Physiologic Changes
63 yo F with pancreatic cancer, on home palliative care, is admitted to the hospital for pain control, nausea, vomiting. She has been on fentanyl patch for several months and dose was increased from 125 mcg -> 150 mcg q72 hours but it seems not to be improving; she is requiring more IV dilaudid. She’s lost 10 lbs in the last month, weight 90 lbs. What is the next best step?
A. increase fentanyl basal dose
B. schedule dilaudid and keep current fentanyl dose
C. discontinue fentanyl, start on dilaudid CADD pump with basal dose+ PRN
D. discontinue fentanyl, start methadone
Answer: C. Discontinue fentanyl and start on dilaudid CADD pump with basal dose and PRN
Patient likely has poor absorption of fentanyl patch given weight loss. Aging skin also atrophies and becomes thinner, and blood flow to dermal layer may be reduced; these factors may alter the systemic absorption from topical products. Ideal to convert meds to IV in this case
What happens to the kidneys as one ages?
A. Decrease in renal size, decrease blood flow, decrease in functioning nephrons
B. Decrease in renal size, increase in blood flow, increase in functioning nephrons
C. Increase in renal size, decrease in blood flow, decrease in functioning nephrons
Answer: A
Decrease in kidney size
Decrease renal blood flow
Decrease in number of functioning nephrons
Decrease renal tubular secretion
Lower GFR
82 year old male with CAD, afib, HTN, HLD, DM, anemia, osteoporosis has persistent constipation. Identify the meds that could be causing constipation:
lisinopril, diltiazem, iron, Calcium, Vit D, alendronate, aspirin
LISINOPRIL, DILTIAZEM, IRON, CALCIUM, ALENDRONATE
Constipation is a VERY common issue among older adults, especially due to decreased mobility and medications inducing constipation
Be aware of meds that can cause constipation: opioids, antacids, CCB, anticholinergic agents, cholestyramine
An 80-year-old woman comes to the office accompanied by her daughter, who is concerned about changes in her mother’s behavior. The patient has recently withdrawn from former activities, such as attending book clubs and lectures. Her self-reported health status has changed: last year she rated her health as excellent, but now she rates it as average. During the appointment she misunderstands some of the questions asked, and she appears to struggle to understand some of what is said. In response to direct questions, she states that over the past 2 weeks she has felt a little down and mentions that if people would include her in conversation, she would probably feel better and be more inclined to engage in the activities she previously enjoyed. Her memory does not seem as keen as it was on previous visits.
On examination, blood pressure and electrocardiography findings are normal. Her score on the Mini–Mental State Examination is 26 of 30. Findings from routine laboratory tests are normal.
Which one of the following is the most appropriate next step?
A.Begin antidepressant therapy.
B.Provide referral to audiologist for hearing aids.
C.Refer for neurologic evaluation.
D.Administer in-office hearing screen.
Answer D
First step should be screening for hearing loss. Hearing loss affects more than 2/3 of older adults and tends to be underrecognized and underreported
What is the goal TSH level of the geriatric population?
A. 0.5-4.0
B. 4.0-7.0
C. <10.0
Answer: B. 4.0-7.0
-In older adults with mild subclinical hypothyroidism, levothyroxine supplementation has not been shown to be beneficial for relief of symptoms, or to reduce risk of cognitive dysfunction or cardiovascular events.
-TSH>=10 more likely to experience symptomatic improvement with levothyroxine.
Which anticoagulant is least likely to have interactions with presence of PEG tube?
A. Dabigatran (Pradaxa)
B. Warfarin (Coumadin)
C. Apixaban (Eliquis)
Solution:
Answer: C. Apixaban can be crushed
Bioavailability of PO Pradaxa ranges from 3-7%. This is increased by up to 75% if the capsule is opened and the pellets are ingested without an intact capsule shell.
Warfarin can be crushed but it may be bound by proteins in formula
How often should you titrate maintenance dose of IV opioids?
A. Every 4 hours
B. Every 8 hours
C. Every 16 hours
Answer: B
-½ life: time it take for ½ of drug’s plasma serum [C] to decline by 50%
-Steady state: amount of drug going in = amount of drug going out;
--steady state depends on ½ life.
-usually takes about 4-5 half lives to reach steady state
-2 hours x4 half lives = 8 hours
-if IV half life is 2 hours, the fastest you should up-titrate an opioid drip is every 8 hours (~4 half lives; risk of up-titrating prior to reaching steady state: stacking)
67 yo M with history of HTN, HLD, DM2, chronic BLE swelling. TTE with normal EF, no diastolic dysfunction; normal albumin, no liver disease; no history of radiation; no sob or pulmonary edema.
-medications: losartan, amlodipine, Lasix, potassium, rosuvastatin, metformin
-BP 108/64; HR 72; RR18; O2 sat 99% on RA
What is the next best step?
A. Send him to lymphedema clinic
B. Increase Lasix dose
C. Add thiazide or metolazone to improve diuresis
D. Discontinue amlodipine
Answer: D
-amlodipine can cause LE swelling -> the Lasix is being prescribed to decrease the LE swelling -> the potassium is being prescribed due to hypokalemia caused by the Lasix
Prescription cascade...
-solution: trial dc amlodipine, then f/u and dc Lasix, remeasure lytes and likely can dc potassium
Which of the following has the strongest evidence for delirium prevention in hospitalized older adults?
A. Prophylactic low-dose melatonin
B. Multicomponent nonpharmacologic interventions
C. Routine use of one-to-one sitters
D. Use of regional block over general anesthesia
Answer: B. Multicomponent nonpharmacologic interventions.
SOE=A.
Widely used model is HELP--Hospital Elder Life Program. Includes IDT with daily visits, orientation, therapeutic activities, sleep enhancement, early mobilization, vision and hearing adaptation, fluid repletion, and feeding assistance. HELP can also reduce falls and health care costs.
Mixed results regarding melatonin for delirium prevention (SOE=C)
You are covering your colleague’s inbox and TSH for 70 yoF comes back elevated 8.0, asymptomatic; TSH was normal 10 years ago. What to do?
A. Treat
B. Don’t treat, this is normal
C. Don’t treat, remeasure in 4-6 weeks
Answer: C. Don't treat, remeasure in 4-6 weeks
Goal TSH in older adults is different than for younger patients
-TSH may normalize within 1-2 years in up to half of older adults with singly mildly increased TSH level; therefore, hypothyroidism should be confirmed by combination of PERSISTENTLY increased TSH concentration and decreased free T4.
What happens to … as one ages? (Increase vs decrease?)
-TBW
-body mass
-fat stores
-plasma protein
Answer:
TBW: decrease
Body mass: decrease
Fat stores: increase
Plasma protein: decrease
Why can’t I use Creatinine as a reliable marker of renal function in older patients?
Decrease in lean body mass -> lower serum creatinine
In older people with reduced GFR, serum creatinine may still be within normal range (use CrCl)
82 yo F with long standing DM complicated by retinopathy, neuropathy, CKD, gastroparesis. Patient was given a medication in the ED last month for nausea/vomiting and now comes to your clinic with headache, insomnia, inner restlessness, resting tremor, shuffling gait, masked facies.
What medication was prescribed?
A. Metoclopramide
B. Erythromycin
C. Zofran
Answer: A. Metoclopramide
-Patient has metoclopramide-induced parkinsonism
-Metoclopramide is a D2-antagonist that can induce Parkinson features; you should discontinue this medication.
A 73-year-old woman comes to the office 2 weeks after her husband died from end-stage renal disease and metastatic cancer. She was his sole caregiver for 3 years and took care of all medical and practical decisions in his last days, neglecting friendships because of the demands of caregiving. She now is visibly distressed; she is sleeping poorly, has lost weight, and is unable to function. She declines medication to help her sleep but agrees to return for follow-up.
Two weeks later she is calmer, but still feels sad all the time, cries easily, has trouble focusing on tasks, and cannot sleep. She continues to have poor appetite and has been avoiding visits with her daughter (who lives locally) and grandchildren. She feels that she has no purpose and wonders why she is still alive, but she denies any active suicidal ideation. She realizes that she neglected her health during her husband’s illness and wants to start taking care of herself, but she has a feeling of futility at the idea of engaging in any activity. History includes hypertension, osteoarthritis, and hypercholesterolemia.
Which one of the following is the most appropriate next step in care of this patient?
A. No treatment is necessary for her normal grief reaction.
B. Start an antidepressant for major depressive episode.
C. Refer to a dietitian to establish healthy eating habits.
D. Encourage her to start seeing friends and family.
ine
Answer: B. Start an antidepressant for major depressive episode
DSM-5 does not consider bereavement to be an exclusion criterion for the diagnosis of a major depressive episode, and establishes that while many symptoms overlap, there are notable differences. In depression, the dysphoria is persistent, with little capacity to experience pleasure; feelings of pessimism and poor self-esteem are characteristic. In grief, negative thoughts are tied to memories of the lost loved one, while positive emotions can still be experienced. Bereaved individuals may wish to join the deceased, whereas, for those who are depressed, thoughts of dying are related to feelings of worthlessness.
This patient’s persistent low mood, avoidance of family contact, feeling that she has no purpose, passive suicidal thoughts, and sense of futility point to depression in addition to bereavement. Her loss of a spouse and her role as caregiver for several years also place her at increased risk of depression and prolonged grief.
85 year-old male with HTN, HLD, DM2 (A1c 7.5), CAD, CKD2, poor vision, lives alone comes to clinic for DM f/u; he’s had 3 hypoglycemic episodes in the last month.
-home meds: metoprolol, losartan, rosuvastatin, metformin 500 mg bid, glipizide 5 mg bid
Next step?
A. Continue regimen
B. Discontinue glipizide, start insulin
C. Discontinue glipizide, increase metformin, re-evaluate in 6 weeks
Answer: C. Discontinue glipizide, increase metformin, re-evaluate in 6 weeks.
Sulfonylureas, Insulin can cause hypoglycemia which can be very dangerous, increasing risk of falls of syncopal episodes, especially unsafe for someone who lives at home alone.
Intensive glycemic control is not necessary for someone who has multiple co-morbidities, poor support network, getting hypoglycemic episodes, short life expectancy.
Time to benefit for tight glycemic control to prevent microvascular change: 8-10 years
A 72-year-old woman comes to the clinic because she recently fell, and she would like an evaluation for underlying causes to prevent a recurrence. Previously, she had walked with friends 1 or 2 times each week at a moderate pace for 1 hour. She has stopped this exercise because she is afraid that she will fall again. She takes a multivitamin daily and no other medications. Her diet is varied and balanced. She does not smoke, and she drinks a glass of wine about twice each month.
On examination, she appears well. Weight is 74.8 kg (165 lb); BMI is 28.3 kg/m2. Blood pressure is 155/85 mmHg, with no postural change, and pulse is 85 beats per minute. The remainder of the examination, including cognition, is unremarkable. ECG is normal. Results from dual-energy x-ray absorptiometry scans are normal.
Laboratory findings:
In addition to balance exercises, which of the following would reduce her fall risk?
A. Resumption of past activity
B. Increased intake of calcium and vitamin D
C. Diet and exercise program to treat metabolic syndrome
D. Event monitor to assess for arrhythmia
Answer: C. Diet and exercise program to treat metabolic syndrome.
This is a link between metabolic syndrome and frailty--especially those with increased CRP and insulin resistance.
Fear of falling is VERY common and persistent.
Strongest predictor of falls: having a history of falls
72 yo F with history of CAD, HFrEF (EF 25%), severe AS s/p MVR on warfarin, CKD3 was diagnosed with cellulitis last week, started on an antibiotic, now comes in for generalized weakness, poor PO intake; labs significant for hyperkalemia and AKI, ECG with peaked T waves.
Home meds: metoprolol, lisinopril, Lasix, spironolactone, aspirin, atorvastatin
-Which antibiotics was she started on?
A. Keflex
B. Clindamycin
C. Bactrim
Answer: C
Bactrim is cleared by the kidneys
Increased risk of hyperkalemia when used concurrently with ACEi or ARB in presence of decreased CrCl
*also note drug-drug interaction: Bactrim can increase risk of bleeding when used with warfarin, monitor INR closely if used
An 84-year-old woman is brought to the clinic by her daughter because she has recently developed urinary urgency and incontinence requiring pads. The patient takes 15 medications. At her last visit 3 months ago, medications were adjusted as follows: levothyroxine was increased to 0.112 mg/d, donepezil 5 mg/d was started, and hydrochlorothiazide 25 mg/d and simvastatin 20 mg/d were discontinued.
Which of the following would be most likely to improve the patient’s urinary urgency and incontinence?
A. Discontinue donepezil.
B. Start extended-release oxybutynin.
C. Start memantine
D. Decrease levothyroxine to previous dosage.
Answer: A. Discontinue donepezil
Procholinergics (acetylcholinesterase inhibitors like donepezil) can interact with bladder anticholinergics and cause sudden worsening of bladder symptoms. Patients started on anticholinergics may also demonstrate worsening cognition.
An 82-year-old patient comes to the office for follow-up on management of her depression. Because she did not respond to sertraline and venlafaxine, mirtazapine was started. She has had a partial response to mirtazapine, despite adequate dosage and duration of therapy. Her mood is improved, and she is better able to focus yet she continues to report poor energy, little motivation to engage in activities, and ongoing arguments with her unemployed son. She describes sometimes feeling hopeless, although she denies any suicidal ideation. Since beginning treatment with mirtazapine, she has gained weight and is finding it difficult to control her diabetes. Referral for cognitive-behavioral therapy is impractical because there is no skilled provider in the area.
Which one of the following treatment options should be considered next?
A. Hospitalization and electroconvulsive therapy
B. Augmentation with bupropion
C. Switch from mirtazapine to duloxetine
D.Referral for family therapy
Answer B
- In cases of partial response, common strategies include augmentation either with a second antidepressant, second-generation antipsychotic or litium, or with CBT
- Bupropion is a good choice because of it's different pharmacologic class than mirtazapine and has shown to be useful as an augmenting agent
•Because she did not respond to an SSRI or SNRI a switch to another SNRI may not be helpful
•Augmentation with lithium or a second-generation anti-psychotic could also be considered but given patient's comorbidities and weight gain these options carry greater risk of adverse effects
Which of the following agents increases bone mass and reduces fracture risk by stimulating osteoblast activity and promoting bone formation?
A.Alendronate
B.Estradiol
C.Teriparatide
D.Calcitonin
Answer C
Teriparatide and abaloparatide are human parathyroid hormone analogues that increase bone mass and reduce fracture risk y stimulating osteoblast activity
Most agents for osteoporosis are antiresoprtive including: Ca, Vit D, Estrogen, SERM, bisphosphonates, and calcitoin
72 yo Caucasian F with depression (on fluoxetine), OA, CAD, HFrEF comes in for knee pain from OA. Tylenol, Voltaren gel did not work so you started her on Tramadol 3 months ago and have titrated up but it’s not working. What do you do next?
A. Add on adjunct like meloxicam
B. Discontinue tramadol, trial Norco 5-325mg
C. Knee surgery
Answer: B. Discontinue tramadol, trial Norco
10% of white people are poor metabolizers (PM): deficient in CYP2D6 isoenzyme and have reduced ability to clear and increased sensitivity to CYP2D6 substrates.
Trama-DON'T
This patient is probably a PM AND she is taking a CYP2D6 inhibitor, fluoxetine
Note: NSAIDs in elderly with HF can cause fluid retention, HF exacerbation. Don’t do it.
