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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 are the vascular changes of presyncope?
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
Cholinesterase inhib - use: dementia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
Falls - delirium - malnutrition - P ulcers - opportunistic i2

2. How does the aging heart compensate for lower HR to maintain unchanged CO?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
^SV (diastolic stroke volume)
No: chest pain - yes: fatigue - nausea - low functional status - SOB

3. substituted judgment
Determined by Dr for a patient - -> used to determine competency
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
1/2
Falls - delirium - malnutrition - P ulcers - opportunistic i2

4. urinary incontinence types
Stress: #1 - functional - urge - overflow
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

5. rivastigmine
Cholinesterase inhib - use: dementia
^BP -> a-HTN
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait

6. BZD + antidepressant: interaction outcome
Confusion - sedation - falls
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
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
Parkinsonism -> l-DOPA

7. How does aging increase incontinence?
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
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
^BP -> a-HTN
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

8. surrogate decision making heirarchy

9. physical neglect
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
1/2
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

10. how is the CAM used to diagnose delirium?
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
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness

11. How does aging impact syncope-preventing reflexes
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
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
#1 patient's last competent indication of wishes - substituted judgment - beneficence

12. How does aging affect GI absorption of Rx?
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
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

13. Alb-bound Rx
Universal - progressive - partially encoded (genetic) - destructive -
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Phenytoin

14. fall causes
30% preventable - of these - 40% serious - of these 40% preventable
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Bone loss -> osteopenia -> osteoporosis -> Fx
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

15. Approach to idioPx - recurrent syncope
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Consider responsibilities - drivin
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

16. preventing malnutrition
Pressure ulcer - fecal impaction - dehydration
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Figure out a good diet - social aspect - resources - dental/oral comfort
^BP -> a-HTN

17. incontinence complication
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
Isolated systolic HTN
Therapy - SSRI

18. What is sCr?
Serum Cr: used for Cr clearance equation
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
P2-metab: Lorazepam - Trazepam - Oxazepam
Begin @25-50% recommended dose - APAP may be dose-limiting

19. delirium diagnosis
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec

20. What is the Cockcroft Gault equation?
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
Used to calculate renal fcn - clearance of Cr adjusted for age
Cachexia - PEM - FTT - obesity
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

21. delirium: medical rf
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Make sure to discuss with patient - some states require reporting
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Used to calculate renal fcn - clearance of Cr adjusted for age

22. what normally prevents syncope?
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
3 reflexes: baroreceptor - renal nerve - ANF
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids

23. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Vertigo - presyncope - disequilibrium - lightheadedness
1/2
P2-metab: Lorazepam - Trazepam - Oxazepam

24. how may hypertension compensate for aging?
Pressure ulcer - fecal impaction - dehydration
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Worse for cardiac causes v noncardia
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

25. antiarrhythmic + diuretic: interaction outcome
Electrolyte imbalance - arrhythmia
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
BMD (bone mineral density): T-score >2.5 std dev below normal 1

26. how can you determine whether Rx is appropriate to use in elderly patient?
Beers criteria - medication appropriateness index (12 ?)
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Determined by Dr for a patient - -> used to determine competency

27. What are the 4 forms of 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
Used to calculate renal fcn - clearance of Cr adjusted for age
Doctors
Vertigo - presyncope - disequilibrium - lightheadedness

28. Aging descriptors
Normal: progressive - universal - usual: normal + common dx (CAD) - successful: preserved fcn wo morbidity
Therapy - SSRI
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
>9 Rx

29. PEM
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Mechanical loading - skin care - avoid friction/shear
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Electrolyte imbalance - arrhythmia

30. How does aging affect GI absorption rate of Rx?
^SV (diastolic stroke volume)
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Delayed absorption - like competitive inhib
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

31. memantine
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
NMDR antagonist - use: dementia
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

32. functional incontinence tx
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Figure out a good diet - social aspect - resources - dental/oral comfort
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Environment modification: obstacles - mobility - -bladder fcn ok

33. What are common physical abuse Sx in elderly?
Confusion - sedation - falls
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies

34. delirium: tx approach
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Receptors changes: # - sensitivity - counter-regulatory moa
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

35. What are common medical causes of syncope?
^BP -> a-HTN
Arrythmia - aortic stenosis - carotid sinus hypersensitivity: vasovagal reflex - hypoglycemia - orthostatic hypotension - postprandial hypotension - psychogenic - PE - vasovagal: #1 etio - 1/3-1/2 idioPx
Serum Cr: used for Cr clearance equation
Intrinsic: chronic dx - postural: changing position - mediating: risk taking

36. What is the preferred depression treatment in elderly?
Therapy - SSRI
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Determined by Dr for a patient - -> used to determine competency
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals

37. frailty signs
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
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
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

38. What are the rf for caregiver to abuse elderly?
Used to calculate renal fcn - clearance of Cr adjusted for age
Receptors changes: # - sensitivity - counter-regulatory moa
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

39. dementia tx
Multisystemic vulnerability - -lowered reserves
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
A-blockers - B-blockers - TCA

40. What are the pharmacodynamic changes associated with aging?
Falls - delirium - malnutrition - P ulcers - opportunistic i2
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Receptors changes: # - sensitivity - counter-regulatory moa
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

41. 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
Catch-all of unspecified dizziness
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible

42. thiazide diuretic may lead to what prescription cascade?
IdioPx - psychiatric: depression - anxiety - somatoform
Vertigo - presyncope - disequilibrium - lightheadedness
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Hyperuricemia -> gout

43. What are the narrative elements of clinical ethics?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Voice - character - plot - context - time - reader
Universal - progressive - partially encoded (genetic) - destructive -

44. What is a mattering map?
Mechanical loading - skin care - avoid friction/shear
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Bone loss -> osteopenia -> osteoporosis -> Fx
Map of people - perceptions - etc - varies by perspective

45. what nutritional interventions help underweight?
Doctors
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Constipation -> laxatives
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

46. violation of rights
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

47. vertigo
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
Serum Cr: used for Cr clearance equation

48. How does renal nerve prevent syncope?
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Diagnosis - risk/benefit analysis to choose Rx
Isolated systolic HTN
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)

49. 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
Receptors changes: # - sensitivity - counter-regulatory moa
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
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

50. when selecting an P1-metabolite or P2-metabolite safer in elderly?
P2-metabolite - phase 1 biotx much more affected than phase 2
Cachexia - PEM - FTT - obesity
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness