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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. How does aging affect Rx renal elimination?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

2. How does baroreceptor reflex prevent syncope?
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Hypotension - ^K+
Figure out a good diet - social aspect - resources - dental/oral comfort
^ANS tone -> ^periph vasoconstriction - ^HR

3. What is the best approach to malnutrition
Parkinsonism -> l-DOPA
Cholinesterase inhib - use: dementia
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Treat underlying disease/lack resources

4. What is the STOPP criteria?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
3 reflexes: baroreceptor - renal nerve - ANF
BMD (bone mineral density): T-score >2.5 std dev below normal 1
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

5. osteopenia
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd 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
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Hyperuricemia -> gout

6. 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
Receptors changes: # - sensitivity - counter-regulatory moa
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Consider responsibilities - drivin

7. 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
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Beers criteria - medication appropriateness index (12 ?)
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

8. What are the rf for caregiver to abuse elderly?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

9. Aging principles
CVA: stroke - AMI: acute MI - HF
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

10. when selecting an P1-metabolite or P2-metabolite safer in elderly?
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Delayed absorption - like competitive inhib
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
P2-metabolite - phase 1 biotx much more affected than phase 2

11. BZD + antidepressant: interaction outcome
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Confusion - sedation - falls
Phenytoin
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

12. describe the % of ADR considered preventable - and of those serious
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
^ANS tone -> ^periph vasoconstriction - ^HR
Catch-all of unspecified dizziness
30% preventable - of these - 40% serious - of these 40% preventable

13. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
5% - underreported
Begin @25-50% recommended dose - APAP may be dose-limiting
Diagnosis - risk/benefit analysis to choose Rx

14. thyroid dx + atypical Sx
P2-metab: Lorazepam - Trazepam - Oxazepam
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

15. Cockcroft Gault equation
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Used to calculate renal fcn - clearance of Cr adjusted for age
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

16. incontinence epidemiology
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

17. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Electrical: change in HR - structural: aortic outflow obstruction
Determined by Dr for a patient - -> used to determine competency

18. MI + atypical Sx
Diagnosis - risk/benefit analysis to choose Rx
>9 Rx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
>60yo - low abuse risk - ^ monitoring possible

19. How does aging affect pharmacokinetics?
Receptors changes: # - sensitivity - counter-regulatory moa
Catch-all of unspecified dizziness
5% - underreported
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

20. preventing malnutrition
1/2
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Cholinesterase inhib - use: dementia
Figure out a good diet - social aspect - resources - dental/oral comfort

21. Syncope prognosis based on etio
Worse for cardiac causes v noncardia
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
^ANS tone -> ^periph vasoconstriction - ^HR
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

22. How does ANF prevent syncope?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Stress: #1 - functional - urge - overflow
ANF: Na+ retention - disinhib vasoconstriction
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

23. osteoporosis etio
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Insiduous onset
Legal: Cruzan v Hamon
30% preventable - of these - 40% serious - of these 40% preventable

24. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
80% of hospital admission for syncope for >65yo
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Treat underlying disease/lack resources

25. what % of hospitalizations of elderly are due to ADR + noncompliance?
3 reflexes: baroreceptor - renal nerve - ANF
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
28% - ADR: 17% - non-compliance 11%
CVA: stroke - AMI: acute MI - HF

26. What are the key points of safe prescription for elderly - lecture
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Begin @25-50% recommended dose - APAP may be dose-limiting
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Diagnosis - risk/benefit analysis to choose Rx

27. metoclopramide may lead to what prescription cascade?
IdioPx - psychiatric: depression - anxiety - somatoform
Parkinsonism -> l-DOPA
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Screen for potentially embarrassing dx - patient/Dr trust

28. Why is abuse underreported?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Tx underlying etio - + Kegels - pessary - surgery
Serum Cr: used for Cr clearance equation
Universal - progressive - partially encoded (genetic) - destructive -

29. What are the common types of elder mistreatment?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

30. 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
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Phenytoin
Receptors changes: # - sensitivity - counter-regulatory moa

31. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Used to calculate renal fcn - clearance of Cr adjusted for age
Doctors
Legal: Cruzan v Hamon

32. elderly abuse epidemiology
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Confusion - sedation - falls
5% - underreported

33. Aging features
Insiduous onset
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Universal - progressive - partially encoded (genetic) - destructive -
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

34. What is a mattering map?
Catch-all of unspecified dizziness
Map of people - perceptions - etc - varies by perspective
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

35. How does aging affect GI absorption rate of Rx?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
^BP -> a-HTN
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Delayed absorption - like competitive inhib

36. delirium: mgmt
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Mechanical loading - skin care - avoid friction/shear
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

37. How to prevent pressure ulcers?
IdioPx - psychiatric: depression - anxiety - somatoform
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
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
Mechanical loading - skin care - avoid friction/shear

38. Presyncope
Figure out a good diet - social aspect - resources - dental/oral comfort
Serum Cr: used for Cr clearance equation
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

39. What are the common causes of lightheadedness?
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Confusion - sedation - falls
Injury - neglect - physical/psychosocial - financial - violation of rights
IdioPx - psychiatric: depression - anxiety - somatoform

40. documenting elderly abuse

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41. ADR rf
Therapy - SSRI
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
^morbidity + mortality - -frailest @ greatest risk
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

42. stress incontinence tx
Tx underlying etio - + Kegels - pessary - surgery
Parkinsonism -> l-DOPA
1/2
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

43. What is the Cockcroft Gault equation?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Used to calculate renal fcn - clearance of Cr adjusted for age
80% of hospital admission for syncope for >65yo

44. frailty raises vulnerability to...
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Pressure ulcer - fecal impaction - dehydration
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

45. what illnesses are underreported in elderly?
NMDR antagonist - use: dementia
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

46. What are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

47. malnutrition
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
Figure out a good diet - social aspect - resources - dental/oral comfort
3 reflexes: baroreceptor - renal nerve - ANF
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

48. Disequilibrium
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

49. What is abuse?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Begin @25-50% recommended dose - APAP may be dose-limiting
>60yo - low abuse risk - ^ monitoring possible
Injury - neglect - physical/psychosocial - financial - violation of rights

50. physical neglect
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Temporalis muscle wasting = temporal wasting
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease