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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 rf for osteoporosis?
Universal - progressive - partially encoded (genetic) - destructive -
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

2. fall causes
Confusion - sedation - falls
Bone loss -> osteopenia -> osteoporosis -> Fx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
BMD (bone mineral density): T-score >2.5 std dev below normal 1

3. Approach to idioPx - recurrent syncope
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Consider responsibilities - drivin
Cholinesterase inhib - use: dementia

4. what illnesses are underreported in elderly?
Threats/ terrorizing - isolation - denying food/privileges/liberty
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

5. How does the aging heart compensate for lower HR to maintain unchanged CO?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
ANF: Na+ retention - disinhib vasoconstriction
^K+
^SV (diastolic stroke volume)

6. elderly abuse epidemiology
5% - underreported
Bone loss -> osteopenia -> osteoporosis -> Fx
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

7. vision changes: elderly
Cholinesterase inhib - use: dementia
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
ANF: Na+ retention - disinhib vasoconstriction
Vertigo - presyncope - disequilibrium - lightheadedness

8. cachexia
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

9. NSAID may lead to what prescription cascade?
^BP -> a-HTN
80% of hospital admission for syncope for >65yo
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Cholinesterase inhib - use: dementia

10. What are the common causes of lightheadedness?
Cachexia - PEM - FTT - obesity
Insiduous onset
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
IdioPx - psychiatric: depression - anxiety - somatoform

11. donepezil
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Cholinesterase inhib - use: dementia
Threats/ terrorizing - isolation - denying food/privileges/liberty
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

12. What is a mattering map?
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Map of people - perceptions - etc - varies by perspective
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
1/2

13. Disequilibrium
Hypothetical plan - serves as patient's last competent indicated wishes
Make sure to discuss with patient - some states require reporting
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

14. What is the bone deterioration cascade?
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
Receptors changes: # - sensitivity - counter-regulatory moa
Bone loss -> osteopenia -> osteoporosis -> Fx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

15. who is a good candidate for opioid tx?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
>60yo - low abuse risk - ^ monitoring possible
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Tx underlying etio - + Kegels - pessary - surgery

16. substituted judgment
Used to calculate renal fcn - clearance of Cr adjusted for age
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

17. overflow incontinence tx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Universal - progressive - partially encoded (genetic) - destructive -
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

18. what % of hospitalizations of elderly are due to ADR + noncompliance?
3 reflexes: baroreceptor - renal nerve - ANF
Universal - progressive - partially encoded (genetic) - destructive -
28% - ADR: 17% - non-compliance 11%
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

19. surrogate decision making heirarchy
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Legal: Cruzan v Hamon
#1 patient's last competent indication of wishes - substituted judgment - beneficence

20. How does renal nerve prevent syncope?
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Universal - progressive - partially encoded (genetic) - destructive -
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

21. How does sliding scale glycemic control relate to elderly?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Treat underlying disease/lack resources
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

22. What are the narrative elements of clinical ethics?
Voice - character - plot - context - time - reader
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

23. malnutrition
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Cholinesterase inhib - use: dementia
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

24. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
Pressure ulcer - fecal impaction - dehydration
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

25. What is the natural history of syncope?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Screen for potentially embarrassing dx - patient/Dr trust
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

26. which benzodiazepines are most appropriate for elderly?
P2-metab: Lorazepam - Trazepam - Oxazepam
^morbidity + mortality - -frailest @ greatest risk
Catch-all of unspecified dizziness
Constipation -> laxatives

27. What is the preferred depression treatment in elderly?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Figure out a good diet - social aspect - resources - dental/oral comfort
Therapy - SSRI

28. what professional is least likely to report abuse?
Doctors
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
CVA: stroke - AMI: acute MI - HF
Worse for cardiac causes v noncardia

29. What is sCr?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Determined by Dr for a patient - -> used to determine competency
Serum Cr: used for Cr clearance equation
Diagnosis - risk/benefit analysis to choose Rx

30. 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
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Treat underlying disease/lack resources
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

31. how can you determine whether Rx is appropriate to use in elderly patient?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Beers criteria - medication appropriateness index (12 ?)

32. thyroid dx + atypical Sx
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

33. What are common scenarios of untreated indications in elderly?
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
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
>9 Rx

34. frailty raises vulnerability to...
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Electrolyte imbalance - arrhythmia

35. using long-acting opioids in 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
Respect for autonomy - nonmaleficence - beneficence - justice
Pressure ulcer - fecal impaction - dehydration

36. delirium diagnosis
Electrolyte imbalance - arrhythmia
Delayed absorption - like competitive inhib
80% of hospital admission for syncope for >65yo
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

37. Beers criteria
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
Figure out a good diet - social aspect - resources - dental/oral comfort
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope

38. depression + atypical Sx
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
>9 Rx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

39. describe the % of ADR considered preventable - and of those serious
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
80% of hospital admission for syncope for >65yo
30% preventable - of these - 40% serious - of these 40% preventable
Voice - character - plot - context - time - reader

40. What are the pharmacodynamic changes associated with aging?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Receptors changes: # - sensitivity - counter-regulatory moa
Diagnosis - risk/benefit analysis to choose Rx
Appointed by court if no substituted judgment -conservator of finance -conservator of person

41. functional incontinence tx
Confusion - sedation - falls
Bone loss -> osteopenia -> osteoporosis -> Fx
Environment modification: obstacles - mobility - -bladder fcn ok
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

42. ADR rf
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Delayed absorption - like competitive inhib
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Receptors changes: # - sensitivity - counter-regulatory moa

43. frailty
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Multisystemic vulnerability - -lowered reserves
Respect for autonomy - nonmaleficence - beneficence - justice
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD

44. Presyncope
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Phenytoin
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

45. What is abuse?
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Injury - neglect - physical/psychosocial - financial - violation of rights
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
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

46. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Cholinesterase inhib - use: dementia
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Delayed absorption - like competitive inhib

47. rule of doable effect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
ANF: Na+ retention - disinhib vasoconstriction

48. osteoporosis
Prescribing - monitoring - patient adherence
Appointed by court if no substituted judgment -conservator of finance -conservator of person
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Hypotension - ^K+

49. rivastigmine
Cholinesterase inhib - use: dementia
Respect for autonomy - nonmaleficence - beneficence - justice
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

50. What are the vascular changes of presyncope?
Serum Cr: used for Cr clearance equation
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
5% - underreported

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