Aging Physiology And Pharmacology

Instructions:

• Answer 50 questions in 15 minutes.
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• Match each statement with the correct term.
• Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

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. how is cachexia different from wasting?
Injury - neglect - physical/psychosocial - financial - violation of rights
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Legal: Cruzan v Hamon
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP


2. How does aging affect Rx renal elimination?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Threats/ terrorizing - isolation - denying food/privileges/liberty
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor


3. What are common scenarios of untreated indications in elderly?
Map of people - perceptions - etc - varies by perspective
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
IdioPx - psychiatric: depression - anxiety - somatoform
Pressure ulcer - fecal impaction - dehydration


4. delirium: Rx that contribute
Begin @25-50% recommended dose - APAP may be dose-limiting
Electrolyte imbalance - arrhythmia
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Breast cancer + 2o LBP


5. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
30% preventable - of these - 40% serious - of these 40% preventable
Worse for cardiac causes v noncardia


6. What is the Cockcroft Gault equation?
Treat underlying disease/lack resources
Used to calculate renal fcn - clearance of Cr adjusted for age
Threats/ terrorizing - isolation - denying food/privileges/liberty
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin


7. how is syncope related to elderly admission to hospital?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
80% of hospital admission for syncope for >65yo
No: fever - leukocytosis - yes: falls - appetite change - low functional status


8. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Hyperuricemia -> gout
Cholinesterase inhib - use: dementia
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
P2-metabolite - phase 1 biotx much more affected than phase 2


9. what drugs can cause dizziness?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Begin @25-50% recommended dose - APAP may be dose-limiting
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical


10. How does aging impact syncope-preventing reflexes
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Breast cancer + 2o LBP
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Prescribing - monitoring - patient adherence


11. How does aging affect pharmacokinetic protein binding?
Respect for autonomy - nonmaleficence - beneficence - justice
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Consider responsibilities - drivin
Hypotension - ^K+


12. osteoporosis epidemiology
Prescribing - monitoring - patient adherence
Screen for potentially embarrassing dx - patient/Dr trust
Electrical: change in HR - structural: aortic outflow obstruction
High mortality - esp + Fx - very common in elderly


13. How does aging increase incontinence?
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
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Confusion - sedation - falls


14. ACE inhib + diuretic: interaction outcome
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
^ANS tone -> ^periph vasoconstriction - ^HR
Voice - character - plot - context - time - reader
Hypotension - ^K+


15. falls epidemiology
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
#1 patient's last competent indication of wishes - substituted judgment - beneficence
1/2
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)


16. delirium: mgmt
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Consider responsibilities - drivin
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids


17. malnutrition
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Falls - delirium - malnutrition - P ulcers - opportunistic i2
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
High mortality - esp + Fx - very common in elderly


18. elderly abuse epidemiology
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Confusion - sedation - falls
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
5% - underreported


19. What is the preferred depression treatment in elderly?
Prescribing - monitoring - patient adherence
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
P2-metabolite - phase 1 biotx much more affected than phase 2
Therapy - SSRI


20. malignancy + atypical Sx
Breast cancer + 2o LBP
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
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


21. frailty signs
Cholinesterase inhib - use: dementia
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible


22. What are the risks of uncontrolled ISH?
Hypothetical plan - serves as patient's last competent indicated wishes
^SV (diastolic stroke volume)
CVA: stroke - AMI: acute MI - HF
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)


23. PEM
Phenytoin
Cholinesterase inhib - use: dementia
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
3 reflexes: baroreceptor - renal nerve - ANF


24. MRP: medication related problems
Hypothetical plan - serves as patient's last competent indicated wishes
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx


25. How does baroreceptor reflex prevent syncope?
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
^ANS tone -> ^periph vasoconstriction - ^HR
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Confusion - sedation - falls


26. How does aging affect Rx pharmacokinetic metabolism?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies


27. tube feeding
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness


28. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
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
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation


29. What is ISH?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Isolated systolic HTN
Threats/ terrorizing - isolation - denying food/privileges/liberty
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M


30. lipid-soluble Rx
Begin @25-50% recommended dose - APAP may be dose-limiting
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly


31. delirium diagnosis
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Bone loss -> osteopenia -> osteoporosis -> Fx
Serum Cr: used for Cr clearance equation


32. memantine
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
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
NMDR antagonist - use: dementia


33. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Respect for autonomy - nonmaleficence - beneficence - justice
Delayed absorption - like competitive inhib
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear


34. fall sequelae


35. anticholinergic drugs may lead to what prescription cascade?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Injury - neglect - physical/psychosocial - financial - violation of rights
Delayed absorption - like competitive inhib
CNS suppression -> cholinesterase inhibitors


36. How does aging affect GI absorption rate of Rx?
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
^morbidity + mortality - -frailest @ greatest risk
Delayed absorption - like competitive inhib
Therapy - SSRI


37. delirium: medical rf
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Confusion - sedation - falls
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction


38. how is the CAM used to diagnose delirium?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
F>M (until 80yo) - stress incontinence #1 - $26B/yr
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness


39. how can you determine whether Rx is appropriate to use in elderly patient?
Diagnosis - risk/benefit analysis to choose Rx
Beers criteria - medication appropriateness index (12 ?)
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Injury - neglect - physical/psychosocial - financial - violation of rights


40. galantamine
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
Respect for autonomy - nonmaleficence - beneficence - justice
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical


41. What is the epidemiology of dizziness?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Isolated systolic HTN


42. What are the pharmacodynamic changes associated with aging?
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Receptors changes: # - sensitivity - counter-regulatory moa
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment


43. Syncope prognosis based on etio
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
1/2
Diagnosis - risk/benefit analysis to choose Rx
Worse for cardiac causes v noncardia


44. What is abuse?
Hypotension - ^K+
Injury - neglect - physical/psychosocial - financial - violation of rights
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine


45. opioid tx in elderly
Bone loss -> osteopenia -> osteoporosis -> Fx
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Begin @25-50% recommended dose - APAP may be dose-limiting
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards


46. What are the vascular changes of presyncope?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
^ANS tone -> ^periph vasoconstriction - ^HR
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly


47. what receptors increase sensitivity with aging?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
P2-metabolite - phase 1 biotx much more affected than phase 2


48. what Rx are commonly monifoted in elderly for ADR?
^ANS tone -> ^periph vasoconstriction - ^HR
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Insiduous onset
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants


49. incontinence epidemiology
^morbidity + mortality - -frailest @ greatest risk
F>M (until 80yo) - stress incontinence #1 - $26B/yr
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants


50. What is the bone deterioration cascade?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
A-blockers - B-blockers - TCA
Bone loss -> osteopenia -> osteoporosis -> Fx