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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. What are common physical abuse Sx in elderly?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Doctors

2. Aging features
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Universal - progressive - partially encoded (genetic) - destructive -
Tx underlying etio - + Kegels - pessary - surgery
Temporalis muscle wasting = temporal wasting

3. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Hypotension - ^K+
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

4. opioid tx in elderly
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Begin @25-50% recommended dose - APAP may be dose-limiting
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

5. What are rf for osteoporosis?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

6. What are the common types of elder mistreatment?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Legal: Cruzan v Hamon
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

7. lightheadedness
Catch-all of unspecified dizziness
Determined by Dr for a patient - -> used to determine competency
NMDR antagonist - use: dementia
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

8. What is abuse?
Injury - neglect - physical/psychosocial - financial - violation of rights
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Electrolyte imbalance - arrhythmia
High mortality - esp + Fx - very common in elderly

9. Beers criteria
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
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

10. narcotics may lead to what prescription cascade?
Respect for autonomy - nonmaleficence - beneficence - justice
Insiduous onset
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Constipation -> laxatives

11. dementia tx
Injury - neglect - physical/psychosocial - financial - violation of rights
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Hypothetical plan - serves as patient's last competent indicated wishes
Threats/ terrorizing - isolation - denying food/privileges/liberty

12. Alb-bound Rx
Phenytoin
Threats/ terrorizing - isolation - denying food/privileges/liberty
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

13. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Electrical: change in HR - structural: aortic outflow obstruction
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

14. how is cachexia different from wasting?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Doctors
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

15. 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
CVA: stroke - AMI: acute MI - HF
Electrolyte imbalance - arrhythmia
F>M (until 80yo) - stress incontinence #1 - $26B/yr

16. delirium: mgmt
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Pressure ulcer - fecal impaction - dehydration
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

17. what ADR are common in elderly patient?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

18. NSAID may lead to what prescription cascade?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
^BP -> a-HTN
^SV (diastolic stroke volume)

19. antiarrhythmic + diuretic: interaction outcome
>60yo - low abuse risk - ^ monitoring possible
80% of hospital admission for syncope for >65yo
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
Electrolyte imbalance - arrhythmia

20. How does an 80yo renal fcn compare to that of a 20yo?
Multisystemic vulnerability - -lowered reserves
Confusion - sedation - falls
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
1/2

21. What are the hazards of elderly hospitalization?
^morbidity + mortality - -frailest @ greatest risk
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Cholinesterase inhib - use: dementia
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

22. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

23. 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
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

24. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Universal - progressive - partially encoded (genetic) - destructive -
Mechanical loading - skin care - avoid friction/shear
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

25. How does aging affect GI absorption rate of Rx?
Prescribing - monitoring - patient adherence
Doctors
Delayed absorption - like competitive inhib
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

26. How does aging affect Rx pharmacokinetic metabolism?
Hypothetical plan - serves as patient's last competent indicated wishes
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
28% - ADR: 17% - non-compliance 11%
Begin @25-50% recommended dose - APAP may be dose-limiting

27. osteopenia
^BP -> a-HTN
Confusion - sedation - falls
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
F>M (until 80yo) - stress incontinence #1 - $26B/yr

28. LBW equation
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Breast cancer + 2o LBP
Doctors

29. Aging principles
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

30. delirium: tx approach
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Consider responsibilities - drivin

31. clues of neglect
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
^ANS tone -> ^periph vasoconstriction - ^HR
^SV (diastolic stroke volume)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

32. urinary incontinence types
Mechanical loading - skin care - avoid friction/shear
Screen for potentially embarrassing dx - patient/Dr trust
^K+
Stress: #1 - functional - urge - overflow

33. What are the 3 stages of ADRs?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Prescribing - monitoring - patient adherence
Diagnosis - risk/benefit analysis to choose Rx
Therapy - SSRI

34. what receptors increase sensitivity with aging?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Figure out a good diet - social aspect - resources - dental/oral comfort

35. nutrition syndromes
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Cachexia - PEM - FTT - obesity
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Prescribing - monitoring - patient adherence

36. How does aging affect pharmacokinetics?
Beers criteria - medication appropriateness index (12 ?)
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
>9 Rx

37. what can enhance reporting in elderly?
Prescribing - monitoring - patient adherence
Screen for potentially embarrassing dx - patient/Dr trust
Delayed absorption - like competitive inhib
Legal: Cruzan v Hamon

38. restrain requirements
Therapy - SSRI
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics

39. delirium incidence
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Prescribing - monitoring - patient adherence
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

40. red flags for further inquiry
Hypothetical plan - serves as patient's last competent indicated wishes
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Map of people - perceptions - etc - varies by perspective

41. using long-acting opioids in elderly
80% of hospital admission for syncope for >65yo
Tx underlying etio - + Kegels - pessary - surgery
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

42. lipid-soluble Rx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
#1 patient's last competent indication of wishes - substituted judgment - beneficence

43. How does sliding scale glycemic control relate to elderly?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Cholinesterase inhib - use: dementia
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Insiduous onset

44. delirium diagnosis
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Confusion - sedation - falls
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

45. preventing malnutrition
Electrical: change in HR - structural: aortic outflow obstruction
Screen for potentially embarrassing dx - patient/Dr trust
Figure out a good diet - social aspect - resources - dental/oral comfort
Stress: #1 - functional - urge - overflow

46. What is the epidemiology of dizziness?
Confusion - sedation - falls
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

47. what professional is least likely to report abuse?
Doctors
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Environment modification: obstacles - mobility - -bladder fcn ok
^ANS tone -> ^periph vasoconstriction - ^HR

48. what nutritional interventions help underweight?
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Respect for autonomy - nonmaleficence - beneficence - justice
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

49. thyroid dx + atypical Sx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Universal - progressive - partially encoded (genetic) - destructive -
^BP -> a-HTN
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

50. What is a mattering map?
Map of people - perceptions - etc - varies by perspective
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
High mortality - esp + Fx - very common in elderly
Appointed by court if no substituted judgment -conservator of finance -conservator of person