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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. What are the rf for elderly abuse?
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Hypotension - ^K+
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Begin @25-50% recommended dose - APAP may be dose-limiting

2. lipid-soluble Rx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Stress: #1 - functional - urge - overflow
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

3. What is the preferred depression treatment in elderly?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Therapy - SSRI
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Determined by Dr for a patient - -> used to determine competency

4. urinary incontinence types
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Stress: #1 - functional - urge - overflow
Constipation -> laxatives
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

5. malnutrition
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Falls - delirium - malnutrition - P ulcers - opportunistic i2
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

6. rivastigmine
Voice - character - plot - context - time - reader
Cholinesterase inhib - use: dementia
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
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

7. Aging principles
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Hypothetical plan - serves as patient's last competent indicated wishes
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

8. fall causes
P2-metab: Lorazepam - Trazepam - Oxazepam
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Phenytoin
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

9. clues of neglect
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Insiduous onset
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

10. what professional is least likely to report abuse?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Doctors
1/2

11. osteopenia
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
#1 patient's last competent indication of wishes - substituted judgment - beneficence
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

12. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Mechanical loading - skin care - avoid friction/shear
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
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

13. What is the best approach to malnutrition
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Respect for autonomy - nonmaleficence - beneficence - justice
Treat underlying disease/lack resources

14. what receptors decrease sensitivity with aging?
A-blockers - B-blockers - TCA
>60yo - low abuse risk - ^ monitoring possible
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Map of people - perceptions - etc - varies by perspective

15. restrain requirements
Figure out a good diet - social aspect - resources - dental/oral comfort
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
P2-metabolite - phase 1 biotx much more affected than phase 2
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

16. What are the pharmacodynamic changes associated with aging?
Isolated systolic HTN
Receptors changes: # - sensitivity - counter-regulatory moa
Cholinesterase inhib - use: dementia
Doctors

17. What drugs can contribute to syncope?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
A-blockers - B-blockers - TCA
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

18. How does aging affect pharmacokinetic protein binding?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Begin @25-50% recommended dose - APAP may be dose-limiting

19. cachexia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
>60yo - low abuse risk - ^ monitoring possible
1/2
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

20. physical neglect
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

21. surrogate decision making heirarchy

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22. lightheadedness
Phenytoin
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Catch-all of unspecified dizziness
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

23. how can you determine whether Rx is appropriate to use in elderly patient?
28% - ADR: 17% - non-compliance 11%
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Beers criteria - medication appropriateness index (12 ?)
^BP -> a-HTN

24. malignancy + atypical Sx
Breast cancer + 2o LBP
Cholinesterase inhib - use: dementia
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

25. How does ANF prevent syncope?
ANF: Na+ retention - disinhib vasoconstriction
Breast cancer + 2o LBP
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

26. NSAID may lead to what prescription cascade?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
NMDR antagonist - use: dementia
^BP -> a-HTN
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

27. delirium incidence
IdioPx - psychiatric: depression - anxiety - somatoform
Temporalis muscle wasting = temporal wasting
Confusion - sedation - falls
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

28. fall sequelae

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29. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
Voice - character - plot - context - time - reader
Temporalis muscle wasting = temporal wasting
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

30. What are the common types of elder mistreatment?
Receptors changes: # - sensitivity - counter-regulatory moa
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

31. How does aging affect Rx pharmacokinetic distribution?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
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
Beers criteria - medication appropriateness index (12 ?)
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

32. incontinence epidemiology
Cholinesterase inhib - use: dementia
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Vertigo - presyncope - disequilibrium - lightheadedness
F>M (until 80yo) - stress incontinence #1 - $26B/yr

33. frailty signs
Phenytoin
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Constipation -> laxatives

34. what nutritional interventions help underweight?
Electrical: change in HR - structural: aortic outflow obstruction
Prescribing - monitoring - patient adherence
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

35. How does aging increase incontinence?
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
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
^BP -> a-HTN

36. Aging descriptors
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Diagnosis - risk/benefit analysis to choose Rx
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

37. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
5% - underreported

38. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Diagnosis - risk/benefit analysis to choose Rx

39. overflow incontinence tx
Pressure ulcer - fecal impaction - dehydration
Universal - progressive - partially encoded (genetic) - destructive -
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Treat underlying disease/lack resources

40. nutrition syndromes
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
A-blockers - B-blockers - TCA
Cachexia - PEM - FTT - obesity
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

41. Why is abuse underreported?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Respect for autonomy - nonmaleficence - beneficence - justice
Stress: #1 - functional - urge - overflow
Confusion - sedation - falls

42. Beers criteria
ANF: Na+ retention - disinhib vasoconstriction
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
Electrical: change in HR - structural: aortic outflow obstruction
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

43. BZD + antipsychotic: interaction outcome
ANF: Na+ retention - disinhib vasoconstriction
Cholinesterase inhib - use: dementia
30% preventable - of these - 40% serious - of these 40% preventable
Confusion - sedation - falls

44. What is sCr?
Confusion - sedation - falls
Bone loss -> osteopenia -> osteoporosis -> Fx
1/2
Serum Cr: used for Cr clearance equation

45. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

46. elderly abuse epidemiology
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
5% - underreported
Serum Cr: used for Cr clearance equation
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

47. pulm edema + atypical Sx
Tx underlying etio - + Kegels - pessary - surgery
Insiduous onset
Electrical: change in HR - structural: aortic outflow obstruction
Delayed absorption - like competitive inhib

48. acute abdomen + atypical Sx
P2-metab: Lorazepam - Trazepam - Oxazepam
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Confusion - sedation - falls

49. What are the rf for caregiver to abuse elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Tx underlying etio - + Kegels - pessary - surgery

50. What is polypharmacy
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Confusion - sedation - falls
>9 Rx
Beers criteria - medication appropriateness index (12 ?)