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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. lightheadedness
Electrolyte imbalance - arrhythmia
Catch-all of unspecified dizziness
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Hypothetical plan - serves as patient's last competent indicated wishes

2. what Rx are commonly monifoted in elderly for ADR?
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Phenytoin

3. delirium: medical rf
Confusion - sedation - falls
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids

4. How does aging increase incontinence?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Phenytoin
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

5. What is the epidemiology of dizziness?
Serum Cr: used for Cr clearance equation
IdioPx - psychiatric: depression - anxiety - somatoform
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Environment modification: obstacles - mobility - -bladder fcn ok

6. malnutrition
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Breast cancer + 2o LBP
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

7. BZD + antidepressant: interaction outcome
Receptors changes: # - sensitivity - counter-regulatory moa
Confusion - sedation - falls
Screen for potentially embarrassing dx - patient/Dr trust
30% preventable - of these - 40% serious - of these 40% preventable

8. What is polypharmacy
>9 Rx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Figure out a good diet - social aspect - resources - dental/oral comfort
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

9. what professional is least likely to report abuse?
Insiduous onset
Doctors
F>M (until 80yo) - stress incontinence #1 - $26B/yr
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

10. cachexia
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Phenytoin
Pressure ulcer - fecal impaction - dehydration

11. What is the best approach to malnutrition
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Treat underlying disease/lack resources

12. frailty
Diagnosis - risk/benefit analysis to choose Rx
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Cholinesterase inhib - use: dementia
Multisystemic vulnerability - -lowered reserves

13. Aging principles
Prescribing - monitoring - patient adherence
Treat underlying disease/lack resources
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
5% - underreported

14. refusing intervention
Legal: Cruzan v Hamon
Begin @25-50% recommended dose - APAP may be dose-limiting
Used to calculate renal fcn - clearance of Cr adjusted for age
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

15. What are the narrative elements of clinical ethics?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Voice - character - plot - context - time - reader
A-blockers - B-blockers - TCA

16. How does renal nerve prevent syncope?
Hypotension - ^K+
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Determined by Dr for a patient - -> used to determine competency

17. incontinence complication
Appointed by court if no substituted judgment -conservator of finance -conservator of person
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

18. rule of doable effect
CNS suppression -> cholinesterase inhibitors
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
F>M (until 80yo) - stress incontinence #1 - $26B/yr
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

19. pressure ulcer: staging
NMDR antagonist - use: dementia
Cholinesterase inhib - use: dementia
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

20. How does the aging heart compensate for lower HR to maintain unchanged CO?
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Beers criteria - medication appropriateness index (12 ?)
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
^SV (diastolic stroke volume)

21. advanced directive/care plan

22. what can enhance reporting in elderly?
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Screen for potentially embarrassing dx - patient/Dr trust
Hypothetical plan - serves as patient's last competent indicated wishes
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

23. red flags for further inquiry
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
F>M (until 80yo) - stress incontinence #1 - $26B/yr
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

24. metoclopramide may lead to what prescription cascade?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Parkinsonism -> l-DOPA

25. What is abuse?
ANF: Na+ retention - disinhib vasoconstriction
Mechanical loading - skin care - avoid friction/shear
Injury - neglect - physical/psychosocial - financial - violation of rights
NMDR antagonist - use: dementia

26. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

27. How does aging affect GI absorption of Rx?
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Catch-all of unspecified dizziness
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

28. BZD + antipsychotic: interaction outcome
Confusion - sedation - falls
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Delayed absorption - like competitive inhib
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

29. opioid tx in elderly
80% of hospital admission for syncope for >65yo
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Diagnosis - risk/benefit analysis to choose Rx
Begin @25-50% recommended dose - APAP may be dose-limiting

30. what drugs can cause dizziness?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation

31. how is the CAM used to diagnose delirium?
Voice - character - plot - context - time - reader
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
30% preventable - of these - 40% serious - of these 40% preventable

32. pulm edema + atypical Sx
Electrical: change in HR - structural: aortic outflow obstruction
Insiduous onset
Used to calculate renal fcn - clearance of Cr adjusted for age
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

33. What are the risks of uncontrolled ISH?
CVA: stroke - AMI: acute MI - HF
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
1/2

34. osteoporosis
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Phenytoin
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

35. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
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
Phenytoin

36. urge incontinence tx
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
^K+
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

37. what mechanical loading helps to prevent pressure ulcers?
Worse for cardiac causes v noncardia
3 reflexes: baroreceptor - renal nerve - ANF
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

38. How does aging affect Rx pharmacokinetic metabolism?
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Environment modification: obstacles - mobility - -bladder fcn ok
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Respect for autonomy - nonmaleficence - beneficence - justice

39. What is START criteria?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
NMDR antagonist - 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
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

40. delirium incidence
Breast cancer + 2o LBP
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Electrolyte imbalance - arrhythmia

41. rivastigmine
Hypothetical plan - serves as patient's last competent indicated wishes
Cholinesterase inhib - use: dementia
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Hypotension - ^K+

42. Beers criteria
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Confusion - sedation - falls
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

43. dementia tx
Vertigo - presyncope - disequilibrium - lightheadedness
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Receptors changes: # - sensitivity - counter-regulatory moa

44. What are the common types of elder mistreatment?
Consider responsibilities - drivin
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Screen for potentially embarrassing dx - patient/Dr trust
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

45. anticholinergic drugs may lead to what prescription cascade?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Respect for autonomy - nonmaleficence - beneficence - justice
CNS suppression -> cholinesterase inhibitors
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

46. driving considerations
Environment modification: obstacles - mobility - -bladder fcn ok
Make sure to discuss with patient - some states require reporting
>9 Rx
>60yo - low abuse risk - ^ monitoring possible

47. antiarrhythmic + diuretic: interaction outcome
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Electrolyte imbalance - arrhythmia
Cholinesterase inhib - use: dementia
Confusion - sedation - falls

48. Why is abuse underreported?
Temporalis muscle wasting = temporal wasting
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

49. What is the bone deterioration cascade?
Voice - character - plot - context - time - reader
Legal: Cruzan v Hamon
Bone loss -> osteopenia -> osteoporosis -> Fx
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx

50. Beers criteria: what 10 Rx should elderly avoid or use + caution?
Mechanical loading - skin care - avoid friction/shear
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Doctors
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen