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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 illnesses are underreported in elderly?
3 reflexes: baroreceptor - renal nerve - ANF
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

2. pulm edema + atypical Sx
Map of people - perceptions - etc - varies by perspective
Insiduous onset
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 disease/lack resources

3. what professional is least likely to report abuse?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Doctors

4. Disequilibrium
Determined by Dr for a patient - -> used to determine competency
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

5. nutrition syndromes
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Begin @25-50% recommended dose - APAP may be dose-limiting
Cachexia - PEM - FTT - obesity
Catch-all of unspecified dizziness

6. osteoporosis
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Isolated systolic HTN
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

7. which benzodiazepines are most appropriate for 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
^K+
Hypotension - ^K+
P2-metab: Lorazepam - Trazepam - Oxazepam

8. refusing intervention
Universal - progressive - partially encoded (genetic) - destructive -
Legal: Cruzan v Hamon
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
#1 patient's last competent indication of wishes - substituted judgment - beneficence

9. What are common medical causes of syncope?
Treat underlying disease/lack resources
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 etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

10. vision changes: elderly
Multisystemic vulnerability - -lowered reserves
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Isolated systolic HTN
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

11. driving considerations
Make sure to discuss with patient - some states require reporting
IdioPx - psychiatric: depression - anxiety - somatoform
Electrical: change in HR - structural: aortic outflow obstruction
1/2

12. What are common scenarios of untreated indications in elderly?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Cholinesterase inhib - use: dementia
Make sure to discuss with patient - some states require reporting

13. How does an 80yo renal fcn compare to that of a 20yo?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Treat underlying disease/lack resources
1/2

14. how can you determine whether Rx is appropriate to use in elderly patient?
ANF: Na+ retention - disinhib vasoconstriction
Electrolyte imbalance - arrhythmia
Beers criteria - medication appropriateness index (12 ?)
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

15. fall sequelae

16. advanced directive/care plan

17. Aging descriptors
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
CNS suppression -> cholinesterase inhibitors
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

18. functional incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
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
BMD (bone mineral density): T-score >2.5 std dev below normal 1

19. What are the rf for elderly abuse?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Cholinesterase inhib - use: dementia

20. What are the 4 forms of dizziness?
^ANS tone -> ^periph vasoconstriction - ^HR
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Vertigo - presyncope - disequilibrium - lightheadedness

21. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Cholinesterase inhib - use: dementia
Tx underlying etio - + Kegels - pessary - surgery

22. What is the best approach to malnutrition
Treat underlying disease/lack resources
Cachexia - PEM - FTT - obesity
A-blockers - B-blockers - TCA
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

23. narcotics may lead to what prescription cascade?
Insiduous onset
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Constipation -> laxatives
Temporalis muscle wasting = temporal wasting

24. 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
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
A-blockers - B-blockers - TCA
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

25. thiazide diuretic may lead to what prescription cascade?
Hyperuricemia -> gout
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
^BP -> a-HTN
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

26. What are the 3 sentinel events for LT care?
>60yo - low abuse risk - ^ monitoring possible
Parkinsonism -> l-DOPA
Pressure ulcer - fecal impaction - dehydration
Temporalis muscle wasting = temporal wasting

27. how is syncope related to elderly admission to hospital?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Breast cancer + 2o LBP
80% of hospital admission for syncope for >65yo
Worse for cardiac causes v noncardia

28. What are the common causes of lightheadedness?
Treat underlying disease/lack resources
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
#1 patient's last competent indication of wishes - substituted judgment - beneficence
IdioPx - psychiatric: depression - anxiety - somatoform

29. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

30. what Rx are commonly monifoted in elderly for ADR?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
BMD (bone mineral density): T-score >2.5 std dev below normal 1
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

31. 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
Treat underlying disease/lack resources
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
5% - underreported

32. What are rf for osteoporosis?
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly

33. BZD + antidepressant: interaction outcome
Map of people - perceptions - etc - varies by perspective
Confusion - sedation - falls
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

34. delirium incidence
Beers criteria - medication appropriateness index (12 ?)
Breast cancer + 2o LBP
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

35. what % of hospitalizations of elderly are due to ADR + noncompliance?
28% - ADR: 17% - non-compliance 11%
Phenytoin
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

36. incontinence epidemiology
Mechanical loading - skin care - avoid friction/shear
^ANS tone -> ^periph vasoconstriction - ^HR
Phenytoin
F>M (until 80yo) - stress incontinence #1 - $26B/yr

37. delirium: medical rf
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
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)
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

38. fall causes
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

39. How does aging impact syncope-preventing reflexes
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Confusion - sedation - falls
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
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 rf for caregiver to abuse elderly?
Delayed absorption - like competitive inhib
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

41. osteoporosis etio
Delayed absorption - like competitive inhib
^SV (diastolic stroke volume)
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

42. ACE inhib + K+: interaction outcome
^K+
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
^BP -> a-HTN

43. using long-acting opioids in elderly
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Electrical: change in HR - structural: aortic outflow obstruction
Isolated systolic HTN

44. dementia tx
Hyperuricemia -> gout
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

45. How does aging affect pharmacokinetic Rx distribution?
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
>60yo - low abuse risk - ^ monitoring possible
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

46. What is the preferred depression treatment in elderly?
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Therapy - SSRI
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

47. What is abuse?
Vertigo - presyncope - disequilibrium - lightheadedness
Injury - neglect - physical/psychosocial - financial - violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Worse for cardiac causes v noncardia

48. what normally prevents syncope?
3 reflexes: baroreceptor - renal nerve - ANF
Cholinesterase inhib - use: dementia
Multisystemic vulnerability - -lowered reserves
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

49. Presyncope
Map of people - perceptions - etc - varies by perspective
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
^BP -> a-HTN
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

50. frailty raises vulnerability to...
Receptors changes: # - sensitivity - counter-regulatory moa
Beers criteria - medication appropriateness index (12 ?)
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Falls - delirium - malnutrition - P ulcers - opportunistic i2