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Question 1

What is the molecular theory of aging?

Answer 1

• Age-related programmed regulation of gene expression at different stages of life
• Epigenetic Modification - not born with these nor do they alter the primary sequence of the DNA, however they can be inherited (Examples: DNA Methylation (this makes gene expression more active but in a non-regulated manner - may be related to increase change of cancer in older age, Histone Acetylation)

Question 2

A) Autosomal Recessive Chances?

B) Autosomal Dominant.

C) x-linked dominant

Answer 2

A)

• 50% CARRIER
• 25% CHANCE AFFECTED
• 75% UNAFFECTED

B) 50% the child will have it
50% will not have it

C)
If father affected = boys not affected, girls are definitly affected but less severly

If mother has it = 50% a boy wil have it, 50% not. some boys will die in utero. girls are not as severely affected

Question 3

What is the cellular theory behind ageing?

Answer 3

Telomere shortening every time a cell replicates - progressive loss of chromosome

• Free radical oxidative stress
• Apoptosis - programmed cell death of terminally differentiated cell

Question 4

Environmental and Evolutionary Theory

Answer 4

▪ ‘Wear and tear’ - inability to regenerate damaged tissue
▪ Cumulative DNA damage by UV AND ionizing energy
▪ ‘Disposable soma’ - there is no evolutionary advantage in survival beyond reproduction and rearing children

Question 5

The record times for a 100m sprint declines massively once you reach the ages of 30,40,50’s. However, the record times for 10km doesn’t not decline as drastically until you reach the ages in 60’s. Why is this?

Answer 5

Decline in maximal energy output

Question 6

Decline in Kidney Function with age

Answer 6

relatively stationary up to the age of 50 then there is progressive decline which is purely age related and not due to disease

Question 7

Decline in Cardiac Output

Answer 7

there is progressive decline from around 10 years old, again not related to any disease but simply age-related

Question 8

What is the consequence of decline in organ function?

Answer 8

• The decline int he function of organs is not functioning-limiting themselves, however there is less reserves in the event of acute or chronic illness
• So the person becomes frail
• at one point a minor illess begins to make the person dependent due to functional effects whihch previously would not have had an effect

Question 9

A) Describe pharmacokinetics in elderly.

B) What about Pharmacodynamics.

Answer 9

• Reduced Renal Clearance
• Reduced liver size
• Reduced enzyme activity in the liver
• Increased sensitivity to certain medicine (e.g GO effects from opioids seen more, drug absorption may be more in some cases like levadopa)

Question 10

What are extrapyramidal SE’s?

Answer 10

Extrapyramidal side effects: Physical symptoms, including tremor, slurred speech, akathesia, dystonia (abnormal muscle contractions), anxiety, distress, paranoia, and bradyphrenia, that are primarily associated with improper dosing of or unusual reactions to neuroleptic (antipsychotic) medications.

tardive dyskinesia (irregular, jerky movements).

Question 11

List Drugs not tolerated well by the elderly.

Answer 11

• Antipsychotics due to extra pyramidal effect
• Digoxine - anything over >250mcg can cause renal impairment
• Benzos - prone to falls
• Opiates/with analgesics = hypotensive effects -> increase risk in falls
• Anticholinergics
• NSAID’s (Bleed)

Question 12

What is a problem with the elderly prescribing that is common ?

Answer 12

• Concordance!
• Make the regimen simple, and clearly explain
• Start small dose, and slow, and review regularly

Question 13

How do you carry out information reconciliation?

Answer 13

• Emergency Care Summary
• Key Information Summary
• SCIDC (Special data base for diabetes)
• MAR Chart (medication administration records for care homes)

Question 14

What patients should be targeted first for med reviews?

Answer 14

• High degree of frailty
• On high-risk medications based on side-effect profile
• Prescribed 10 or more
• Palliative care
• Acute admissions

Question 15

Give examples of high risk meds/

Answer 15

• Immunosuppresants = methotrexate and tacrolimus
• Lithium
• Opioids

Question 16

What is anticholinergics Toxidrome?

Answer 16

• Hot as as a desert (hyperthermia)
• Blind as a bat - cant see
• Dry as a bone - dry mouth and urinary retention
• red as a beet - flushed skin
• mad as a hatter - confused
  + tachy cardia and absent bowel sounds

Question 17

What are the High risk scenarios of NSAIDs clinically

Answer 17

• Dehydration
• +ACEi/ARB + diuretic
• • ckd
• • AGE >75 with no PPI

Question 18

Risk high risk clinical scenarios with medications in the elderly.

Answer 18

• Metformin with dehydration
• Diuretics + dehydration
• Warfarin + macrolide/quinolin

Question 19

When does muscle mass peak?

Answer 19

around 25 uears and can be maintained during mid life

Question 20

What is sarcopenia?

Answer 20

Progressive and generalised skeletal muscle disorder

increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality

it leads to frailty

Question 21

Describe how you would diagnose sarcopenia.

Answer 21

▪ Use SARC-F Questionnaire
▪ Score of 4 or more is predictive of sarcopenia and poor outcome
▪ After a positive SARC-F screening you assess for evidence of sarcopenia
▪ Assessment for evidence = Grip Strength (Men = <27kg, Women = <16kg) + Chair Stand Test (>15 seconds for five rises)
▪ If Sarcopenia is probable = assess causes and start intervention
▪ Finally, to confirm the diagnosis = detection of both low muscle quantity and quality are required
▪ Muscle quality is measured through Dual-Energy X-Ray Absorptiometry (DXA)
▪ You then assess severity (low physical performance is severe - you use gait speed (4m usual walking - equal or lower than 0.8 meters/s means low performance)

Question 22

Describe the difference between primary and secondary sarcopenia.

Answer 22

▪ Primary = Age is the only factor
▪ Secondary = factors other than aging are the cause (when it is secondary to a systemic disease like cancer)
▪ Frailty is different to sarcopenia - sarcopenia contributes to frailty

Question 23

Describe the difference between acute and chronic Sarcopenia.

Answer 23

Acute = <6 months (related to an illness or injury) 
Chronic = equal or more than 6 months (related to chronic disease)

Obesity has a negative effect on the severity of sarcopenia

Physical inactivity influences the sarcopenia of a patient

Question 24

Describe causes Malnutrition-associated sarcopenia and cachexia.

Answer 24

▪ Low dietary intake (inability to eat)
▪ Reduced nutrient bioavailability (diarrhea + vomiting)
▪ High nutrient requirement (with inflammatory diseases such as cancer or organ failure)
▪ Disease-related malnutrition - this leads to secondary sarcopenia

Question 25

What is cachexia?

Answer 25

▪ Malnutrition-related sarcopenia | ▪ Defined as the combination of disease-related malnutrition due to the presence of a systemic inflammatory response

Question 26

A) What are the main elements of metabolic adaptation? B) Why is this concept important?

Answer 26

A) - After prolonged starvation the body goes into Gluconeogensis due to glycogen depletion - Brain relies on ketones now - sharp decrease in insulin as less glucose is needed - Glucagon is released eventually leading to lipolysis which produces fatty acids for the production of ketones needed for the brain - Less protein is required for energy so less muscle break down to use amino acids for Gluconeogensis - Main elements 1- production of ketones from fatty acids from fat (spares muscles) 2- Sharp decrease in insulin and increase in glucagon which increases fatty immobilisation 3- Basal/resting metabolic rate decreases (however in inflammatory response the metabolic rate markedly increases) B) but in inflammatory disease this concept is not functioning as it should -> insulin is produced -> glucose is needed -> Gluconeogenesis instigates the break down of proteins to use the AA's

Question 27

Effects of drugs on nutrient metabolism and excretion:

Answer 27

▪ CHO Metabolism (Glucose intolerance) - oral contraceptives and corticosteroids ▪ Lipid metabolism (Hyperlipidemia) - chlorpromazine

Question 28

Effects of drug treatments on Food intake:

Answer 28

▪ Anorexia and Diarrhea -antibiotics ▪ Nausea and vomiting - common SE to many ▪ GI - NSAIDS, Antibiotics ▪ Taste changes/sore mouth - cytotoxic and psychiatric drugs Increase appetite and cravings - insulin and corticosteroids

Question 29

What are the protein requirements per Kg in adults?

Answer 29

1-1.2g /kg 1.2-1.5g with acute or chronic illness

Question 30

What is key to prevent muscle wasting at end of life?

Answer 30

Physical activity

Question 31

After what age is an individual deemed to have capacity unless proven otherwise?

Answer 31

16 year old

Question 32

List the elements that may be present which indicate a lack of capacity.

Answer 32

``` ▪ Incapable of acting; or ▪ Incapable of making decisions; ▪ Communicating decisions ▪ Understanding decisions Retaining the memory of decisions ```

Question 33

What are the ethical and legal issues in the end of life care?

Answer 33

▪ First Legal and Ethical Issue: Treatment and age (ageism) ○ Tendency to assume older people are less likely to have capacity ○ Drop in treatment rates for people over 70-75 years ○ Implies that people are not being given the right information to make their own decisions ○ Ageism - why? Because the decisions are being made not based on the person but on one characteristic which is peripheral to the decisions being made ○ All adults have autonomy - to deny it is to deny their basic human dignity - morally wrong and unlawful ○ Consent is vital in providing medical treatment ▪ Second: Competence and Refusal of Treatment (Dignity) ○ Tendency to assume that an older person making an irrational decision is incompetent ○ This is incorrect as incompetence is a legal term and requires a set criteria to be met ○ Furthermore, someone who is incompetent in one area does not mean they are incompetent in other areas. Therefore they may well be able to make their own decisions.

Question 34

True or False. If a decision is made by a patient regarding their own health which leads to detrimental health outcomes for that patient, you should act in the best interest of the patient and provide the appropriate treatment.

Answer 34

False

Question 35

Explain the essence of the ruling in the Montgomery case.

Answer 35

Any competent adult has the right to make nay decisions regarding their health, including refusing treatment

Question 36

Explain what is meant by the doctrine of double effect.

Answer 36

▪ It means that it maybe that to maintain someone's dignity you need to do something that may shorten their life ▪ Example: using great amount of analgesia on someone with cancer to alleviate the pain, however it is expected that the analgesia will shorten their life Courts have stated: as long as the intent is to treat and maintain dignity then the death is seen as a side effect of the treatment and the doctor is not guilty

Question 37

Describe the role of advanced directives/Advanced decisions.

Answer 37

▪ These are living wills (a document) where the person will decide what should be done in regards of their health in the event they end up lacking capacity (what treatments they want or do not want) e.g. dementia, and a coma ▪ Adults with Incapacity (Scotland) Act 2000 = health care professional MUST take into the account the past and present wishes of the person

Question 38

Describe the role of welfare power of attorney.

Answer 38

▪ Instead of a document, an individual may chose to appoint a wellfare attorney who will make decisions on the behalf of the person in the event they lack capacity/Loss of communication This will only come into effect in the event the person in question is deemed to not have capacity

Question 39

Why does it matter to recognise frailty?

Answer 39

▪ Important to recognize it so you can try and prevent it + we have an aging population ▪ Older frail patients have more hospital admissions ▪ Admissions are often unplanned ▪ Frail patients: ▪ Longer stays ▪ Muscle loss (10 days for someone over 80 is 10 years muscle wastage) ▪ More susceptible to complications of admission (e.g delirium, nutritional porblmebs, dehydrations, pressure sores) ▪ Higher rates of mortality

Question 40

How do you deal with recognition of frailty:

Answer 40

Assess, plan, intervention

Question 41

If an old person is admitted to hospital who maybe frail how do you assess?

Answer 41

1- Use Frailty Assessment Tool 2- this will then let you know if a CGA is required

Question 42

Explain what Is meant by frailty.

Answer 42

▪ Clinical state related to aging ▪ Increasing vulnerability from a decline in physiological and psychological reserve ▪ A minor insult can lead to significant functional decline and disability

Question 43

List, and describe, the two models that can be used to define frailty.

Answer 43

▪ Phenotype Model - uses a core group of 5 clinical core presentations (3/5 identify adverse outcomes associated with frailty): ○ Unintentional Weight Loss ○ Reduced Muscle Strength ○ Reduced Gait Speed ○ Self-reported Exhaustion ○ Low Energy Expenditure ▪ Cumulative Deficit Model - introduces the concept of frailty index based on the assumption that accumulation of deficits results in an increase in adverse outcomes

Question 44

List Frailty Syndromes

Answer 44

- Delirium - Falls - Incontinence - Medication Side-effects - Immobility

Question 45

There is evidence to show that sarcopenia is an important feature of frailty. Under which of the two models used to define frailty does it fall.

Answer 45

Phenotype approach (More prevalent in women)

Question 46

List the domains of a CGA.

Answer 46

``` ▪ Physical ▪ Socioeconomic/Environmental ▪ Functional ▪ Mobility/balance ▪ Psychological/Mental - Health - Medication Review ```

Question 47

ACS in Elderly:

Answer 47

▪ Atypical presentation (only 40% over-85s present with chest pain) ▪ Complications from ACS are more common: heart failure, arrhythmias ▪ Side effects from medications are more commonNon-specific raised troponin ▪ 'type 2' MI - MI driven by myocardial oxygen supply and demand mismatch in the absence of coronary thrombosis ▪ Sepsis ▪ CKD ▪ Heart Failure

Question 48

You suspect delirium and carry out 4AT. What do you do after if it is 4 or above?

Answer 48

TIME BUNDLE (Triggers, Investigations, Management Plan, Engage and Explore) - you go through various elements which allow you to see what triggers there are which may have caused the delirium

Question 49

Describe physiological changes with ageing..

Answer 49

Cardio = reduced vascular compliance, increase in pressure -> LVH and aortic sclerosis, arrhytmias, increased risk of postural hypotension Resp = reduced lung compliance and immune function and reduced cough reflex Renal = reduced blood flow , reduced e GFR, and increase nocturia, increased risk of AKI and Adverse drug reactions and UTI GI - reduced gastric motility so malabsorption, you may have anaemia as a result (B12, FOLATE) and weak bones (calcium)

Question 50

Atypical Presentations of elderly.

Answer 50

- Silent MI - Pulmonary oedema without SOB - Paradoxical presentation of thyroid disease - infection without fever or raised inflammatory markers - Low mood vs cognitive impairement