DIP Episode 267 - The USMLE and Normal Changes in The Elderly

Okay, welcome. My name is Divine. This is episode 267 of the Divine Intervention Podcasts. And this podcast is going to highlight a very important topic. This topic shows very frequently on the USMLE Step 1, Step 2, Step 3 exams. And basically this podcast highlights the normal changes that happen as the pressing gets over. So I noticed that it's really hard to find comprehensive resources that deal with this. I'm sure you've seen some of these questions. We were like, wait, the only thing I can see them describe. This question, this is some red factoid from No Man's Land. I've never seen it anywhere. And you have to look through papers, look through a tomogogool, and all that stuff to figure it out. So I decided to delve deep into my research and collect all these high-yield NV Me findings in old people that are normal. And then I decided to essentially bring them together so that we can talk about them in this podcast. So if you listen to this podcast, you should be able to get most of those questions right. And again, this is one of those things I can pretty much promise you. You can look as hard as you want. You very, rarely find this covered in pretty much any resource. But I'm certain if you've taken practice tests, you've done NV Me exams. You know that these things are high-yield. So just look at this as a comprehensive compendium of all these things. So let's get right into it. So let's go from, I guess, maybe go from the top to the bottom of the individual.

So let's start with the brain. So what happens to the brain as the pressing gets older? And then as the pressing gets older, the brain should get smaller. Right? So because many times the NV Me is the way they test these like normal changes with, you know, being old, is they will give you some finding and they will say, oh, which of the following deserves more investigation? Right? Well, they can give you some finding in an old person and they will say, which of the following is us? Which of the following, like they will give you like some problem? Let's say the person's blood pressure goes up, like systolic blood pressure goes up and they will say, oh, which of the following is the most likely finding in the out? Like is most likely responsible for this presentation and stuff like that, right? Or they may give you something where you can just reassure the patient and send them home, right? So I would encourage you to actually pay attention to this podcast. Maybe like define this podcast as a little weird. And it is to be honest with you, even as I'm giving it, I'm like, why would the NV Me care about this? But to be honest with you, I actually see why? Because as clinicians in medicine, right, you don't want to just see every symptom and jump on it. No, right? The Australian things that you should just let go and move on from, right? And we assure you of patients that those things are normal, right? So in terms of the brain, remember, as a person gets older, right?

They are bringing again, should get smaller, right? I mean, this is one of the reasons why people that are old tend to be susceptible to sub-girl hematomas, right? Because their brains get smaller, right? They can, you know, it's not like the skull gets smaller. It's the actual brainmaster gets smaller. So as the brain is like, as the brain is like moving, dom dom dom dom dom dom dom dom all around, right? You can shed those bridging vins and cause a sub-girl hematoma, right? And also cerebral blood flow also goes down, right? As a person gets older, right? Or they can even give you a question about an old person and, you know, they can tell you that the person, you know, has good cognition and all that stuff. And then they'll see that, oh, for some reason, they perform brain imaging and they find some non-specific white matter changes, right? And then if they ask for your next best step, go ahead and reassure the patient, right? Again, as long as vision is fine, changes in the white matter are completely normal in a person that is old, right? And then from a psychiatric perspective, right? Remember, as people get older, you know, they're not able to process things as quickly, right? So even if you're doing like an MMSC and they have like very, you know, minor mild defects, right? Like where they're not able to comprehend things very rapidly. It doesn't mean that they have Alzheimer's, right? Doesn't mean they have Alzheimer's, right?

And then remember that as a person gets older, the working memory also goes down a bit, right? So again, they have like a mild decrease in working memory. But again, if the person is beginning to have problems with activities of daily living or they're beginning to get missing on the way back from the store and all that stuff, right? That's not normal, right? Once you start having problems with activities of daily living, that's not normal. That's something you need to, you absolutely need to investigate, right? And then as a person gets older, right? If we're looking more from like the perspective of like they're sensitive, like they're sensitive, right? Like they're nervous systems, right? Remember, having some opacification of the lens is normal as a person gets older. Again, they won't, like if a person has cataracts, they'll make it pretty clear on the exam. But if you notice, again, they say that, oh, examination of the lens is shows like some mild opacification. But the person has like pretty good visual acuity. Again, that's normal as the person gets older. And again, remember, as the person gets older, their visual acuity should go down, right? It's a thing that it's something normal that happens as a person gets older. And also, an ausmia and loss of taste sensation. Remember, an ausmia means you can't smell, right? And they give you a question about a very old person that is having trouble smelling. You don't have to do this million dollar workup for those people.

It's completely normal, right? Losing smell, losing taste sensation, that's absolutely normal as a person gets older. You don't find any very old person, but if you do, it's not a cause for alarm, right? And also, being able to hear high frequency sounds, right? That ability goes down as a person gets older, right? And also just having good, like, knowledge of where you are in space, right? Like, like, activity of your vestibular system, again, that also goes down as a person gets older, right? And then if we're looking at things from like the cardiovascular perspective, right? So don't forget that your pulse pressure gets wider as you get older, right? So why does the pulse pressure get wider? Remember, the pulse pressure is the spread between your systolic and systolic blood pressures, right? So the systolic blood pressure actually goes up as you get older. I mean, if you look at the hypertension guidelines, right? In terms of, like, blood pressure targets, you see that it's a little more liberal as a person gets older, right? So systolic blood pressure actually goes up as a person gets older. And the systolic blood pressure actually goes down, right? So your systolic goes up as you get older, your systolic gets down, right? So your pulse pressure should get wider, right? I mean, if you're looking at other cardiovascular parameters, right? Like, your heart rate should go down as you get older, your cardiac output, right?

Remember, cardiac output is heart rate times stroke volume, right? So your heart rate is going down as you get older, right? Because, again, you have fibrosin, some parts of the conductance system, right? That should bring down the person's cardiac output, right? And then don't forget, right? Many of these, like cardiovascular related and reflexes, right? So like your barri reflex, like, oh, if you stand up from a seated from a supine position, right? Like, how you don't pass out because blood is pulling your leg because your bar receptors are responding normally? Those reflexes get less eye. They don't work as well as the person gets older, right? And also, like, as a person gets older, this one is particularly high, you know, for example. The person's blood vessels, they become a lot less complex. The person's blood vessels, they become a lot less compliant, right? Like, they become, they are not, they are, let's just say that the person's blood vessels are not very elastic as they get older. That's actually a frequently tested factoid on USMEL exams, right? So blood vessels, they are not very elastic anymore, right? They are not very elastic anymore. That's actually one of the things that contributes to an increase in cisplodial blood pressure as the person gets older, right? And also remember that the size of the person's heart should get smaller as the person gets older. So when you see a person that's older with a very big heart, that's not normal, right?

They probably have some kind of ischemic or like diluted cardiomyopathy, right? So basically the number of cardiac myocytes actually goes down, right? And the size of the cardiac myocytes also goes down as a person gets older. Again, all these things conspire to create that low cardiac output situation that I talked about, right? And then, if you're looking from the perspective of the lungs, right? Remember, a person's pulmonary parameters, right? They are not very robust as the person gets older, right? Like really like a person's pulmonary reserve really does go down as the person gets older, right? So like for example, like your FIV1 should actually decrease gradually as you age, right? Should decrease gradually as you age. I mean, if you're a smoker, you're essentially accelerating that process, right? So like a smoker at 50 may have the lungs that you find in a person that is like 90 years old. Just because smoking has accelerated the rate of decline of the FIV1. But the thing is once they stop smoking, their FIV1 will still keep declining, right? But it will decline at the same rate as an older person that doesn't smoke, right? So remember, your FIV1 should go down as you age, right? So a decline in FIV1 as a person ages doesn't mean that you have some lung pathology. It's just a normal finding that happens as a person gets older, right? And then remember, people's ability, right, to like a, as a person gets older, their lungs are not very great at recoiling, right?

