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Aging Physiology And Pharmacology

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Answer 50 questions in 15 minutes.
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1. How does renal nerve prevent syncope?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
EtOH/substance abuse - cognitive dysfcn - v exercise - depression/mental status - immobility - resources: inadequate $ - transport
BMD (bone mineral density): T-score >2.5 std dev below normal 1
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

2. fall causes
IdioPx - psychiatric: depression - anxiety - somatoform
Insiduous onset
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

3. ADR rf
^BP -> a-HTN
Figure out a good diet - social aspect - resources - dental/oral comfort
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
Threats/ terrorizing - isolation - denying food/privileges/liberty

4. What is the STOPP criteria?
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
Voice - character - plot - context - time - reader
B-adrenergic - ACE inhib - baroreceptors - -> ^K+ with NSAIDS - ACEI - K+ sparing diuretics
V contrast sensitivity: target + bg - v visual acuity - lat motion - depth perception - ^ glare sensitivity

5. what drugs can cause dizziness?
Consider responsibilities - drivin
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
NMDR antagonist - use: dementia
Phenytoin

6. what Rx are commonly monifoted in elderly for ADR?
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
Pressure ulcer - fecal impaction - dehydration
Receptors changes: # - sensitivity - counter-regulatory moa
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants

7. what mechanical loading helps to prevent pressure ulcers?
Phenytoin
Constipation -> laxatives
Falls - delirium - malnutrition - P ulcers - opportunistic i2
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers

8. What are the risks of uncontrolled ISH?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Multisystemic vulnerability - -lowered reserves
CVA: stroke - AMI: acute MI - HF
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

9. driving considerations
Make sure to discuss with patient - some states require reporting
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
Orthostatic hypotension - vagal stimulation (vasovagal reflex)

10. pulm edema + atypical Sx
Insiduous onset
Multisystemic vulnerability - -lowered reserves
Depression + nursing home - osteoporosis + nursing home - aFib/anti-coagulant - HTN - MI 1o/2o prevention - opioids: addiction fear
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

11. ACE inhib + diuretic: interaction outcome
Hypothetical plan - serves as patient's last competent indicated wishes
Hypotension - ^K+
Begin @25-50% recommended dose - APAP may be dose-limiting
Cachexia - PEM - FTT - obesity

12. refusing intervention
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Confusion - sedation - falls
Legal: Cruzan v Hamon
Therapy - SSRI

13. surrogate decision making heirarchy

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14. MRP: medication related problems
Overactive detrussor contraction/spasm - tx: anticholinergice --| overactive detrusor
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
Cholinesterase inhib - use: dementia

15. osteopenia
Delayed absorption - like competitive inhib
BMD (bone mineral density): T-score 1-2.5 std dev below normal 1 - Z-score age-adjusted
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
Vertigo - presyncope - disequilibrium - lightheadedness

16. How does ANF prevent syncope?
^renin from JGA -> ang 2: vasoconstriction -> aldo: Na+ retention (-> H2O retention)
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
ANF: Na+ retention - disinhib vasoconstriction
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

17. What is the best approach to malnutrition
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
Treat underlying disease/lack resources
P2-metab: Lorazepam - Trazepam - Oxazepam
Routes: nasoenteric - PEG - jejunostomy - required high level of care - formula depends on nutritional status - risk: aspiration - i2

18. How does aging affect GI absorption rate of Rx?
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Delayed absorption - like competitive inhib
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych

19. LBW equation
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
Social restraint - sitter/family - avoid physical restraint - if necessary: haloperidol - remove tethers: cathethers - IV - orientation aids: glasses - hearing aids
LBWm=50kg + (2.3*inches >5ft) - LBWf=45kg + (2.3*inches>5ft)
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

20. delirium: medical rf
#1 patient's last competent indication of wishes - substituted judgment - beneficence
Acute MI/pulm events - immobility - i2 - drug withdrawal: CNS depressant - EtOH - fecal impaction
CV - diuretics - esp loop - non-opioid analgesics - hypoglycemics - anticoagulants
3 reflexes: baroreceptor - renal nerve - ANF

21. lightheadedness
Electrical: change in HR - structural: aortic outflow obstruction
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Catch-all of unspecified dizziness

22. What is the Cockcroft Gault equation?
Used to calculate renal fcn - clearance of Cr adjusted for age
Catch-all of unspecified dizziness
Hypotension - ^K+
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo

23. dementia tx
80% of hospital admission for syncope for >65yo
Begin @25-50% recommended dose - APAP may be dose-limiting
Cholinesterase inhib: donepezil - rivastigmine - galantamine - NMDR antag: memantine
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights

24. rivastigmine
^morbidity + mortality - -frailest @ greatest risk
Caution in opioid-naive patient - less serum Rx availability - prescribe short-acting for BTP - upward titration
Cholinesterase inhib - use: dementia
EtOH - antibiotics - anticholinergics - anticonvulsants - antidepressants - antihistamines - anti-PD - antipsychotics - barbituates - BZD - chloral hydrate - H2-blockers - Li - opioid

25. NSAID may lead to what prescription cascade?
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
^BP -> a-HTN
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards

26. Cockcroft Gault equation
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Loss of balance wo head mvmt - factors: vestibuloPx - visual - M/S - gait - somatosensory
Orthostatic hypotension - vagal stimulation (vasovagal reflex)
CrClm= ((140-age)LBW/ Scr72) - CrClf=CrClm*0.85

27. what can enhance reporting in elderly?
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Screen for potentially embarrassing dx - patient/Dr trust
'long lie' decline in functional status - ^ risk of being in nursing home - ^ Use of medical services - fear
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

28. What are the pharmacodynamic changes associated with aging?
Hyperthyroid: apathetic thyrotoxicosis - hypothyroid: confusion + agitation
Injury - neglect - physical/psychosocial - financial - violation of rights
Receptors changes: # - sensitivity - counter-regulatory moa
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR

29. How does sliding scale glycemic control relate to elderly?
ANF: Na+ retention - disinhib vasoconstriction
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Electrolye/renal - GI - hemorrhagic - metabolic/endocrine - neuropsych
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar

30. red flags for further inquiry
P2-metabolite - phase 1 biotx much more affected than phase 2
Change in cognitive status - personality - Rx discrepancy - change in somatic Sx - recurrent falls - hospitalizations - other
Doctors
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical

31. What are the 4 basic ethical principles?
Respect for autonomy - nonmaleficence - beneficence - justice
HTN may prevent orthostatic hypotension - -> lower fall risk (and maybe v morbidity)
Hypotension - ^K+
Appointed by court if no substituted judgment -conservator of finance -conservator of person

32. nutrition syndromes
Physical abuse - least common - physical neglect #1 - psych abuse - financial exploitation - violation of rights
Cachexia - PEM - FTT - obesity
I: peristent erythema - II: partial thickness - III: full thickness - IV: full thickness + extensive damage - unstageable
Estrogen deficiency - androgen deficiency - vCa2+ - ^PTH - changes in bone formation - 2o causes/Rx

33. What are rf for osteoporosis?
Beers criteria - medication appropriateness index (12 ?)
3 reflexes: baroreceptor - renal nerve - ANF
Early menopause - white/Asian race - sedentary - smoking - vBMI - EtOH - hyperPTH - hyperthyroidism - GC Rx
CNS suppression -> cholinesterase inhibitors

34. violation of rights
ANF: Na+ retention - disinhib vasoconstriction
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
Personal liberty -living at home - personal property - speech - assembly - privacy - voting
Mild discomfort - constipation - tachypnea - vague resp Sx - fewer bowel sounds

35. How does the aging heart compensate for lower HR to maintain unchanged CO?
Polypharmacy - female gender - age - small body size; BMI <22 - hepatic/ renal insufficiency - prior ADR
P2-metabolite - phase 1 biotx much more affected than phase 2
^SV (diastolic stroke volume)
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease

36. what nutritional interventions help underweight?
Oral nutrition + supplements - tube feeding - parenteral nutrition - refeeding
Universal - progressive - partially encoded (genetic) - destructive -
Phenytoin
Cellulitis - P ulcers - UTI - sleep deprivation - falls - sexual dysfcn - depression - social withdrawal - v QoL

37. rule of doable effect
Age - psychosocial: depression - isolation - lack resources:education - $ - minority - substance abuse
Decreased: gastric emptying rate - intestinal motility - BF - surface area - gastric acid secretion - increased: gastric pH - outcome: delaye onset - peak; quant abs similar
IdioPx - psychiatric: depression - anxiety - somatoform
Palliative care will -relieve discomfort/suffering -may hasten death (resp depression)

