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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 the narrative elements of clinical ethics?
Phenytoin
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Voice - character - plot - context - time - reader
Universal - progressive - partially encoded (genetic) - destructive -

2. How does ANF prevent syncope?
Phenytoin
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
ANF: Na+ retention - disinhib vasoconstriction
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine

3. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
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
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

4. osteoporosis etio
BMD (bone mineral density): T-score >2.5 std dev below normal 1
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

5. how is the CAM used to diagnose delirium?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Electrical: change in HR - structural: aortic outflow obstruction
Figure out a good diet - social aspect - resources - dental/oral comfort
28% - ADR: 17% - non-compliance 11%

6. How does aging affect Rx pharmacokinetic distribution?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Used to calculate renal fcn - clearance of Cr adjusted for age
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
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

7. Aging principles
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Respect for autonomy - nonmaleficence - beneficence - justice
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Hypothetical plan - serves as patient's last competent indicated wishes

8. urge incontinence tx
^K+
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

9. Syncope prognosis based on etio
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Hypotension - ^K+
Worse for cardiac causes v noncardia

10. clues of neglect
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Worse for cardiac causes v noncardia

11. what professional is least likely to report abuse?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Doctors
NMDR antagonist - use: dementia
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

12. How to prevent pressure ulcers?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Mechanical loading - skin care - avoid friction/shear
Cholinesterase inhib - use: dementia

13. What drugs can contribute to syncope?
A-blockers - B-blockers - TCA
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Cholinesterase inhib - use: dementia
Confusion - sedation - falls

14. What are the pharmacodynamic changes associated with aging?
Multisystemic vulnerability - -lowered reserves
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Receptors changes: # - sensitivity - counter-regulatory moa

15. What are the 4 forms of dizziness?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Injury - neglect - physical/psychosocial - financial - violation of rights
Vertigo - presyncope - disequilibrium - lightheadedness
Cholinesterase inhib - use: dementia

16. overflow incontinence tx
Diagnosis - risk/benefit analysis to choose Rx
CNS suppression -> cholinesterase inhibitors
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

17. opioid tx in elderly
Begin @25-50% recommended dose - APAP may be dose-limiting
Hypothetical plan - serves as patient's last competent indicated wishes
Hyperuricemia -> gout
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

18. preventing malnutrition
CNS suppression -> cholinesterase inhibitors
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Figure out a good diet - social aspect - resources - dental/oral comfort
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

19. vision changes: elderly
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Stress: #1 - functional - urge - overflow
ANF: Na+ retention - disinhib vasoconstriction

20. ADR rf
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
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
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

21. What are the 4 basic ethical principles?
Confusion - sedation - falls
Respect for autonomy - nonmaleficence - beneficence - justice
Screen for potentially embarrassing dx - patient/Dr trust
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

22. What are the 3 sentinel events for LT care?
Cholinesterase inhib - use: dementia
Pressure ulcer - fecal impaction - dehydration
P2-metab: Lorazepam - Trazepam - Oxazepam
Cachexia - PEM - FTT - obesity

23. delirium: mgmt
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

24. Cockcroft Gault equation
Serum Cr: used for Cr clearance equation
Universal - progressive - partially encoded (genetic) - destructive -
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

25. osteoporosis
Delayed absorption - like competitive inhib
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
BMD (bone mineral density): T-score >2.5 std dev below normal 1

26. ACE inhib + K+: interaction outcome
^morbidity + mortality - -frailest @ greatest risk
^K+
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

27. red flags for further inquiry
Used to calculate renal fcn - clearance of Cr adjusted for age
3 reflexes: baroreceptor - renal nerve - ANF
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
A-blockers - B-blockers - TCA

28. what normally prevents syncope?
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Pressure ulcer - fecal impaction - dehydration
Temporalis muscle wasting = temporal wasting
3 reflexes: baroreceptor - renal nerve - ANF

29. How does aging impact syncope-preventing reflexes
Isolated systolic HTN
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

30. How does aging affect pharmacokinetic Rx distribution?
>9 Rx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
>60yo - low abuse risk - ^ monitoring possible
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

31. how may hypertension compensate for aging?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
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
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

32. What are the hazards of elderly hospitalization?
Catch-all of unspecified dizziness
^morbidity + mortality - -frailest @ greatest risk
>60yo - low abuse risk - ^ monitoring possible
Voice - character - plot - context - time - reader

33. malignancy + atypical Sx
Electrical: change in HR - structural: aortic outflow obstruction
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Breast cancer + 2o LBP

34. frailty
Multisystemic vulnerability - -lowered reserves
A-blockers - B-blockers - TCA
Beers criteria - medication appropriateness index (12 ?)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

35. i2 + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Delayed absorption - like competitive inhib
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
^morbidity + mortality - -frailest @ greatest risk

36. How does renal nerve prevent syncope?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Consider responsibilities - drivin
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
28% - ADR: 17% - non-compliance 11%

37. metoclopramide may lead to what prescription cascade?
Electrolyte imbalance - arrhythmia
Make sure to discuss with patient - some states require reporting
Parkinsonism -> l-DOPA
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

38. What is a mattering map?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Map of people - perceptions - etc - varies by perspective
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

39. rule of doable effect
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Hypothetical plan - serves as patient's last competent indicated wishes
Make sure to discuss with patient - some states require reporting
P2-metab: Lorazepam - Trazepam - Oxazepam

40. pressure ulcer: staging
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Cholinesterase inhib - use: dementia

41. surrogate decision making heirarchy

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42. Aging descriptors
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
BMD (bone mineral density): T-score >2.5 std dev below normal 1
IdioPx - psychiatric: depression - anxiety - somatoform
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

43. incontinence epidemiology
>60yo - low abuse risk - ^ monitoring possible
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
1/2

44. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Bone loss -> osteopenia -> osteoporosis -> Fx
Make sure to discuss with patient - some states require reporting
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

45. tube feeding
Used to calculate renal fcn - clearance of Cr adjusted for age
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
Hypotension - ^K+

46. frailty signs
Hyperuricemia -> gout
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Voice - character - plot - context - time - reader
Catch-all of unspecified dizziness

47. incontinence complication
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
^K+
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

48. What is the Cockcroft Gault equation?
Used to calculate renal fcn - clearance of Cr adjusted for age
Prescribing - monitoring - patient adherence
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Hyperuricemia -> gout

49. advanced directive/care plan

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50. who is a good candidate for opioid tx?
^BP -> a-HTN
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
28% - ADR: 17% - non-compliance 11%
>60yo - low abuse risk - ^ monitoring possible