So like remember, when you're taking a deep breath, right? And then you, you, you're expiring or remember it's like a passive recall process that happens, right? That elastic recall of the lungs actually goes down as a person ages, right? And then don't forget that it also gets a lot harder for you to clear out like mucus and stuff from your early as you get older, right? That's why people as they get older, they become more susceptible to like aspiration, pneumonia, and things of that, things of that sort, right? Then I guess if we're looking at the belly, right, and the GI tract, right? Remember, as a person gets older, right? Again, they begin to have like some mild malabsorption, right? Because the thing is the villa that you see lining the small intestines, they begin to undergo atrophy as a person gets older, right? And if you notice again, GERD is a predominant thing, unfortunately, in people that get older, why? Because again, their suffocates is not as great at peristalsis, right? Compared to a younger individual, right? And again, if you notice, old people, they get the, they don't tolerate drugs very well, right? Because the thing is, the liver mass actually goes down, right? Your liver mass should go down as you age, right? So you're less able to deal with all these like toxic chemicals, right? That's why if a person is really young, they can probably tolerate like astronomical amounts of alcohol.

But if you get old and you drink heavily, I wish all your liver the best. I wish your liver all the best, right? So you kind of want to be careful with that. I mean, drinking alcohol in general is not maybe the most predominant thing in the world, but it's not my role here to talk about alcohol. Okay. And then also as a person gets older, right? Like if you notice, those people begin to have like decreased blood mineral density, right? They begin to develop a lot of anemia. That's why it's not every anemia in a non-person that is colon cancer, right? But in general, as a person gets older, they become less able to reabsorb calcium and iron in the guts, right? And if you're not able to reabsorb iron, you're going to get an iron deficiency anemia. You're going to get a micrositic anemia from that, right? And if you also want to be able to reabsorb calcium, right? You can already begin to see why it should not be a big surprise. Why as people get older, you begin to find a bigger and bigger incidence of fractures and osteoporosis, right? Of fractures and osteoporosis. And then if we're going to the flank, right? For getting towards the kidneys and, you know, like the urinary system, remember, some proteinuria is mild. I mean, like some mild proteinuria is normal in an old person. Again, finding, even if the person is not a diabetic, finding some protein in the urine of an old person is completely normal, right? And also, the person gets older, right?

They begin to have increased urinary frequency, right? That's why, again, urinary and continence is more common as people get old, right? And it's actually high yield to know this. This part is actually very high yield. As the person gets older, their creatinine should begin to go up little by little, little by little, because the creatinine clearance is not as robust, again, as the person gets older, right? So those people's creatinine should go up, right? So like a creatinine that may be abnormally in a young person, may be actually perfectly normal in a young person. That's why many of these renal calculations of GFR, we need to adjust them for age. We also need to adjust them for race because they are age differences, they are race differences in creatinine clearance, right? And then, also remember, again, one of the reasons why bone marrow density goes down as a person gets older, right, is again, the kidney's ability, right? In fact, basically, like the one alpha hydroxylase activity of the kidneys, right? Remember those peritobular capillary cells? It actually goes down as a pressing agent, right? So if you have decreased activity of one alpha hydroxylase, you're not going to be able to make active vitamin D. That's going to cause a decrease, reabsorption of calcium and phosphate in the gut, right? And again, that's going to predispose the person to getting like osteoporosis, right?

And also, one of the reasons that people get more incontinence of urine as they get older is that the bladder has a lot less capacity as a person gets older, right? So your bladder, basically, the pouch where you store your urine is not going to be as robust, right? So again, that's going to cause problems as the person begins to eat, right? And then from a reproductive perspective, if we're going down towards the center of action, you know, like the penis and the vagina, right? Remember, as people get older, the hydrogen levels go down, right? So sex drive, libido goes down as the pressing gets older. I mean, for a woman, it's, I mean, for a guy, it's because the testicles on the go atrophy as the guy ages. For a woman, remember, the ovaries atrophy as the woman ages, right? So if your ovaries are not working, sorry, essentially what will happen is those pica-lutin cells, right? Those pica cells that produce hydrogen are gone. If they go, there goes your sauce of testosterone, there goes your libido, there goes your sex drive, right? I don't know. For people who listen to this podcast, sorry, I'm apologizing because I feel like I'm just like disbursing bad news to people. But I'm just think of it more for exams, okay? Don't worry about yourself. You'll be healthy, personally, you get old. At least that's my prayer. Okay, right? And then remember, estrogen also goes down as the pressing gets older, right? Again, off from a very an atrophy, right?

