Week 1 Geriatric stuff

Question 1

In older age, fat _______(increases/decreases)

Answer 1

Increases

Question 2

In older age, total both water ______ (increases/decreases)

Answer 2

Decreases

Question 3

T/F the brain atrophies by 7% as a part of normal aging

Answer 3

True

Question 4

Which stages of sleep decrease with aging?

Answer 4

Stage 3 and 4(nonREM) - can even dissapear
REM preserved
More frequent awakenings
Less sleep efficiency

Question 5

T/F it’s normal for visual acuity to decrease with aging

Answer 5

True - decreases up to 70%

Question 6

Decreased hearing acuity is also normal with aging. _______ (low/high) frequency is lost first

Answer 6

High

Question 7

How much does taste decline in old age?

Answer 7

Up to 70%!

Question 8

How is renal perfusion affected in old age?

Answer 8

reduced renal perfusion each decade up to 50% (is considered normal aging changes)

Question 9

Normal changes to sexual function with aging

Answer 9

Reduced intensity & persistence of erections
Decreased ejaculate and ejaculatory flow
Reduced lubrication
Vaginal atrophy

Question 10

How does lens elasticity change with aging?

Answer 10

Markedly reduced by age 40-50
**results in need for reading glasses

Question 11

What is a normal change in prostate size with old age

Answer 11

Normally doubles in size!

Question 12

What does “geriatric syndome” refer to generally?

Answer 12

The term “geriatric syndrome” is used to capture those clinical conditions in older persons that do not fit into discrete disease categories.

Question 13

Name some examples of geriatric syndromes

Answer 13

Many of the most common conditions cared for by geriatricians are all classified as geriatric syndromes:

delirium
depression
falls
frailty
dizziness
syncope
urinary incontinence
polypharmacy
dysphasia

Question 14

Want to take a stab at defining frailty?

Answer 14

Frailty is broadly seen as a state of increased vulnerability and functional impairment caused by cumulative declines across
multiple systems.

Frailty has multiple causes and contributors5
and may be physical, psychological, social, or a combination of
these.

Frailty may include loss of muscle mass and strength, reduced energy and exercise tolerance, cognitive impairment, and
decreased physiological reserve, leading to poor health outcomes and a reduced ability to recover from acute stress.

**If frail, a small external stressor can lead to much more significant deterioration & they may not return to baseline

Question 15

Risk factors for frailty

Answer 15

• advanced age
• polypharmacy
• functional decline
• poverty and/or isolation
• poor nutrition and/or weight loss
• medical and/or psychiatric comorbidity

Question 16

What is the “rule of fourths” in aging

Answer 16

A way to understanding the cause of changes in aging.
1/4 of changes in aging can be attributed to:
1) Disease
2) Disuse
3) Misuse
4) physiologic aging

Question 17

What does disuse refer to in the rule of fourths?

Answer 17

Sedentary lifestyle, lack of mental stimulation, etc
I think of this one as “use it or lose it”

Question 18

What does “misuse” refer to in the rule of fourths?

Answer 18

Smoking, injuries from sports, AEs from prescription/recreational drugs…etc

Question 19

What is polypharmacy

Answer 19

Describes the administration of more drugs than are clinically indicated

in frail older adults, even ‘appropriate’ medicines can present as a situational challenge and be harmful due to multiple reserve deficits impairing mechanisms to deal with even a minor side-effect

Question 20

Deprescribing = ?

Answer 20

the process of withdrawal of an inappropriate medication with the aim of reducing polypharmacy and improving health outcomes

Fun fact: Studies on medication withdrawal in elderly patients show that up to 60% of medications can be successfully withdrawn without undesirable effects (according to polypharmacy.ca)

Question 21

What is a prescribing cascade?

Answer 21

problem of mistakenly identifying adverse medication effects as new medical condition…and then you prescribe a new med to manage that side effect…and then that new medication’s side effect requires a new prescription…etc etc until lots of meds are ordered unnecessary

Question 22

What are the iADLs and what is a handy acronym to remember them?

Answer 22

SHAFT-TT

Shopping

Housework

Accounting/ finances

Food prep

Transportation

Taking meds

Question 23

Differentiate pharmacokinetics & pharmacodynamics

Answer 23

Kinetics = what the body does to the drug (absorption, distribution, metabolism, and elimination)

Dynamics = what the drug does to the body

Question 24

Why are older adults more susceptible to AEs from drugs? Describe the changes that occur with regard to pharmacokinetics.

Answer 24

Older age –> decreased organ fx and physiologic reserve –> enhanced susceptibility to A/Es

• decreased first pass metabolism
• decreased rate of abdorption
• decreased lean mass & total body water (which decreases the volume of distribution of these components)
• increased fat content
• decreased food intake/catabolic disease states
• Decreased CYP 450 metabolic pathways, which decreases metabolism & increases half life
• decreased renal elimination

Question 25

What changes in older age affect the bioavailability of the drug? (hint: think changes to stomach/digestion)

Answer 25

reduced acidity of the stomach, gastric motility, and first-pass metabolism

Question 26

How does increased fat in older adults affect elimination & duration of therapeutic/toxic effect?

Answer 26

lipophilic medications have a larger volume of distribution –> longer elimination phase & prolonged therapeutic or toxic effect as drugs not as efficiently eliminated from lipid compartment

Question 27

Cultural competency vs cultural humility

Answer 27

Cultural competency is a “set of congruent behaviours, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross cultural situations”

Cultural humility: less emphasis on knowledge acquisition (of a culture) and competency, more emphasis on personal reflection. Dynamic, lifelong process. Emphasizes addressing power imbalances and learning from patients. Requires attitude of openness.

Question 28

T/F your differential diagnosis for a geriatric condition should always include adverse drug reactions

Answer 28

True!

Question 29

Four criteria may help in deciding whether to start or continue medications in patients
What are they?

Answer 29

1) Life expectancy (consider comorbidities, functional status, disease markers of poor prognosis)

2) Time until benefit from medication (varies drastically- i.e., statins for primary prevention of CVD takes many years and larger NNT, whereas opioids have short time to benefit and low NNT)

3) Goals of care (made collaboratively by patient, provider, family)

4) Treatment targets (i.e., symptom targeted vs. disease modifying; curative vs. palliative)

Question 30

Anticholinergic medications are generally not a good choice for older adults. What are the potential adverse effects?

Answer 30

sedation, confusion, urinary retention, and constipation