38. How does aging affect Rx renal elimination?
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient
Malnutrition/dehydration - frequent visits to ER - same proglems - delay in seeking care - inadequate Rx taking/ noncompliance - poor hygiene - P ulcers
Decreased: renal BF - tubular sec - GFR - CrCl -stable sCr due to v muscle mass - avg renal fcn 80yo ~50% of 20yo
F>M (until 80yo) - stress incontinence #1 - $26B/yr

39. ACE inhib + K+: interaction outcome
^K+
5% - underreported
Stress: #1 - functional - urge - overflow
Rx use wo indication - untreated indication - failure to receive Rx - subtherapeutic Rx - OD Rx - improper Rx selection - ADR - drug interaction

40. how can you determine whether Rx is appropriate to use in elderly patient?
No: chest pain - yes: fatigue - nausea - low functional status - SOB
Depression - incontinence - M/S stiffness - falls - EtOH/Rx abuse - hearing loss - dementia - dental dx - malnutrition - sexual dysfcn - OA - OP
Beers criteria - medication appropriateness index (12 ?)
Legal: Cruzan v Hamon

41. documenting elderly abuse

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42. What is the preferred depression treatment in elderly?
Isolated systolic HTN
Therapy - SSRI
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

43. what professional is least likely to report abuse?
Confusion - sedation - falls
Doctors
Intrinsic: chronic dx - postural: changing position - mediating: risk taking
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics

44. Presyncope
>orthostasis/CNS: anticholinergics - a1-blockers - CV/anti-HTN Rx: B-blockers - a1-blockers - psychotropics
Reposition/2h - movement if possible - look @heel - 20% all pressure ulcers
Sensation of impending faint - etio: v cerebral perfusion (cardiac - vascular or postural +/- orthostatic hypotension)
P2-metab: Lorazepam - Trazepam - Oxazepam

45. memantine
1+2 +3 or 4 - 1 acute mental status change or fluctuation - 2 inattention - 3 disorganized thinking - 4 altered consiousness
NMDR antagonist - use: dementia
Rec for: benzodiazepines - CNS depressants - anticholinergics - VKORC (Warfarin) - Na+/K+ ATPase (digozin) - -> ^tardive dyskinesia - parkinsonism
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

46. What is the natural history of syncope?
Change in systemic BP/ ^cerebral vasc rest -> low cerebral perfusion -> syncope
+/- sadness - hyperactivity - somatic Sx: appetite - vague GI - constip - sleep
Avoid sliding scale - it is reactive - no proactive -will cause hyper/hypoglycemia -control carb intake instead
Lack of identification - victim isolation - reluctance to confront offenders - consequences for reporting - subtle presentation by patient

47. osteoporosis
Tx underlying etio - + Kegels - pessary - surgery
BMD (bone mineral density): T-score >2.5 std dev below normal 1
Failure to provide services: healthcare - goods: food - clothing - shelter - hydration - prevention of risks/hazards
Severe wt loss + low nutrition intake - cytokine-mediated response - etio: RA - CHF - COPD - HIV

48. delirium: tx approach
Tx underlying dx - review Rx - avoid complications: hygiene - constip - pain - orientation aids
ANF: Na+ retention - disinhib vasoconstriction
1/2
Legal: Cruzan v Hamon

49. What are common physical abuse Sx in elderly?
Assault/battery - pattern injuries - sexual assault - prolonged deprivation of food - H2O - restraint: physical - chemical
Multisystemic vulnerability - -lowered reserves
Decreased: TBW - CO - muscle mass - increased: body fat - altered: regional BF - outcome: ^Vd lipid-sol Rx; v Vd H2O-sol Rx
Threats/ terrorizing - isolation - denying food/privileges/liberty

50. How does aging affect pharmacokinetics?
Electrolyte imbalance - arrhythmia
Abs: delayed onset - peak - distrib: more fat - less H2O - metab: phase 1 more affected v phase 2 - excr: renal - liver fcn decrease
No: chest pain - yes: fatigue - nausea - low functional status - SOB
1 most alike at birth - 2 ^ frailty - 3 risk dx - 4 homeostenosis: reduced reserve