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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. ADR rf
Multisystemic vulnerability - -lowered reserves
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

2. How does the aging heart compensate for lower HR to maintain unchanged CO?
Consider responsibilities - drivin
^SV (diastolic stroke volume)
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Phenytoin

3. frailty
Multisystemic vulnerability - -lowered reserves
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Catch-all of unspecified dizziness
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

4. thyroid dx + atypical Sx
Mechanical loading - skin care - avoid friction/shear
A-blockers - B-blockers - TCA
NMDR antagonist - use: dementia
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

5. What is the bone deterioration cascade?
Bone loss -> osteopenia -> osteoporosis -> Fx
28% - ADR: 17% - non-compliance 11%
Confusion - sedation - falls
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

6. when selecting an P1-metabolite or P2-metabolite safer in elderly?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
P2-metabolite - phase 1 biotx much more affected than phase 2
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism

7. BZD + antidepressant: interaction outcome
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
A-blockers - B-blockers - TCA
Confusion - sedation - falls

8. how is syncope related to elderly admission to hospital?
Used to calculate renal fcn - clearance of Cr adjusted for age
Make sure to discuss with patient - some states require reporting
Parkinsonism -> l-DOPA
80% of hospital admission for syncope for >65yo

9. Alb-bound Rx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Phenytoin
^SV (diastolic stroke volume)
>9 Rx

10. osteoporosis
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
BMD (bone mineral density): T-score >2.5 std dev below normal 1
1/2
30% preventable - of these - 40% serious - of these 40% preventable

11. cachexia
Parkinsonism -> l-DOPA
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

12. what professional is least likely to report abuse?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Doctors
Multisystemic vulnerability - -lowered reserves
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

13. Aging features
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Universal - progressive - partially encoded (genetic) - destructive -
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment

14. vertigo
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
IdioPx - psychiatric: depression - anxiety - somatoform
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
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

15. how can you determine whether Rx is appropriate to use in elderly patient?
28% - ADR: 17% - non-compliance 11%
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Beers criteria - medication appropriateness index (12 ?)

16. How does ANF prevent syncope?
A-blockers - B-blockers - TCA
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Doctors
ANF: Na+ retention - disinhib vasoconstriction

17. What drugs can contribute to syncope?
Respect for autonomy - nonmaleficence - beneficence - justice
A-blockers - B-blockers - TCA
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding

18. What are the key points of safe prescription for elderly - lecture
>60yo - low abuse risk - ^ monitoring possible
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Diagnosis - risk/benefit analysis to choose Rx
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

19. metoclopramide may lead to what prescription cascade?
Parkinsonism -> l-DOPA
Begin @25-50% recommended dose - APAP may be dose-limiting
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Insiduous onset

20. What are the common causes of lightheadedness?
IdioPx - psychiatric: depression - anxiety - somatoform
NMDR antagonist - use: dementia
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
^BP -> a-HTN

21. osteopenia
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
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
ANF: Na+ retention - disinhib vasoconstriction
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

22. MI + atypical Sx
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
CVA: stroke - AMI: acute MI - HF
ANF: Na+ retention - disinhib vasoconstriction
No: chest pain - yes: fatigue - nausea - low functional status - SOB

23. How does aging affect Rx renal elimination?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
3 reflexes: baroreceptor - renal nerve - ANF

24. What is abuse?
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Figure out a good diet - social aspect - resources - dental/oral comfort
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Injury - neglect - physical/psychosocial - financial - violation of rights

25. depression + atypical Sx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Phenytoin

26. What is the preferred depression treatment in elderly?
Hypothetical plan - serves as patient's last competent indicated wishes
Therapy - SSRI
Serum Cr: used for Cr clearance equation
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

27. What are the pharmacodynamic changes associated with aging?
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Receptors changes: # - sensitivity - counter-regulatory moa
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

28. How does aging affect pharmacokinetics?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
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
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

29. How does aging affect pharmacokinetic protein binding?
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Appointed by court if no substituted judgment -conservator of finance -conservator of person

30. How does aging affect GI absorption rate of Rx?
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
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
Delayed absorption - like competitive inhib

31. BZD + antipsychotic: interaction outcome
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Confusion - sedation - falls
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
Hypotension - ^K+

32. osteoporosis epidemiology
Serum Cr: used for Cr clearance equation
Temporalis muscle wasting = temporal wasting
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
High mortality - esp + Fx - very common in elderly

33. What is sCr?
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Insiduous onset
Serum Cr: used for Cr clearance equation

34. incontinence epidemiology
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
F>M (until 80yo) - stress incontinence #1 - $26B/yr

35. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Breast cancer + 2o LBP
Multisystemic vulnerability - -lowered reserves
Tx underlying etio - + Kegels - pessary - surgery

36. surrogate decision making heirarchy

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37. what receptors increase sensitivity with aging?
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
P2-metabolite - phase 1 biotx much more affected than phase 2
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity

38. rivastigmine
^BP -> a-HTN
Diagnosis - risk/benefit analysis to choose Rx
Cholinesterase inhib - use: dementia
Worse for cardiac causes v noncardia

39. Cockcroft Gault equation
Serum Cr: used for Cr clearance equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
No: fever - leukocytosis - yes: falls - appetite change - low functional status

40. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Confusion - sedation - falls
Respect for autonomy - nonmaleficence - beneficence - justice
Tx underlying etio - + Kegels - pessary - surgery

41. what nutritional interventions help underweight?
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
30% preventable - of these - 40% serious - of these 40% preventable
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
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

42. delirium: medical rf
3 reflexes: baroreceptor - renal nerve - ANF
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
^SV (diastolic stroke volume)
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

43. fall causes
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
CNS suppression -> cholinesterase inhibitors
Tx underlying etio - + Kegels - pessary - surgery

44. What are rf for osteoporosis?
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Environment modification: obstacles - mobility - -bladder fcn ok
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

45. who is a good candidate for opioid tx?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
>60yo - low abuse risk - ^ monitoring possible
Map of people - perceptions - etc - varies by perspective

46. pulm edema + atypical Sx
Receptors changes: # - sensitivity - counter-regulatory moa
Electrical: change in HR - structural: aortic outflow obstruction
Insiduous onset
^BP -> a-HTN

47. what ADR are common in elderly patient?
Begin @25-50% recommended dose - APAP may be dose-limiting
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Bone loss -> osteopenia -> osteoporosis -> Fx
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

48. lipid-soluble Rx
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

49. How does renal nerve prevent syncope?
Electrical: change in HR - structural: aortic outflow obstruction
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

50. NSAID may lead to what prescription cascade?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
^BP -> a-HTN