78 yo F with HTN, CAD , MCI admitted to the hospital for CHF exacerbation was treated with IV diuretics. She was discharged on higher dosages of her meds – lisinopril, po Lasix, spironolactone. 4 days after discharge, she was admitted for sob. She states that she has been taking her meds as directed. Vitals T37.4, bp 115/78, HR 80, RR 18, O2 sat 89%; exam significant for bibasilar crackles, pitting edema. Labs significant for normal BMP and Cr unchanged from baseline 1.2. CXR with bilateral hilar infiltrates consistent with pulmonary edema.
What is the patient’s most likely reason for admission
A. Diuretic resistance
B. Inadequate hospital follow-up
C. Medication non-adherence
D. Spironolactone intolerance
Answer: C. Medication non-adherence
Medication non-adherence as high as 50% among older patients
May result from clinician’s failure to consider patient’s financial, cognitive, functional status
May result form patient’s beliefs and understanding of drugs and diseases
66 yo F with history of HTN, HLD, DM (A1c 7), CKD 3, OA depression, anxiety comes to the ED for nausea, headache, confusion, lethargy x3 days. Her PCP just started her on sertraline 3.5 weeks ago. No fevers, chills, diarrhea, join/ muscle pain. Exam without clonus, diaphoresis, hyperreflexia.
-Home meds: lisinopril, rosuvastatin, prn Tylenol, prn voltaren gel, prn tramadol, metformin.
What mostly likely caused these symptoms?
A. Serotonin syndrome due to SSRI
B. Hyponatremia due to SSRI
C. Hyperkalemia due to SSRI
Answer: B
-SSRI, SNRI, even mirtazapine can cause hyponatremia, usually 2-4 weeks after starting
-the risk seems to diminish over time
-By 3-6 months, hyponatremia risk is the same as for those who do not take antidepressants
-1 study showed paroxetine has the highest rate of hyponatremia, as high as 12% in the elderly patients with mean duration of 9 days. Those with cardiovascular comorbidities are more likely to develop hyponatremia.
61 yo M with spastic quadriplegia due to cerebral palsy, epilepsy, dementia with behavioral disturbances due to head trauma, and HTN was admitted to the hospital for sepsis of unclear etiology with suspected GI source. EGD was done 2 days ago and colonoscopy was done yesterday to evaluate for source.
-Versed and Demerol were given for procedures; mirtazapine was started due to depressed mood and poor PO intake 4 days ago.
-Patient developed rhythmic, uncontrollable mouth movements yesterday, and new onset head tremor today with diaphoresis and agitation. Hyperreflexia was found on exam. He is afebrile, hemodynamically stable.
-Home meds were continued inpatient: Tylenol prn, atorvastatin, losartan, Ativan prn, metoprolol, Seroquel, valproate, tramadol prn.
What is the most likely cause of these symptoms?
A. Neuroleptic malignant syndrome
B. Catatonia
C. Serotonin syndrome
Answer: C
-serotonin syndrome: spontaneous clonus, agitation, diaphoresis, tremor, hyperreflexia
•patient already on multiple serotonergic agents (Seroquel, tramadol) and 2 more were added: mirtazapine and Demerol
- NMS: AMS, muscular rigidity, hyperthermia, autonomic instability
- catatonia: dystonic posturing, waxy flexibility, and stereotyped repetitive movements
An 84-year-old man undergoes evaluation because he has difficulty walking and is fatigued. History includes heart failure, hypertension, hyperlipidemia, and type 2 diabetes mellitus. Current medications are amlodipine, lisinopril, simvastatin, and glipizide. He describes his legs as weak, and over the last 2 months he has had aching pain along his lower thighs and anterior shins that is aggravated by weight bearing.
On examination, there is tenderness over the lower femurs and bilateral anterior tibias. He uses a walker and has a waddling gait.
Laboratory results:
Which one of the following is the most appropriate next test in the evaluation?
Answer: B. Measure 25 (OH)D Level
Patient has classic symptoms of osteomalacia: weakness, aching pain with weight bearing, bone tenderness, and waddling gait. Vitamin D deficiency results in: hypocalcemia, hypophosphatemia, and increased PTH level.