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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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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. frailty
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Insiduous onset
Multisystemic vulnerability - -lowered reserves
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

2. How does aging affect GI absorption rate of Rx?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Mechanical loading - skin care - avoid friction/shear
Confusion - sedation - falls
Delayed absorption - like competitive inhib

3. incontinence complication
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Parkinsonism -> l-DOPA

4. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Delayed absorption - like competitive inhib
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
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

5. What is polypharmacy
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Receptors changes: # - sensitivity - counter-regulatory moa
>9 Rx
No: chest pain - yes: fatigue - nausea - low functional status - SOB

6. What are common scenarios of untreated indications in elderly?
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Parkinsonism -> l-DOPA

7. opioid tx in elderly
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Bone loss -> osteopenia -> osteoporosis -> Fx
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Begin @25-50% recommended dose - APAP may be dose-limiting

8. advanced directive/care plan

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9. What are the possible cardiac causes of presyncope?
Begin @25-50% recommended dose - APAP may be dose-limiting
Electrical: change in HR - structural: aortic outflow obstruction
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

10. lightheadedness
Catch-all of unspecified dizziness
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 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

11. BZD + antidepressant: interaction outcome
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
5% - underreported
Confusion - sedation - falls

12. surrogate decision making heirarchy

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13. what Rx are commonly monifoted in elderly for ADR?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Cholinesterase inhib - use: dementia

14. What are the narrative elements of clinical ethics?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Map of people - perceptions - etc - varies by perspective
Voice - character - plot - context - time - reader

15. osteoporosis epidemiology
High mortality - esp + Fx - very common in elderly
P2-metabolite - phase 1 biotx much more affected than phase 2
P2-metab: Lorazepam - Trazepam - Oxazepam
Parkinsonism -> l-DOPA

16. how is syncope related to elderly admission to hospital?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
80% of hospital admission for syncope for >65yo

17. delirium: mgmt
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
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Legal: Cruzan v Hamon

18. MI + atypical Sx
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Delayed absorption - like competitive inhib
Confusion - sedation - falls
No: chest pain - yes: fatigue - nausea - low functional status - SOB

19. What is the bone deterioration cascade?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Bone loss -> osteopenia -> osteoporosis -> Fx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

20. How does aging affect GI absorption of Rx?
Cholinesterase inhib - use: dementia
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
1/2
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

21. What are the rf for elderly abuse?
Isolated systolic HTN
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
80% of hospital admission for syncope for >65yo
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

22. How to prevent pressure ulcers?
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Bone loss -> osteopenia -> osteoporosis -> Fx
Used to calculate renal fcn - clearance of Cr adjusted for age
Mechanical loading - skin care - avoid friction/shear

23. i2 + atypical Sx
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
>60yo - low abuse risk - ^ monitoring possible
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
No: fever - leukocytosis - yes: falls - appetite change - low functional status

24. osteopenia
30% preventable - of these - 40% serious - of these 40% preventable
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Isolated systolic HTN

25. How does an 80yo renal fcn compare to that of a 20yo?
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Breast cancer + 2o LBP
1/2
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

26. What is the STOPP criteria?
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
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
Insiduous onset
Electrolyte imbalance - arrhythmia

27. dementia tx
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Screen for potentially embarrassing dx - patient/Dr trust

28. fall causes
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Figure out a good diet - social aspect - resources - dental/oral comfort

29. antiarrhythmic + diuretic: interaction outcome
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Temporalis muscle wasting = temporal wasting
Electrolyte imbalance - arrhythmia
CVA: stroke - AMI: acute MI - HF

30. narcotics may lead to what prescription cascade?
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Constipation -> laxatives
Hypothetical plan - serves as patient's last competent indicated wishes

31. donepezil
Confusion - sedation - falls
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Cholinesterase inhib - use: dementia
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

32. LBW equation
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
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Vertigo - presyncope - disequilibrium - lightheadedness
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)

33. falls epidemiology
Legal: Cruzan v Hamon
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

34. What are the hazards of elderly hospitalization?
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
3 reflexes: baroreceptor - renal nerve - ANF
^morbidity + mortality - -frailest @ greatest risk

35. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Delayed absorption - like competitive inhib
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted

36. anticholinergic drugs may lead to what prescription cascade?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Doctors
P2-metab: Lorazepam - Trazepam - Oxazepam
CNS suppression -> cholinesterase inhibitors

37. what % of hospitalizations of elderly are due to ADR + noncompliance?
Constipation -> laxatives
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
28% - ADR: 17% - non-compliance 11%

38. Aging descriptors
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Tx underlying etio - + Kegels - pessary - surgery

39. metoclopramide may lead to what prescription cascade?
Consider responsibilities - drivin
Parkinsonism -> l-DOPA
Used to calculate renal fcn - clearance of Cr adjusted for age
Map of people - perceptions - etc - varies by perspective

40. documenting elderly abuse

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41. which benzodiazepines are most appropriate for elderly?
Cholinesterase inhib - use: dementia
P2-metab: Lorazepam - Trazepam - Oxazepam
Worse for cardiac causes v noncardia
Screen for potentially embarrassing dx - patient/Dr trust

42. ADR rf
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

43. elderly abuse epidemiology
5% - underreported
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Vertigo - presyncope - disequilibrium - lightheadedness

44. what receptors increase sensitivity with aging?
IdioPx - psychiatric: depression - anxiety - somatoform
^morbidity + mortality - -frailest @ greatest risk
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
P2-metab: Lorazepam - Trazepam - Oxazepam

45. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
F>M (until 80yo) - stress incontinence #1 - $26B/yr
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
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

46. ACE inhib + K+: interaction outcome
^K+
No: fever - leukocytosis - yes: falls - appetite change - low functional status
^SV (diastolic stroke volume)
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

47. urge incontinence tx
Respect for autonomy - nonmaleficence - beneficence - justice
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Map of people - perceptions - etc - varies by perspective
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

48. thiazide diuretic may lead to what prescription cascade?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Hyperuricemia -> gout

49. delirium incidence
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Cachexia - PEM - FTT - obesity
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

50. 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
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Worse for cardiac causes v noncardia
Electrolyte imbalance - arrhythmia