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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. what professional is least likely to report abuse?
Determined by Dr for a patient - -> used to determine competency
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Doctors

2. How does the aging heart compensate for lower HR to maintain unchanged CO?
Receptors changes: # - sensitivity - counter-regulatory moa
Parkinsonism -> l-DOPA
^SV (diastolic stroke volume)
Treat underlying disease/lack resources

3. how can you determine whether Rx is appropriate to use in elderly patient?
Beers criteria - medication appropriateness index (12 ?)
30% preventable - of these - 40% serious - of these 40% preventable
Diagnosis - risk/benefit analysis to choose Rx
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

4. osteoporosis etio
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Stress: #1 - functional - urge - overflow

5. antiarrhythmic + diuretic: interaction outcome
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Worse for cardiac causes v noncardia
Electrolyte imbalance - arrhythmia

6. what drugs can cause dizziness?
Consider responsibilities - drivin
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Map of people - perceptions - etc - varies by perspective
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

7. nutrition syndromes
Multisystemic vulnerability - -lowered reserves
Cachexia - PEM - FTT - obesity
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
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

8. frailty raises vulnerability to...
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Breast cancer + 2o LBP
Treat underlying disease/lack resources

9. red flags for further inquiry
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Injury - neglect - physical/psychosocial - financial - violation of rights

10. ADR rf
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Treat underlying disease/lack resources
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

11. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

12. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Receptors changes: # - sensitivity - counter-regulatory moa
Respect for autonomy - nonmaleficence - beneficence - justice
^K+

13. Approach to idioPx - recurrent syncope
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Consider responsibilities - drivin
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

14. How does renal nerve prevent syncope?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Delayed absorption - like competitive inhib
Confusion - sedation - falls

15. What are the 4 forms of dizziness?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Vertigo - presyncope - disequilibrium - lightheadedness
Voice - character - plot - context - time - reader

16. What is the bone deterioration cascade?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Bone loss -> osteopenia -> osteoporosis -> Fx

17. refusing intervention
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Legal: Cruzan v Hamon
Constipation -> laxatives

18. thyroid dx + atypical Sx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Cholinesterase inhib - use: dementia
Worse for cardiac causes v noncardia
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

19. How does an 80yo renal fcn compare to that of a 20yo?
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
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
1/2
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

20. What is sCr?
Electrical: change in HR - structural: aortic outflow obstruction
CNS suppression -> cholinesterase inhibitors
Serum Cr: used for Cr clearance equation
Cholinesterase inhib - use: dementia

21. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
P2-metab: Lorazepam - Trazepam - Oxazepam
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

22. What are the hazards of elderly hospitalization?
Confusion - sedation - falls
^morbidity + mortality - -frailest @ greatest risk
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

23. MI + atypical Sx
Diagnosis - risk/benefit analysis to choose Rx
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
No: chest pain - yes: fatigue - nausea - low functional status - SOB
P2-metab: Lorazepam - Trazepam - Oxazepam

24. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Used to calculate renal fcn - clearance of Cr adjusted for age

25. rule of doable effect
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Serum Cr: used for Cr clearance equation

26. documenting elderly abuse

27. how may hypertension compensate for aging?
Doctors
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Hyperuricemia -> gout

28. metoclopramide may lead to what prescription cascade?
Confusion - sedation - falls
Temporalis muscle wasting = temporal wasting
Parkinsonism -> l-DOPA
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

29. delirium: tx approach
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Confusion - sedation - falls
Treat underlying disease/lack resources
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

30. How does ANF prevent syncope?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
ANF: Na+ retention - disinhib vasoconstriction
Therapy - SSRI
Multisystemic vulnerability - -lowered reserves

31. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
^morbidity + mortality - -frailest @ greatest risk

32. dementia tx
Tx underlying etio - + Kegels - pessary - surgery
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Hyperuricemia -> gout
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

33. Aging features
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Universal - progressive - partially encoded (genetic) - destructive -
Electrical: change in HR - structural: aortic outflow obstruction
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

34. describe the % of ADR considered preventable - and of those serious
30% preventable - of these - 40% serious - of these 40% preventable
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
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

35. What are the pharmacodynamic changes associated with aging?
Tx underlying etio - + Kegels - pessary - surgery
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Receptors changes: # - sensitivity - counter-regulatory moa

36. Disequilibrium
Confusion - sedation - falls
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

37. overflow incontinence tx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
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
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

38. how is cachexia different from wasting?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
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
Voice - character - plot - context - time - reader
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness

39. How does aging affect Rx renal elimination?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Tx underlying etio - + Kegels - pessary - surgery
Environment modification: obstacles - mobility - -bladder fcn ok

40. which benzodiazepines are most appropriate for elderly?
Voice - character - plot - context - time - reader
P2-metab: Lorazepam - Trazepam - Oxazepam
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

41. What is the natural history of syncope?
Confusion - sedation - falls
Constipation -> laxatives
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

42. Syncope prognosis based on etio
Worse for cardiac causes v noncardia
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Electrical: change in HR - structural: aortic outflow obstruction
IdioPx - psychiatric: depression - anxiety - somatoform

43. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Consider responsibilities - drivin
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

44. cachexia
^morbidity + mortality - -frailest @ greatest risk
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Bone loss -> osteopenia -> osteoporosis -> Fx
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

45. vision changes: elderly
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Beers criteria - medication appropriateness index (12 ?)
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

46. What are common scenarios of untreated indications in elderly?
Voice - character - plot - context - time - reader
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cachexia - PEM - FTT - obesity
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear

47. donepezil
Delayed absorption - like competitive inhib
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Cholinesterase inhib - use: dementia
28% - ADR: 17% - non-compliance 11%

48. what can enhance reporting in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Begin @25-50% recommended dose - APAP may be dose-limiting
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Screen for potentially embarrassing dx - patient/Dr trust

49. pressure ulcer: staging
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Prescribing - monitoring - patient adherence

50. How does aging affect Rx pharmacokinetic distribution?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
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
Tx underlying etio - + Kegels - pessary - surgery
Map of people - perceptions - etc - varies by perspective