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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. clues of neglect
30% preventable - of these - 40% serious - of these 40% preventable
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
A-blockers - B-blockers - TCA

2. tube feeding
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

3. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Universal - progressive - partially encoded (genetic) - destructive -
Respect for autonomy - nonmaleficence - beneficence - justice
Doctors

4. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Therapy - SSRI
Threats/ terrorizing - isolation - denying food/privileges/liberty

5. What are the pharmacodynamic changes associated with aging?
Constipation -> laxatives
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Receptors changes: # - sensitivity - counter-regulatory moa
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

6. What is the STOPP criteria?
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 dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Catch-all of unspecified dizziness
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

7. surrogate decision making heirarchy

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8. conservator
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Receptors changes: # - sensitivity - counter-regulatory moa

9. What are the 4 forms of dizziness?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Vertigo - presyncope - disequilibrium - lightheadedness
Mechanical loading - skin care - avoid friction/shear

10. How does aging affect Rx pharmacokinetic metabolism?
Isolated systolic HTN
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

11. advanced directive/care plan

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12. rivastigmine
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
^morbidity + mortality - -frailest @ greatest risk
Consider responsibilities - drivin
Cholinesterase inhib - use: dementia

13. What are the 3 stages of ADRs?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
High mortality - esp + Fx - very common in elderly
Prescribing - monitoring - patient adherence
Hyperuricemia -> gout

14. MI + atypical Sx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Insiduous onset
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

15. vision changes: elderly
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

16. Presyncope
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

17. what drugs can cause dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Respect for autonomy - nonmaleficence - beneficence - justice
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

18. thiazide diuretic may lead to what prescription cascade?
30% preventable - of these - 40% serious - of these 40% preventable
Hyperuricemia -> gout
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

19. thyroid dx + atypical Sx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

20. what can enhance reporting in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Screen for potentially embarrassing dx - patient/Dr trust
Bone loss -> osteopenia -> osteoporosis -> Fx

21. How does aging affect Rx pharmacokinetic distribution?
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
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Confusion - sedation - falls
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

22. fall sequelae

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23. restrain requirements
Delayed absorption - like competitive inhib
Worse for cardiac causes v noncardia
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Hyperuricemia -> gout

24. What is the preferred depression treatment in elderly?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Mechanical loading - skin care - avoid friction/shear
Therapy - SSRI
>60yo - low abuse risk - ^ monitoring possible

25. osteoporosis epidemiology
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Serum Cr: used for Cr clearance equation
High mortality - esp + Fx - very common in elderly
3 reflexes: baroreceptor - renal nerve - ANF

26. How does aging affect Rx renal elimination?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

27. What is a PE sign of cachexia?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Temporalis muscle wasting = temporal wasting
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

28. describe the % of ADR considered preventable - and of those serious
#1 patient's last competent indication of wishes - substituted judgment - beneficence
30% preventable - of these - 40% serious - of these 40% preventable
High mortality - esp + Fx - very common in elderly
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

29. What is abuse?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Injury - neglect - physical/psychosocial - financial - violation of rights
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Worse for cardiac causes v noncardia

30. how is the CAM used to diagnose delirium?
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Catch-all of unspecified dizziness
Confusion - sedation - falls
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

31. BZD + antidepressant: interaction outcome
Consider responsibilities - drivin
Legal: Cruzan v Hamon
Confusion - sedation - falls
Doctors

32. frailty raises vulnerability to...
Threats/ terrorizing - isolation - denying food/privileges/liberty
Electrolyte imbalance - arrhythmia
Falls - delirium - malnutrition - P ulcers - opportunistic i2
^BP -> a-HTN

33. what ADR are common in elderly patient?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
High mortality - esp + Fx - very common in elderly

34. Beers criteria: what 10 Rx should elderly avoid or use + caution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Multisystemic vulnerability - -lowered reserves
Map of people - perceptions - etc - varies by perspective
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

35. What are the 3 sentinel events for LT care?
Legal: Cruzan v Hamon
Electrical: change in HR - structural: aortic outflow obstruction
Pressure ulcer - fecal impaction - dehydration
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

36. frailty signs
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Threats/ terrorizing - isolation - denying food/privileges/liberty
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

37. How does aging affect pharmacokinetic Rx distribution?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Consider responsibilities - drivin
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

38. BZD + antipsychotic: interaction outcome
^SV (diastolic stroke volume)
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Confusion - sedation - falls
3 reflexes: baroreceptor - renal nerve - ANF

39. What are the common causes of lightheadedness?
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
IdioPx - psychiatric: depression - anxiety - somatoform
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

40. substituted judgment
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
5% - underreported
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

41. What is the best approach to malnutrition
Treat underlying disease/lack resources
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
IdioPx - psychiatric: depression - anxiety - somatoform
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

42. Aging features
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Doctors
Universal - progressive - partially encoded (genetic) - destructive -

43. What is the natural history of syncope?
ANF: Na+ retention - disinhib vasoconstriction
Prescribing - monitoring - patient adherence
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

44. How does an 80yo renal fcn compare to that of a 20yo?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
1/2
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

45. osteoporosis
Beers criteria - medication appropriateness index (12 ?)
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Isolated systolic HTN
BMD (bone mineral density): T-score >2.5 std dev below normal 1

46. psychological abuse
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Threats/ terrorizing - isolation - denying food/privileges/liberty

47. pressure ulcer: staging
^SV (diastolic stroke volume)
Used to calculate renal fcn - clearance of Cr adjusted for age
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
CNS suppression -> cholinesterase inhibitors

48. Cockcroft Gault equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
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
Falls - delirium - malnutrition - P ulcers - opportunistic i2
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

49. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Voice - character - plot - context - time - reader
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
1/2

50. donepezil
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Constipation -> laxatives
Cholinesterase inhib - use: dementia