Polypharmacy

Question 1

Side effects of PPI use

Answer 1

Bone fragility
C difficile infections
Pneumonia ? 
Hypomagnesaemia
Increased mortality?

Question 2

What type of muscle mass is lost in sarcopenia in ageing?

Answer 2

TYPE 2 (fast twitch/fine motor) greater than type 1 (slow twitch, sustained motor)

Question 3

Major cardiovascular changes with getting old?

Answer 3

Ventricular muscle stiffens
Increased LV mass
Reduced relaxation
NO CHANGE in contractility or EF at rest
Loss of atrial pacemaker cells
Loss of baroreceptor reflex
Reduced max HR- dependence on SV to increase CO
Sitting HR decreases
Greater reliance on atrial contraction (approx 30% cardiac output)
Afterload increased due to stiffening of vessels - DBP rises 30-60, systolic increases with age
Decrease beta receptors so less response to beta adrenergic stimulation

Exercise conditioning increases SV and o2 utilisation

Question 4

Resp system changes with age?

Answer 4

DLCO declines
FEV1 declines
FVC declines, but less
Increase VQ mismatch
Increased bronchodilator response
Reduced drive with hypoxia and hypercarbia
Stiffer chest waall
REduced elastic recoil

Question 5

Renal changes in old people?

Answer 5

Reduced renal mass- the cortex more than the medulla
Reduce glomeruli
Sclerotic changes
Reduced blood flow 10% per decade
Reduced max and min osmolality
GFR reduced 8ml/min per decade from 45 years

Question 6

Urinary tract in old people?

Answer 6

Variable reduction in bladder capacity

Question 7

Bladder changes in old people?

Answer 7

Reduced bladder capacity
Reduced bladder contractility
Increased detrusor hyperactivity
Reduced outflow resistance in women
Nocturia

Question 8

Liver in old people?

Answer 8

Reduced volume, weight, blood flow
Note need 70% reduction in hepatic reserve to be significant
No change in LFTs with age
LEss than 10% decline in clearance related to perfusion rather than induction/inhibition of metabolism

Question 9

Changes in drug metabolism in old people?

Answer 9

Slower absorption - reduced bioavailability
Reduced vol distribution
Reduced renal more than hepatic clearance
Increased half life

Question 10

Immune system changes in old people?

Answer 10

Impaired T helper cells–>humeral changes
Ig overall stable but increase A, G, and decreased D and M
Reduced antibody response
Need larger antigenic stimulus, and response not as large
Increase in monoclonal Igs not associated with myeloma after 70
Less diurnal variation in temperature
Reduced temp response to Il1, 6, TNF

Question 11

Endocrine changes in old age?

Answer 11

Insulin resistance
Increase PTH
Increase ADH--> increase hyponatraemia
Increase ANP with increase in intravascular volume
Rise in FSH and LH

Question 12

Use of antipsychotics in the elderly leads to what?

Answer 12

Increased risk of stroke and thromboembolism

Question 13

main side effects SSRI

Answer 13

GI
bleeding from plt dys
falls
hyponatraemia

Question 14

SNRI side effect

Answer 14

headache
gi
diaphoresis, dry moouth
hypertenison

Question 15

TCA side effects

Answer 15

falls risk
dry eyes, urinary retention, constipation
weight gain
cardiac arrhythmia
sedation

Question 16

TCA MOA

Answer 16

NA and serotonin reuptake inhibitors and GABA-A blockers

in overdose, cardiotoxic from block fast sodium channels
seizure and coma before cardiotoxicity

bicarb promotes TCA binding to plasma proteins

Question 17

VZV hibernates in

Answer 17

sensory ganglia

Question 18

Suspect VZV in aseptic meningitis?

Answer 18

anti VZV ab in csf more sensitive than blood and bost better than PCR assay

Question 19

Famciclovir in VZV?

Answer 19

reduced time to new lesions
reduce time to loss vesicles and full crusting
quicker cessation viral shedding
faster pain resolution
Intrials given within 72 hours but some evidence if still new vesicles

NOT CLEAR if reduce post herpetic neuralgia

Question 20

acute zoster pain?

vs post herpetic neuralgia?

Answer 20

NSAIDS, panadol
next opioids

post herp: topical lidocaine, pregabalin, opioids, TCA, capsaicin

Question 21

In AU who gets zoster vaccine

Answer 21

single dose all people over 60 doesnt matter if chicken pox history
Not if preg, HIV under 200, pred more than 20 for 2 weeks, anti TNF therapy, chemo last 3 months, haem malig active

Question 22

Au guidelines who gets famcic or valacic or acic?

The former two are better for pain

Answer 22

all people less than three days

all immunocompromised- if systemic IV aciclovir

Question 23

is there diurnal variation in fibromyalgia?

Answer 23

No

Question 24

What is the new concept with american lipid profiles?

Answer 24

That it is your CV risk at baseline rather than LDL at baseline that determines magnitude of benefit for statin therapy. Reduce risk 20% from baseline.