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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. donepezil
Cholinesterase inhib - use: dementia
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
^BP -> a-HTN

2. delirium: Rx that contribute
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
1/2
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Universal - progressive - partially encoded (genetic) - destructive -

3. What are the 4 forms of dizziness?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Vertigo - presyncope - disequilibrium - lightheadedness
Worse for cardiac causes v noncardia
^K+

4. How does the aging heart compensate for lower HR to maintain unchanged CO?
^SV (diastolic stroke volume)
Cachexia - PEM - FTT - obesity
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)

5. What is polypharmacy
Parkinsonism -> l-DOPA
NMDR antagonist - use: dementia
>9 Rx
Therapy - SSRI

6. what mechanical loading helps to prevent pressure ulcers?
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Isolated systolic HTN
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI

7. using long-acting opioids in elderly
^ANS tone -> ^periph vasoconstriction - ^HR
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Pressure ulcer - fecal impaction - dehydration

8. How does aging affect pharmacokinetics?
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Voice - character - plot - context - time - reader
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

9. malignancy + atypical Sx
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)
Breast cancer + 2o LBP
Pressure ulcer - fecal impaction - dehydration

10. acute abdomen + atypical Sx
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Delayed absorption - like competitive inhib
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

11. substituted judgment
No: fever - leukocytosis - yes: falls - appetite change - low functional status
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
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other

12. malnutrition
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Cachexia - PEM - FTT - obesity
Phenytoin
Breast cancer + 2o LBP

13. how may hypertension compensate for aging?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Screen for potentially embarrassing dx - patient/Dr trust
ANF: Na+ retention - disinhib vasoconstriction

14. advanced directive/care plan

15. What are the common types of elder mistreatment?
Electrolyte imbalance - arrhythmia
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

16. how can you determine whether Rx is appropriate to use in elderly patient?
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Beers criteria - medication appropriateness index (12 ?)

17. tube feeding
Prescribing - monitoring - patient adherence
5% - underreported
Electrolyte imbalance - arrhythmia
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

18. cachexia
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV
80% of hospital admission for syncope for >65yo
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin
Respect for autonomy - nonmaleficence - beneficence - justice

19. conservator
Appointed by court if no substituted judgment -conservator of finance -conservator of person
5% - underreported
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Hyperuricemia -> gout

20. What are the hazards of elderly hospitalization?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
^morbidity + mortality - -frailest @ greatest risk
Vertigo - presyncope - disequilibrium - lightheadedness
Falls - delirium - malnutrition - P ulcers - opportunistic i2

21. What are common physical abuse Sx in elderly?
Delayed absorption - like competitive inhib
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Phenytoin
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

22. MI + atypical Sx
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Treat underlying disease/lack resources
5% - underreported
No: chest pain - yes: fatigue - nausea - low functional status - SOB

23. How does aging increase incontinence?
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
Make sure to discuss with patient - some states require reporting
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
5% - underreported

24. What are the narrative elements of clinical ethics?
Serum Cr: used for Cr clearance equation
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
CNS suppression -> cholinesterase inhibitors
Voice - character - plot - context - time - reader

25. Disequilibrium
NMDR antagonist - use: dementia
Confusion - sedation - falls
5% - underreported
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory

26. surrogate decision making heirarchy

27. delirium: mgmt
Voice - character - plot - context - time - reader
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Universal - progressive - partially encoded (genetic) - destructive -

28. Beers criteria: what 10 Rx should elderly avoid or use + caution?
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

29. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
CVA: stroke - AMI: acute MI - HF
Bone loss -> osteopenia -> osteoporosis -> Fx
Diagnosis - risk/benefit analysis to choose Rx

30. What are the rf for elderly abuse?
Catch-all of unspecified dizziness
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Map of people - perceptions - etc - varies by perspective
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

31. What is a mattering map?
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
^SV (diastolic stroke volume)
Map of people - perceptions - etc - varies by perspective
Consider responsibilities - drivin

32. delirium diagnosis
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx

33. dementia tx
Receptors changes: # - sensitivity - counter-regulatory moa
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Vertigo - presyncope - disequilibrium - lightheadedness
Consider responsibilities - drivin

34. delirium predisposing rf
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

35. 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
Voice - character - plot - context - time - reader
Beers criteria - medication appropriateness index (12 ?)
30% preventable - of these - 40% serious - of these 40% preventable

36. what receptors increase sensitivity with aging?
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
Confusion - sedation - falls
^SV (diastolic stroke volume)

37. What are the 4 basic ethical principles?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Respect for autonomy - nonmaleficence - beneficence - justice
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Receptors changes: # - sensitivity - counter-regulatory moa

38. How does aging affect GI absorption of Rx?
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Hyperuricemia -> gout
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
Delayed absorption - like competitive inhib

39. What is the STOPP criteria?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Respect for autonomy - nonmaleficence - beneficence - justice
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
Appointed by court if no substituted judgment -conservator of finance -conservator of person

40. how is cachexia different from wasting?
Map of people - perceptions - etc - varies by perspective
Wasting: no cytokine-mediated response - etio: marasmus - cancer - AIDS - critical illness
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse

41. what normally prevents syncope?
>9 Rx
3 reflexes: baroreceptor - renal nerve - ANF
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
80% of hospital admission for syncope for >65yo

42. driving considerations
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Worse for cardiac causes v noncardia
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Make sure to discuss with patient - some states require reporting

43. pressure ulcer: staging
Catch-all of unspecified dizziness
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
NSAID/ COX2 inhib - anticholinergics (inc OTC) - antipsychotics - anxiolytics/insomnia: some - muscle relaxant - DM Rx: avoid glyburide - sliding scale insulin - digoxin - meperidine (Demerol) - estrogen

44. How does sliding scale glycemic control relate to elderly?
Hypotension - ^K+
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
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

45. ACE inhib + diuretic: interaction outcome
Hypotension - ^K+
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Breast cancer + 2o LBP
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)

46. How does aging impact syncope-preventing reflexes
NMDR antagonist - use: dementia
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

47. metoclopramide may lead to what prescription cascade?
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Parkinsonism -> l-DOPA
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

48. violation of rights
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
F>M (until 80yo) - stress incontinence #1 - $26B/yr
No: chest pain - yes: fatigue - nausea - low functional status - SOB

49. overflow incontinence tx
Treat underlying etio: BPH - cancer - sacral n dx - -BPH: a1-blockers (finasteride - doxazosin...) - sacral nerve stimulation
Isolated systolic HTN
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
80% of hospital admission for syncope for >65yo

50. delirium: medical rf
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
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