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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. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Legal: Cruzan v Hamon
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Pressure ulcer - fecal impaction - dehydration

2. frailty signs
Breast cancer + 2o LBP
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
A-blockers - B-blockers - TCA
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

3. fall sequelae

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4. nutrition syndromes
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Cachexia - PEM - FTT - obesity

5. narcotics may lead to what prescription cascade?
Constipation -> laxatives
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
3 reflexes: baroreceptor - renal nerve - ANF
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction

6. anticholinergic drugs may lead to what prescription cascade?
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
CNS suppression -> cholinesterase inhibitors
28% - ADR: 17% - non-compliance 11%

7. How does aging affect GI absorption rate of Rx?
A-blockers - B-blockers - TCA
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
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
Delayed absorption - like competitive inhib

8. What is a PE sign of cachexia?
Determined by Dr for a patient - -> used to determine competency
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Temporalis muscle wasting = temporal wasting
5% - underreported

9. what mechanical loading helps to prevent pressure ulcers?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Cholinesterase inhib - use: dementia
NMDR antagonist - use: dementia

10. galantamine
>9 Rx
Cholinesterase inhib - use: dementia
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

11. How does aging affect Rx renal elimination?
Insiduous onset
Begin @25-50% recommended dose - APAP may be dose-limiting
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

12. restrain requirements
ANF: Na+ retention - disinhib vasoconstriction
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Hyperuricemia -> gout
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

13. Beers criteria
Cholinesterase inhib - use: dementia
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
Phenytoin
>9 Rx

14. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Respect for autonomy - nonmaleficence - beneficence - justice
A-blockers - B-blockers - TCA

15. pulm edema + atypical Sx
CNS suppression -> cholinesterase inhibitors
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Insiduous onset
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

16. What are the 4 forms of dizziness?
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
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
Vertigo - presyncope - disequilibrium - lightheadedness

17. how can you determine whether Rx is appropriate to use in elderly patient?
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Beers criteria - medication appropriateness index (12 ?)

18. frailty
P2-metabolite - phase 1 biotx much more affected than phase 2
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Multisystemic vulnerability - -lowered reserves
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

19. rivastigmine
Cholinesterase inhib - use: dementia
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Threats/ terrorizing - isolation - denying food/privileges/liberty

20. What are common physical abuse Sx in elderly?
Cholinesterase inhib - use: dementia
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Treat underlying disease/lack resources
Map of people - perceptions - etc - varies by perspective

21. describe the % of ADR considered preventable - and of those serious
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Confusion - sedation - falls
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
30% preventable - of these - 40% serious - of these 40% preventable

22. how is cachexia different from wasting?
Consider responsibilities - drivin
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Therapy - SSRI

23. elderly abuse epidemiology
Pressure ulcer - fecal impaction - dehydration
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
5% - underreported

24. urinary incontinence types
Stress: #1 - functional - urge - overflow
Catch-all of unspecified dizziness
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Used to calculate renal fcn - clearance of Cr adjusted for age

25. MRP: medication related problems
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Respect for autonomy - nonmaleficence - beneficence - justice
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

26. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
No: chest pain - yes: fatigue - nausea - low functional status - SOB

27. delirium: mgmt
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Environment modification: obstacles - mobility - -bladder fcn ok
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

28. What are the possible cardiac causes of presyncope?
Used to calculate renal fcn - clearance of Cr adjusted for age
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Electrical: change in HR - structural: aortic outflow obstruction
Universal - progressive - partially encoded (genetic) - destructive -

29. surrogate decision making heirarchy

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30. driving considerations
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Make sure to discuss with patient - some states require reporting
Consider responsibilities - drivin
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

31. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Tx underlying etio - + Kegels - pessary - surgery

32. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
>9 Rx
Injury - neglect - physical/psychosocial - financial - violation of rights
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

33. What is the epidemiology of dizziness?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
CVA: stroke - AMI: acute MI - HF
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

34. Presyncope
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Tx underlying etio - + Kegels - pessary - surgery
5% - underreported

35. cachexia
Stress: #1 - functional - urge - overflow
Phenytoin
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

36. 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
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Breast cancer + 2o LBP
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

37. osteoporosis
CVA: stroke - AMI: acute MI - HF
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

38. malnutrition
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Voice - character - plot - context - time - reader
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

39. thiazide diuretic may lead to what prescription cascade?
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Hyperuricemia -> gout
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
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

40. What are the vascular changes of presyncope?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Serum Cr: used for Cr clearance equation
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

41. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Delayed absorption - like competitive inhib
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
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

42. what drugs can cause dizziness?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
5% - underreported
^morbidity + mortality - -frailest @ greatest risk
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

43. vertigo
Worse for cardiac causes v noncardia
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Electrical: change in HR - structural: aortic outflow obstruction
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

44. What is START criteria?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Respect for autonomy - nonmaleficence - beneficence - justice
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

45. MI + atypical Sx
No: chest pain - yes: fatigue - nausea - low functional status - SOB
^BP -> a-HTN
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Map of people - perceptions - etc - varies by perspective

46. incontinence epidemiology
Electrolyte imbalance - arrhythmia
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Vertigo - presyncope - disequilibrium - lightheadedness

47. what nutritional interventions help underweight?
Map of people - perceptions - etc - varies by perspective
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

48. what receptors increase sensitivity with aging?
80% of hospital admission for syncope for >65yo
Screen for potentially embarrassing dx - patient/Dr trust
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
High mortality - esp + Fx - very common in elderly

49. How does baroreceptor reflex prevent syncope?
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
ANF: Na+ retention - disinhib vasoconstriction
^ANS tone -> ^periph vasoconstriction - ^HR

50. What are the key points of safe prescription for elderly - lecture
Figure out a good diet - social aspect - resources - dental/oral comfort
Isolated systolic HTN
Diagnosis - risk/benefit analysis to choose Rx
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR