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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. tube feeding
Treat underlying disease/lack resources
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Hypotension - ^K+
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

2. ADR rf
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

3. ACE inhib + K+: interaction outcome
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Cholinesterase inhib - use: dementia
^K+
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

4. How does aging increase incontinence?
Stress: #1 - functional - urge - overflow
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
^morbidity + mortality - -frailest @ greatest risk
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

5. Alb-bound Rx
5% - underreported
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Cholinesterase inhib - use: dementia
Phenytoin

6. Beers criteria
5% - underreported
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
Beers criteria - medication appropriateness index (12 ?)
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

7. ACE inhib + diuretic: interaction outcome
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
CNS suppression -> cholinesterase inhibitors
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Hypotension - ^K+

8. cachexia
Stress: #1 - functional - urge - overflow
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Receptors changes: # - sensitivity - counter-regulatory moa
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

9. How does aging affect pharmacokinetics?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
^K+
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Parkinsonism -> l-DOPA

10. how is cachexia different from wasting?
Map of people - perceptions - etc - varies by perspective
Phenytoin
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

11. What are the common types of elder mistreatment?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Environment modification: obstacles - mobility - -bladder fcn ok

12. using long-acting opioids in elderly
Electrical: change in HR - structural: aortic outflow obstruction
Environment modification: obstacles - mobility - -bladder fcn ok
Temporalis muscle wasting = temporal wasting
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

13. Syncope prognosis based on etio
NMDR antagonist - use: dementia
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Worse for cardiac causes v noncardia

14. MRP: medication related problems
High mortality - esp + Fx - very common in elderly
Worse for cardiac causes v noncardia
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Cholinesterase inhib - use: dementia

15. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Confusion - sedation - falls
Used to calculate renal fcn - clearance of Cr adjusted for age
Parkinsonism -> l-DOPA

16. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
No: fever - leukocytosis - yes: falls - appetite change - low functional status

17. what illnesses are underreported in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Falls - delirium - malnutrition - P ulcers - opportunistic i2
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

18. frailty raises vulnerability to...
^SV (diastolic stroke volume)
Screen for potentially embarrassing dx - patient/Dr trust
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

19. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Hypotension - ^K+
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

20. who is a good candidate for opioid tx?
>60yo - low abuse risk - ^ monitoring possible
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Universal - progressive - partially encoded (genetic) - destructive -
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

21. What are the risks of uncontrolled ISH?
Universal - progressive - partially encoded (genetic) - destructive -
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
CVA: stroke - AMI: acute MI - HF
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

22. What are the possible cardiac causes of presyncope?
Electrical: change in HR - structural: aortic outflow obstruction
80% of hospital admission for syncope for >65yo
Pressure ulcer - fecal impaction - dehydration
Receptors changes: # - sensitivity - counter-regulatory moa

23. What is a PE sign of cachexia?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Temporalis muscle wasting = temporal wasting
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

24. delirium: tx approach
Electrolyte imbalance - arrhythmia
IdioPx - psychiatric: depression - anxiety - somatoform
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
CVA: stroke - AMI: acute MI - HF

25. How does an 80yo renal fcn compare to that of a 20yo?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
1/2
P2-metabolite - phase 1 biotx much more affected than phase 2
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

26. thiazide diuretic may lead to what prescription cascade?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Falls - delirium - malnutrition - P ulcers - opportunistic i2
^K+
Hyperuricemia -> gout

27. incontinence epidemiology
F>M (until 80yo) - stress incontinence #1 - $26B/yr
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

28. rule of doable effect
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Cholinesterase inhib - use: dementia
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Confusion - sedation - falls

29. violation of rights
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

30. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Cholinesterase inhib - use: dementia
Beers criteria - medication appropriateness index (12 ?)

31. elderly abuse epidemiology
Cholinesterase inhib - use: dementia
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
5% - underreported
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

32. pulm edema + atypical Sx
Insiduous onset
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
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

33. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Used to calculate renal fcn - clearance of Cr adjusted for age
Temporalis muscle wasting = temporal wasting
P2-metabolite - phase 1 biotx much more affected than phase 2
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

34. How does aging affect Rx pharmacokinetic metabolism?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Used to calculate renal fcn - clearance of Cr adjusted for age
Cholinesterase inhib - use: dementia

35. osteoporosis
Insiduous onset
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Tx underlying etio - + Kegels - pessary - surgery
Injury - neglect - physical/psychosocial - financial - violation of rights

36. what normally prevents syncope?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
^K+
3 reflexes: baroreceptor - renal nerve - ANF
Electrical: change in HR - structural: aortic outflow obstruction

37. what receptors increase sensitivity with aging?
P2-metabolite - phase 1 biotx much more affected than phase 2
^K+
Mechanical loading - skin care - avoid friction/shear
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

38. how is syncope related to elderly admission to hospital?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
IdioPx - psychiatric: depression - anxiety - somatoform
80% of hospital admission for syncope for >65yo

39. Aging descriptors
Stress: #1 - functional - urge - overflow
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Cholinesterase inhib - use: dementia

40. What is the best approach to malnutrition
Treat underlying disease/lack resources
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Doctors

41. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
Prescribing - monitoring - patient adherence
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Confusion - sedation - falls

42. lipid-soluble Rx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Map of people - perceptions - etc - varies by perspective
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

43. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Breast cancer + 2o LBP
Hypotension - ^K+
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

44. How does aging affect Rx pharmacokinetic distribution?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
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
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

45. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
28% - ADR: 17% - non-compliance 11%
Used to calculate renal fcn - clearance of Cr adjusted for age
Legal: Cruzan v Hamon

46. advanced directive/care plan

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47. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Treat underlying disease/lack resources
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Used to calculate renal fcn - clearance of Cr adjusted for age

48. delirium predisposing rf
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Diagnosis - risk/benefit analysis to choose Rx
Used to calculate renal fcn - clearance of Cr adjusted for age
28% - ADR: 17% - non-compliance 11%

49. How does renal nerve prevent syncope?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Temporalis muscle wasting = temporal wasting

50. What is START criteria?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Isolated systolic HTN
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)