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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Tx underlying etio - + Kegels - pessary - surgery
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

2. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Constipation -> laxatives
Parkinsonism -> l-DOPA

3. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Cholinesterase inhib - use: dementia
Phenytoin

4. frailty
Cholinesterase inhib - use: dementia
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Multisystemic vulnerability - -lowered reserves
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

5. lightheadedness
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Catch-all of unspecified dizziness
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health

6. What are the 4 basic ethical principles?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Respect for autonomy - nonmaleficence - beneficence - justice
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
^BP -> a-HTN

7. red flags for further inquiry
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

8. anticholinergic drugs may lead to what prescription cascade?
^SV (diastolic stroke volume)
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
CNS suppression -> cholinesterase inhibitors
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

9. what Rx are commonly monifoted in elderly for ADR?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Receptors changes: # - sensitivity - counter-regulatory moa
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

10. What is a mattering map?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Map of people - perceptions - etc - varies by perspective
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

11. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Constipation -> laxatives
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
No: chest pain - yes: fatigue - nausea - low functional status - SOB

12. driving considerations
Treat underlying disease/lack resources
Breast cancer + 2o LBP
Make sure to discuss with patient - some states require reporting
Falls - delirium - malnutrition - P ulcers - opportunistic i2

13. What are the possible cardiac causes of presyncope?
Delayed absorption - like competitive inhib
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Pressure ulcer - fecal impaction - dehydration
Electrical: change in HR - structural: aortic outflow obstruction

14. rivastigmine
Voice - character - plot - context - time - reader
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Cholinesterase inhib - use: dementia

15. acute abdomen + atypical Sx
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Multisystemic vulnerability - -lowered reserves
Universal - progressive - partially encoded (genetic) - destructive -
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

16. How does aging affect Rx renal elimination?
Temporalis muscle wasting = temporal wasting
Doctors
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

17. How does an 80yo renal fcn compare to that of a 20yo?
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Serum Cr: used for Cr clearance equation
CVA: stroke - AMI: acute MI - HF
1/2

18. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
Treat underlying disease/lack resources
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

19. violation of rights
Screen for potentially embarrassing dx - patient/Dr trust
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Universal - progressive - partially encoded (genetic) - destructive -

20. physical neglect
Consider responsibilities - drivin
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
^K+

21. psychological abuse
Threats/ terrorizing - isolation - denying food/privileges/liberty
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Worse for cardiac causes v noncardia
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

22. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

23. i2 + atypical Sx
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Therapy - SSRI
No: fever - leukocytosis - yes: falls - appetite change - low functional status
30% preventable - of these - 40% serious - of these 40% preventable

24. elderly abuse epidemiology
Cholinesterase inhib - use: dementia
5% - underreported
Receptors changes: # - sensitivity - counter-regulatory moa
Isolated systolic HTN

25. Cockcroft Gault equation
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Cholinesterase inhib - use: dementia
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

26. which benzodiazepines are most appropriate for elderly?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
P2-metab: Lorazepam - Trazepam - Oxazepam
Begin @25-50% recommended dose - APAP may be dose-limiting

27. how can you determine whether Rx is appropriate to use in elderly patient?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Beers criteria - medication appropriateness index (12 ?)
Consider responsibilities - drivin
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

28. what nutritional interventions help underweight?
Make sure to discuss with patient - some states require reporting
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

29. malignancy + atypical Sx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Serum Cr: used for Cr clearance equation
Breast cancer + 2o LBP

30. surrogate decision making heirarchy

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31. Aging principles
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

32. what mechanical loading helps to prevent pressure ulcers?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Constipation -> laxatives
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Cholinesterase inhib - use: dementia

33. How does renal nerve prevent syncope?
Phenytoin
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Serum Cr: used for Cr clearance equation
1/2

34. what drugs can cause dizziness?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Figure out a good diet - social aspect - resources - dental/oral comfort
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

35. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
P2-metabolite - phase 1 biotx much more affected than phase 2
Parkinsonism -> l-DOPA

36. osteopenia
Serum Cr: used for Cr clearance equation
Consider responsibilities - drivin
Tx underlying etio - + Kegels - pessary - surgery
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

37. What are common physical abuse Sx in elderly?
CVA: stroke - AMI: acute MI - HF
1/2
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

38. fall sequelae

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39. How does baroreceptor reflex prevent syncope?
Pressure ulcer - fecal impaction - dehydration
^ANS tone -> ^periph vasoconstriction - ^HR
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
ANF: Na+ retention - disinhib vasoconstriction

40. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
P2-metab: Lorazepam - Trazepam - Oxazepam
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

41. restrain requirements
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
30% preventable - of these - 40% serious - of these 40% preventable

42. what professional is least likely to report abuse?
Cholinesterase inhib - use: dementia
Doctors
Cholinesterase inhib - use: dementia
Begin @25-50% recommended dose - APAP may be dose-limiting

43. What are the vascular changes of presyncope?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers

44. ADR rf
#1 patient's last competent indication of wishes - substituted judgment - beneficence
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

45. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Parkinsonism -> l-DOPA
5% - underreported

46. BZD + antipsychotic: interaction outcome
Diagnosis - risk/benefit analysis to choose Rx
5% - underreported
Stress: #1 - functional - urge - overflow
Confusion - sedation - falls

47. What is the epidemiology of dizziness?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

48. How does ANF prevent syncope?
ANF: Na+ retention - disinhib vasoconstriction
Serum Cr: used for Cr clearance equation
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

49. vision changes: elderly
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Temporalis muscle wasting = temporal wasting

50. dementia tx
Insiduous onset
CVA: stroke - AMI: acute MI - HF
NMDR antagonist - use: dementia
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

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Aging Physiology And Pharmacology

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