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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. falls epidemiology
Injury - neglect - physical/psychosocial - financial - violation of rights
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport

2. What are the 3 sentinel events for LT care?
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
3 reflexes: baroreceptor - renal nerve - ANF
Pressure ulcer - fecal impaction - dehydration
Worse for cardiac causes v noncardia

3. urge incontinence tx
Environment modification: obstacles - mobility - -bladder fcn ok
P2-metab: Lorazepam - Trazepam - Oxazepam
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor

4. MI + atypical Sx
Confusion - sedation - falls
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Respect for autonomy - nonmaleficence - beneficence - justice
No: chest pain - yes: fatigue - nausea - low functional status - SOB

5. 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
30% preventable - of these - 40% serious - of these 40% preventable
#1 patient's last competent indication of wishes - substituted judgment - beneficence
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

6. Aging descriptors
IdioPx - psychiatric: depression - anxiety - somatoform
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Stress: #1 - functional - urge - overflow
Breast cancer + 2o LBP

7. refusing intervention
Doctors
Legal: Cruzan v Hamon
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

8. What are rf for osteoporosis?
Cholinesterase inhib - use: dementia
Make sure to discuss with patient - some states require reporting
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
80% of hospital admission for syncope for >65yo

9. how is syncope related to elderly admission to hospital?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
80% of hospital admission for syncope for >65yo
No: fever - leukocytosis - yes: falls - appetite change - low functional status

10. NSAID may lead to what prescription cascade?
80% of hospital admission for syncope for >65yo
Make sure to discuss with patient - some states require reporting
^BP -> a-HTN
Hyperuricemia -> gout

11. incontinence complication
3 reflexes: baroreceptor - renal nerve - ANF
80% of hospital admission for syncope for >65yo
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

12. What are the rf for caregiver to abuse elderly?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Electrical: change in HR - structural: aortic outflow obstruction
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

13. What are the possible cardiac causes of presyncope?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
Electrical: change in HR - structural: aortic outflow obstruction

14. Why is abuse underreported?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
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
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Falls - delirium - malnutrition - P ulcers - opportunistic i2

15. How does sliding scale glycemic control relate to elderly?
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Make sure to discuss with patient - some states require reporting
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead

16. narcotics may lead to what prescription cascade?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Stress: #1 - functional - urge - overflow
Constipation -> laxatives
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

17. What are the 4 forms of dizziness?
Vertigo - presyncope - disequilibrium - lightheadedness
Serum Cr: used for Cr clearance equation
1/2
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

18. What is the bone deterioration cascade?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Bone loss -> osteopenia -> osteoporosis -> Fx

19. frailty raises vulnerability to...
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
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
Falls - delirium - malnutrition - P ulcers - opportunistic i2

20. Aging principles
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Hypotension - ^K+
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Temporalis muscle wasting = temporal wasting

21. How does aging affect GI absorption rate of Rx?
Diagnosis - risk/benefit analysis to choose Rx
Beers criteria - medication appropriateness index (12 ?)
Delayed absorption - like competitive inhib
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

22. What are the narrative elements of clinical ethics?
A-blockers - B-blockers - TCA
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Consider responsibilities - drivin
Voice - character - plot - context - time - reader

23. What is START criteria?
A-blockers - B-blockers - TCA
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

24. How does aging affect pharmacokinetic protein binding?
^SV (diastolic stroke volume)
Environment modification: obstacles - mobility - -bladder fcn ok
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
28% - ADR: 17% - non-compliance 11%

25. Beers criteria: what 10 Rx should elderly avoid or use + caution?
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Treat underlying disease/lack resources
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

26. What is the epidemiology of dizziness?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Hypotension - ^K+

27. delirium: tx approach
^ANS tone -> ^periph vasoconstriction - ^HR
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
P2-metab: Lorazepam - Trazepam - Oxazepam
>60yo - low abuse risk - ^ monitoring possible

28. incontinence epidemiology
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Serum Cr: used for Cr clearance equation
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
F>M (until 80yo) - stress incontinence #1 - $26B/yr

29. metoclopramide may lead to what prescription cascade?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Screen for potentially embarrassing dx - patient/Dr trust
>60yo - low abuse risk - ^ monitoring possible
Parkinsonism -> l-DOPA

30. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Electrolyte imbalance - arrhythmia
IdioPx - psychiatric: depression - anxiety - somatoform
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

31. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
28% - ADR: 17% - non-compliance 11%
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

32. delirium: Rx that contribute
Temporalis muscle wasting = temporal wasting
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Injury - neglect - physical/psychosocial - financial - violation of rights
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

33. delirium: medical rf
Falls - delirium - malnutrition - P ulcers - opportunistic i2
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear

34. 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
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
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
Doctors

35. What are the 3 stages of ADRs?
Prescribing - monitoring - patient adherence
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

36. What is ISH?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Isolated systolic HTN
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

37. dementia tx
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Make sure to discuss with patient - some states require reporting

38. ACE inhib + diuretic: interaction outcome
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Hypotension - ^K+
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

39. 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
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Screen for potentially embarrassing dx - patient/Dr trust
Confusion - sedation - falls

40. Approach to idioPx - recurrent syncope
F>M (until 80yo) - stress incontinence #1 - $26B/yr
80% of hospital admission for syncope for >65yo
Consider responsibilities - drivin
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

41. How does an 80yo renal fcn compare to that of a 20yo?
Hypothetical plan - serves as patient's last competent indicated wishes
NMDR antagonist - use: dementia
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
1/2

42. how may hypertension compensate for aging?
5% - underreported
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
^SV (diastolic stroke volume)
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

43. What are the rf for elderly abuse?
Vertigo - presyncope - disequilibrium - lightheadedness
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

44. frailty signs
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Doctors

45. memantine
Cholinesterase inhib - use: dementia
NMDR antagonist - use: dementia
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
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

46. opioid tx in elderly
CVA: stroke - AMI: acute MI - HF
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Begin @25-50% recommended dose - APAP may be dose-limiting
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

47. thiazide diuretic may lead to what prescription cascade?
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Map of people - perceptions - etc - varies by perspective
Hyperuricemia -> gout
No: fever - leukocytosis - yes: falls - appetite change - low functional status

48. Disequilibrium
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Universal - progressive - partially encoded (genetic) - destructive -
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
80% of hospital admission for syncope for >65yo

49. driving considerations
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Make sure to discuss with patient - some states require reporting
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

50. physical neglect
Figure out a good diet - social aspect - resources - dental/oral comfort
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead