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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. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
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
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

2. how may hypertension compensate for aging?
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
NMDR antagonist - use: dementia
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

3. What are the 4 forms of dizziness?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Hypothetical plan - serves as patient's last competent indicated wishes
Prescribing - monitoring - patient adherence
Vertigo - presyncope - disequilibrium - lightheadedness

4. Why is abuse underreported?
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

5. What is the best approach to malnutrition
P2-metab: Lorazepam - Trazepam - Oxazepam
Treat underlying disease/lack resources
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

6. what ADR are common in elderly patient?
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
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Serum Cr: used for Cr clearance equation

7. What are the vascular changes of presyncope?
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
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

8. What are the narrative elements of clinical ethics?
Voice - character - plot - context - time - reader
Cachexia - PEM - FTT - obesity
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

9. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cholinesterase inhib - use: dementia
Hypotension - ^K+
28% - ADR: 17% - non-compliance 11%

10. incontinence epidemiology
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

11. What is the natural history of syncope?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
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
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

12. What is sCr?
Serum Cr: used for Cr clearance equation
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
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Treat underlying disease/lack resources

13. How does aging increase incontinence?
Legal: Cruzan v Hamon
Respect for autonomy - nonmaleficence - beneficence - justice
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
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

14. restrain requirements
Universal - progressive - partially encoded (genetic) - destructive -
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Isolated systolic HTN
Parkinsonism -> l-DOPA

15. frailty
Delayed absorption - like competitive inhib
CNS suppression -> cholinesterase inhibitors
>9 Rx
Multisystemic vulnerability - -lowered reserves

16. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Confusion - sedation - falls
CVA: stroke - AMI: acute MI - HF
Begin @25-50% recommended dose - APAP may be dose-limiting
P2-metabolite - phase 1 biotx much more affected than phase 2

17. Approach to idioPx - recurrent syncope
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Vertigo - presyncope - disequilibrium - lightheadedness
Consider responsibilities - drivin
F>M (until 80yo) - stress incontinence #1 - $26B/yr

18. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
BMD (bone mineral density): T-score >2.5 std dev below normal 1
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

19. elderly abuse epidemiology
#1 patient's last competent indication of wishes - substituted judgment - beneficence
5% - underreported
Stress: #1 - functional - urge - overflow
Multisystemic vulnerability - -lowered reserves

20. delirium incidence
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Multisystemic vulnerability - -lowered reserves
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

21. How does aging affect GI absorption of Rx?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Universal - progressive - partially encoded (genetic) - destructive -
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

22. What are the rf for caregiver to abuse elderly?
Breast cancer + 2o LBP
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
P2-metabolite - phase 1 biotx much more affected than phase 2
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

23. vertigo
^ANS tone -> ^periph vasoconstriction - ^HR
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

24. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
^SV (diastolic stroke volume)
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
^morbidity + mortality - -frailest @ greatest risk

25. PEM
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

26. How does aging affect GI absorption rate of Rx?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Delayed absorption - like competitive inhib
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
BMD (bone mineral density): T-score >2.5 std dev below normal 1

27. osteopenia
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

28. What are the 3 sentinel events for LT care?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Prescribing - monitoring - patient adherence
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Pressure ulcer - fecal impaction - dehydration

29. overflow incontinence tx
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

30. dementia tx
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
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Cholinesterase inhib - use: dementia

31. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Electrical: change in HR - structural: aortic outflow obstruction
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Threats/ terrorizing - isolation - denying food/privileges/liberty

32. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Make sure to discuss with patient - some states require reporting
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

33. malignancy + atypical Sx
^SV (diastolic stroke volume)
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Breast cancer + 2o LBP
Bone loss -> osteopenia -> osteoporosis -> Fx

34. using long-acting opioids in elderly
Confusion - sedation - falls
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

35. How does aging impact syncope-preventing reflexes
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
^BP -> a-HTN
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

36. tube feeding
Cholinesterase inhib - use: dementia
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Injury - neglect - physical/psychosocial - financial - violation of rights
^SV (diastolic stroke volume)

37. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
ANF: Na+ retention - disinhib vasoconstriction

38. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
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
ANF: Na+ retention - disinhib vasoconstriction

39. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Falls - delirium - malnutrition - P ulcers - opportunistic i2
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
28% - ADR: 17% - non-compliance 11%

40. What is abuse?
Injury - neglect - physical/psychosocial - financial - violation of rights
Cholinesterase inhib - use: dementia
Electrical: change in HR - structural: aortic outflow obstruction
Tx underlying etio - + Kegels - pessary - surgery

41. what receptors increase sensitivity with aging?
5% - underreported
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

42. psychological abuse
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Threats/ terrorizing - isolation - denying food/privileges/liberty
CNS suppression -> cholinesterase inhibitors

43. LBW equation
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

44. how can you determine whether Rx is appropriate to use in elderly patient?
Universal - progressive - partially encoded (genetic) - destructive -
Beers criteria - medication appropriateness index (12 ?)
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
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

45. What is a mattering map?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Diagnosis - risk/benefit analysis to choose Rx
Map of people - perceptions - etc - varies by perspective
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

46. How does an 80yo renal fcn compare to that of a 20yo?
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Injury - neglect - physical/psychosocial - financial - violation of rights
1/2

47. incontinence complication
^SV (diastolic stroke volume)
Vertigo - presyncope - disequilibrium - lightheadedness
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

48. What is polypharmacy
30% preventable - of these - 40% serious - of these 40% preventable
Beers criteria - medication appropriateness index (12 ?)
Cholinesterase inhib - use: dementia
>9 Rx

49. What is the bone deterioration cascade?
Bone loss -> osteopenia -> osteoporosis -> Fx
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Electrolyte imbalance - arrhythmia
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

50. Beers criteria
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
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
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