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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. How does baroreceptor reflex prevent syncope?
Begin @25-50% recommended dose - APAP may be dose-limiting
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
^ANS tone -> ^periph vasoconstriction - ^HR

2. malignancy + atypical Sx
#1 patient's last competent indication of wishes - substituted judgment - beneficence
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Breast cancer + 2o LBP
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

3. what nutritional interventions help underweight?
Confusion - sedation - falls
Breast cancer + 2o LBP
Receptors changes: # - sensitivity - counter-regulatory moa
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

4. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

5. What is the bone deterioration cascade?
Bone loss -> osteopenia -> osteoporosis -> Fx
Pressure ulcer - fecal impaction - dehydration
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

6. What is sCr?
Serum Cr: used for Cr clearance equation
Treat underlying disease/lack resources
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

7. fall causes
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
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

8. What are the rf for elderly abuse?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Map of people - perceptions - etc - varies by perspective
Cachexia - PEM - FTT - obesity

9. What are the vascular changes of presyncope?
^BP -> a-HTN
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

10. donepezil
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Cholinesterase inhib - use: dementia

11. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
Injury - neglect - physical/psychosocial - financial - violation of rights
Begin @25-50% recommended dose - APAP may be dose-limiting
28% - ADR: 17% - non-compliance 11%

12. osteoporosis etio
Universal - progressive - partially encoded (genetic) - destructive -
^SV (diastolic stroke volume)
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/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

13. acute abdomen + atypical Sx
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Worse for cardiac causes v noncardia

14. rivastigmine
Used to calculate renal fcn - clearance of Cr adjusted for age
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Cholinesterase inhib - use: dementia
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

15. Alb-bound Rx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Phenytoin
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

16. urinary incontinence types
Screen for potentially embarrassing dx - patient/Dr trust
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Stress: #1 - functional - urge - overflow
Universal - progressive - partially encoded (genetic) - destructive -

17. What are the 3 sentinel events for LT care?
Vertigo - presyncope - disequilibrium - lightheadedness
Constipation -> laxatives
Pressure ulcer - fecal impaction - dehydration
Receptors changes: # - sensitivity - counter-regulatory moa

18. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Stress: #1 - functional - urge - overflow
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Pressure ulcer - fecal impaction - dehydration

19. What is the best approach to malnutrition
Catch-all of unspecified dizziness
^SV (diastolic stroke volume)
Worse for cardiac causes v noncardia
Treat underlying disease/lack resources

20. How to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
Insiduous onset
Hyperuricemia -> gout
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

21. narcotics may lead to what prescription cascade?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Constipation -> laxatives
^ANS tone -> ^periph vasoconstriction - ^HR
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

22. documenting elderly abuse

23. clues of neglect
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Screen for potentially embarrassing dx - patient/Dr trust
Environment modification: obstacles - mobility - -bladder fcn ok
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

24. physical neglect
NMDR antagonist - use: dementia
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
No: fever - leukocytosis - yes: falls - appetite change - low functional status

25. What is the natural history of syncope?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
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
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

26. What are rf for osteoporosis?
Prescribing - monitoring - patient adherence
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
A-blockers - B-blockers - TCA

27. What are the key points of safe prescription for elderly - lecture
Diagnosis - risk/benefit analysis to choose Rx
Vertigo - presyncope - disequilibrium - lightheadedness
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
#1 patient's last competent indication of wishes - substituted judgment - beneficence

28. What are the rf for caregiver to abuse elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
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
Hypotension - ^K+
Insiduous onset

29. red flags for further inquiry
A-blockers - B-blockers - TCA
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Bone loss -> osteopenia -> osteoporosis -> Fx
Temporalis muscle wasting = temporal wasting

30. What is the preferred depression treatment in elderly?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Therapy - SSRI
Beers criteria - medication appropriateness index (12 ?)
Phenytoin

31. What are the pharmacodynamic changes associated with aging?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Map of people - perceptions - etc - varies by perspective
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Receptors changes: # - sensitivity - counter-regulatory moa

32. osteopenia
Doctors
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Hyperuricemia -> gout
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

33. falls epidemiology
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

34. Aging descriptors
Diagnosis - risk/benefit analysis to choose Rx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
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
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

35. How does sliding scale glycemic control relate to elderly?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Parkinsonism -> l-DOPA
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

36. using long-acting opioids in elderly
IdioPx - psychiatric: depression - anxiety - somatoform
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Treat underlying disease/lack resources
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

37. galantamine
Cholinesterase inhib - use: dementia
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Receptors changes: # - sensitivity - counter-regulatory moa
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

38. describe the % of ADR considered preventable - and of those serious
Stress: #1 - functional - urge - overflow
Insiduous onset
Respect for autonomy - nonmaleficence - beneficence - justice
30% preventable - of these - 40% serious - of these 40% preventable

39. What is polypharmacy
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Therapy - SSRI
#1 patient's last competent indication of wishes - substituted judgment - beneficence
>9 Rx

40. LBW equation
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
NMDR antagonist - use: dementia
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

41. psychological abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
Voice - character - plot - context - time - reader
BMD (bone mineral density): T-score >2.5 std dev below normal 1
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

42. substituted judgment
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
>9 Rx
Cholinesterase inhib - use: dementia

43. advanced directive/care plan

44. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

45. MRP: medication related problems
Stress: #1 - functional - urge - overflow
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
^ANS tone -> ^periph vasoconstriction - ^HR
Cholinesterase inhib - use: dementia

46. frailty
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Multisystemic vulnerability - -lowered reserves
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Environment modification: obstacles - mobility - -bladder fcn ok

47. opioid tx in elderly
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
Begin @25-50% recommended dose - APAP may be dose-limiting
Cholinesterase inhib - use: dementia
Diagnosis - risk/benefit analysis to choose Rx

48. urge incontinence tx
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Bone loss -> osteopenia -> osteoporosis -> Fx
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

49. delirium: mgmt
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Diagnosis - risk/benefit analysis to choose Rx
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

50. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Phenytoin
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid