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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 is the bone deterioration cascade?
Bone loss -> osteopenia -> osteoporosis -> Fx
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
F>M (until 80yo) - stress incontinence #1 - $26B/yr

2. delirium: Rx that contribute
Breast cancer + 2o LBP
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid
3 reflexes: baroreceptor - renal nerve - ANF

3. How does aging impact syncope-preventing reflexes
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA
Determined by Dr for a patient - -> used to determine competency
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
^ANS tone -> ^periph vasoconstriction - ^HR

4. documenting elderly abuse

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5. osteopenia
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
#1 patient's last competent indication of wishes - substituted judgment - beneficence
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
Beers criteria - medication appropriateness index (12 ?)

6. acute abdomen + atypical Sx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
>60yo - low abuse risk - ^ monitoring possible

7. metoclopramide may lead to what prescription cascade?
CVA: stroke - AMI: acute MI - HF
Parkinsonism -> l-DOPA
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
Personal liberty -living at home - personal property - speech - assembly - privacy - voting

8. what professional is least likely to report abuse?
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Vertigo - presyncope - disequilibrium - lightheadedness
Doctors
>9 Rx

9. Approach to idioPx - recurrent syncope
Make sure to discuss with patient - some states require reporting
Consider responsibilities - drivin
Electrical: change in HR - structural: aortic outflow obstruction
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx

10. memantine
NMDR antagonist - use: dementia
Diagnosis - risk/benefit analysis to choose Rx
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds
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

11. how is syncope related to elderly admission to hospital?
80% of hospital admission for syncope for >65yo
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Multisystemic vulnerability - -lowered reserves
Electrolyte imbalance - arrhythmia

12. NSAID may lead to what prescription cascade?
Determined by Dr for a patient - -> used to determine competency
>60yo - low abuse risk - ^ monitoring possible
^BP -> a-HTN
P2-metabolite - phase 1 biotx much more affected than phase 2

13. What are the pharmacodynamic changes associated with aging?
Environment modification: obstacles - mobility - -bladder fcn ok
Serum Cr: used for Cr clearance equation
Multisystemic vulnerability - -lowered reserves
Receptors changes: # - sensitivity - counter-regulatory moa

14. dementia tx
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Consider responsibilities - drivin

15. incontinence epidemiology
BMD (bone mineral density): T-score >2.5 std dev below normal 1
F>M (until 80yo) - stress incontinence #1 - $26B/yr
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

16. what illnesses are underreported in elderly?
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Stress: #1 - functional - urge - overflow
>9 Rx
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP

17. what receptors decrease sensitivity with aging?
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation

18. What are the 3 sentinel events for LT care?
Pressure ulcer - fecal impaction - dehydration
A-blockers - B-blockers - TCA
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration

19. delirium predisposing rf
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Advanced ae - dementia - ADL/IADL impairment - comorbidity - EtOH - M>F - sensory impairment
Map of people - perceptions - etc - varies by perspective
Multisystemic vulnerability - -lowered reserves

20. restrain requirements
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Must be signed by attending daily -medical necessity/patient liberty -as minimal as possible
Relfexes less responsive -less ability to ^HR - less sens to dehydration - comorbidities - Rx: a-blockers - B-blockers - TCA

21. refusing intervention
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Legal: Cruzan v Hamon
Beers criteria - medication appropriateness index (12 ?)
Hyperuricemia -> gout

22. Syncope prognosis based on etio
Worse for cardiac causes v noncardia
P2-metabolite - phase 1 biotx much more affected than phase 2
1/2
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet

23. anticholinergic drugs may lead to what prescription cascade?
CNS suppression -> cholinesterase inhibitors
Substance abuse - frustration/burnout - cognitive impairment - prior history of violence in FHx
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Electrical: change in HR - structural: aortic outflow obstruction

24. substituted judgment
Health care agent/proxy - may have durable power of attorney - may be next of kin/other family/other
Catch-all of unspecified dizziness
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Cholinesterase inhib - use: dementia

25. What are common physical abuse Sx in elderly?
Bone loss -> osteopenia -> osteoporosis -> Fx
Delayed absorption - like competitive inhib
Therapy - SSRI
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

26. i2 + atypical Sx
>60yo - low abuse risk - ^ monitoring possible
Insiduous onset
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Respect for autonomy - nonmaleficence - beneficence - justice

27. lightheadedness
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
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Catch-all of unspecified dizziness

28. BZD + antidepressant: interaction outcome
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Catch-all of unspecified dizziness
Confusion - sedation - falls
Consider responsibilities - drivin

29. What are the key points of safe prescription for elderly - lecture
Undocumented >50% - CAM: Confusion Assessment Method - -95% sens - spec
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Diagnosis - risk/benefit analysis to choose Rx
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

30. frailty
Wt loss - fatigue - impaired grip strength - impaired activity/slow gait
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Electrical: change in HR - structural: aortic outflow obstruction
Multisystemic vulnerability - -lowered reserves

31. How to prevent pressure ulcers?
Mechanical loading - skin care - avoid friction/shear
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
ANF: Na+ retention - disinhib vasoconstriction
F>M (until 80yo) - stress incontinence #1 - $26B/yr

32. What are the 4 forms of dizziness?
^BP -> a-HTN
Cholinesterase inhib - use: dementia
Vertigo - presyncope - disequilibrium - lightheadedness
#1 COD from injury in >65yo - 10-15% result in Fx - highest mortality in elderly white M

33. Aging features
Universal - progressive - partially encoded (genetic) - destructive -
P2-metab: Lorazepam - Trazepam - Oxazepam
Threats/ terrorizing - isolation - denying food/privileges/liberty
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

34. How does renal nerve prevent syncope?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
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
No: fever - leukocytosis - yes: falls - appetite change - low functional status
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

35. Aging principles
Protein-energy malnutrition - biochemical: Alb <3.5g/dL - clinical: wasting - low BMI
Appointed by court if no substituted judgment -conservator of finance -conservator of person
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve

36. What is sCr?
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
5% - underreported
Serum Cr: used for Cr clearance equation
ANF: Na+ retention - disinhib vasoconstriction

37. preventing malnutrition
Figure out a good diet - social aspect - resources - dental/oral comfort
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Recurrent in 25% dizzy patient - common etio: psych - vestibulo/somatosensory - no ^morbidity/mortality - ^risk syncope - falls - depression - self-rated health
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

38. who is a good candidate for opioid tx?
1/3 elderly hospital admisions - 10* risk death in hospital - complications: poor outcome - i2 - COD
Environment modification: obstacles - mobility - -bladder fcn ok
>60yo - low abuse risk - ^ monitoring possible
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other

39. How does aging affect Rx pharmacokinetic metabolism?
Isolated systolic HTN
Decreased: hepatic mass - BF - outcome: vPhase 1 biotransformation (redox) - Phase2 biotx unchanged - CYP450 activity varies - enz inhib/induction varies
Vertigo - presyncope - disequilibrium - lightheadedness
Stress: #1 - functional - urge - overflow

40. What is ISH?
Isolated systolic HTN
Receptors changes: # - sensitivity - counter-regulatory moa
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Decreased: Alb - prot affinity - increased: a1-acid glycoprot (^i2) - outcome: ^free fraction of prot-bound Rx; especially significant for phenytoin

41. clues of neglect
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Constipation -> laxatives
Begin @25-50% recommended dose - APAP may be dose-limiting
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

42. Why is abuse underreported?
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Voice - character - plot - context - time - reader
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
ANF: Na+ retention - disinhib vasoconstriction

43. What are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Treat underlying disease/lack resources
Prescribing - monitoring - patient adherence

44. What are the rf for elderly abuse?
P2-metab: Lorazepam - Trazepam - Oxazepam
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Phenytoin
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx

45. rivastigmine
Rotational sensation - usual etio: BPPV - benign paroxysmal positional vertigo - tx: Epley manuever - dislodge otolith crystals
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

46. 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
^SV (diastolic stroke volume)
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Breast cancer + 2o LBP

47. what Rx are commonly monifoted in elderly for ADR?
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Isolated systolic HTN
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

48. How does ANF prevent syncope?
Confusion - sedation - falls
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
ANF: Na+ retention - disinhib vasoconstriction

49. What is START criteria?
F>M (until 80yo) - stress incontinence #1 - $26B/yr
AFib: Warfarin - CAD/CVA/PVD wo contraindications: Statin - osteoporosis: Ca2+ - Vit D - DM + CVD rf: Statin - Depression: a-Depressant - arterial dx: a-platelet
Make sure to discuss with patient - some states require reporting
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable

50. Disequilibrium
3 reflexes: baroreceptor - renal nerve - ANF
P2-metab: Lorazepam - Trazepam - Oxazepam
Benzodiazepenes - amiodarone - digoxin - huge majority of Rx - ^Vd in elderly
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory