denying food/privileges/liberty
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Universal - progressive - partially encoded (genetic) - destructive -

34. lightheadedness
Catch-all of unspecified dizziness
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

35. Alb-bound Rx
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Phenytoin
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

36. delirium: mgmt
Legal: Cruzan v Hamon
Begin @25-50% recommended dose - APAP may be dose-limiting
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

37. What is the preferred depression treatment in elderly?
^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
Therapy - SSRI
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

38. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
Diagnosis - risk/benefit analysis to choose Rx
^SV (diastolic stroke volume)
80% of hospital admission for syncope for >65yo

39. conservator
Begin @25-50% recommended dose - APAP may be dose-limiting
Appointed by court if no substituted judgment -conservator of finance -conservator of person
High mortality - esp + Fx - very common in elderly
Electrolyte imbalance - arrhythmia

40. what drugs can cause dizziness?
Hypotension - ^K+
Parkinsonism -> l-DOPA
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Treat underlying disease/lack resources

41. What is capacity?
Hypotension - ^K+
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Determined by Dr for a patient - -> used to determine competency

42. frailty
Begin @25-50% recommended dose - APAP may be dose-limiting
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Multisystemic vulnerability - -lowered reserves
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

43. using long-acting opioids in elderly
Electrolyte imbalance - arrhythmia
Injury - neglect - physical/psychosocial - financial - violation of rights
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Doctors

44. How does baroreceptor reflex prevent syncope?
Electrical: change in HR - structural: aortic outflow obstruction
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
^ANS tone -> ^periph vasoconstriction - ^HR

45. How does aging increase incontinence?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
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
Bone loss -> osteopenia -> osteoporosis -> Fx
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

46. what ADR are common in elderly patient?
^SV (diastolic stroke volume)
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

47. frailty signs
Bone loss -> osteopenia -> osteoporosis -> Fx
CNS suppression -> cholinesterase inhibitors
Isolated systolic HTN
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

48. osteoporosis
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Constipation -> laxatives
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

49. what illnesses are underreported in elderly?
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
A-blockers - B-blockers - TCA

50. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Insiduous onset
Hyperuricemia -> gout