Because again, as the estrogen goes down, that's why you see women as they get older. One of the biggest causes of morbidity in a postmenopausal female, right? It's going to be osteoporosis, right? They're going to have that decreased bone mineral density. That's also going to make the vaginal epithelium less well developed, right? So sex becomes very, very painful as the pressing gets older, right? That's why it's in general. For women as the hip menopause, right? They begin to have vaginal atrophy. You want to use those estrogen, those estrogen creams, right? And also, again, men, their sperm count goes down as they age, right? So you're not going to be able to pump as much sperm as you're having intercourse when you're older, right? So sperm count actually goes down, right? Again, that's why one of the reasons why we're productive potentially, even in guys, goes down as they go past the age of 50, right? And even like those glands that are in women's vagina, those glands, again, their secretions go down significantly as a woman gets older, right? So most women, you know, when they're young, right? When they have intercourse, the vagina is extremely well lubricated, right? But as they get older, the vagina becomes a lot less well lubricated again. Those are one of the things that mix intercourse, right? That's dysparonia, mix pain, pain, trade-in intercourse, pain in the butt. As a woman gets a little, no pun intended. As a woman gets an older, right?

And again, one nice corollary application of this principle is if you can palpate a woman, let's say a woman is more than 50, right? And you can palpate her ovaries, that's worrisome, right? You should begin to think about ovarian cancer, also kind of ovarian pathology in those people, right? Again, these are just all backhand ways they used to test these concepts. And remember, as a woman gets older, right? The uterus also gets smaller, the vagina gets smaller, the breast gets smaller, right? I mean, as a woman gets older, you can begin to see that if you work with geriatric patients, you see that the breasts are really small, hanging down, kind of, deal, right? As they get older. I'm just trying to make these things more memorable so that you can remember, right? And then one of the things would also remember, or it gets maybe for a look in more around the adrenals and the endocrine system, remember, your secretion of PTH actually goes up as you get older, right? Again, this is one of the reasons why you'll reach your bone big time when you get older, right? Because if you reach your bone, again, that's going to kill your bone marrow density, that's going to cause us to paralysis, right? So PTH, secretion actually goes up as a pressing gets older, insulin secretion actually goes up as a pressing gets older, right? And also from the blood pressure perspective, nor a benefit on visual pressing levels, they actually go up as well as a pressing gets older, right?

Those things go up as a pressing gets older. But, if you see TTH secretion, right, and thyroid hormone production, right? Like basically like your adrenal hormones and your thyroid hormones, those actually decrease as a pressing gets older, right? So this is one of the reasons why a pressing metabolic rate goes down quite significantly as they get older, right? Because thyroid hormone secretion is decreased and adrenal, like steroid hormone production is also decreased as well. Again, you may be like, define these things you're discussing, they are very weird. I know they are very weird, but I promise you, they are very high to know for exams, right? Trust me again, I've literally thousands of people for these exams, right? I promise you these things, I'm saying on this podcast, they are all very high to know just one of those things where there's no testicking strategy that will get you around these. You either know them or you don't know them, right? You want to be in the camp of the people that know, learning the camp of people that don't know, right? Remember, there's even a part of the Bible that says that my people are destroyed for lack of knowledge, right? You don't want to be destroyed on your USML exams because you don't know, right? So try to know as much as possible so that you can do really well and get those magically high scores, right? And then one thing, if we're getting to the biggest organ in the body, which is the skin, right?

Remember, the thickness of the dermis and epidermis goes down as the pressing gets older, right? I mean, if you take your one old person, right? Again, if you look on that, you're a joe, you can see like your skin literally just hanging down and it's very soft and things like that, right? So all those happen because the epidermis and the dermis have gotten like very thick, right? So as you get older, the epidermis, the dermis, very thick, right? They lose a lot of their thickness, right? And the mechanism behind this, because they can ask you for the mechanism behind this, is because of decreased activity of fibroblast, right? So collagen is not made as much when a pressing gets older, right? That's why they have very brittle, very friable skin, right? Very friable skin. And then the one thing I just want to maybe end with seeing here is, for those of you that are taking the new MBM exams after November 11th, again, remember, I have a clean SP curriculum that I started on. I believe I've made like four or five podcasts on that stuff. Basically, like, if you look at the USMLA content outline, right? The news of the, I'm going to start testing after November 11th. I hope I'm getting that deep correct. I have actually started making podcasts on that very detailed, very comprehensive podcast. And after all you said and done, my goal is to cover all the material in those things, right?

So if you're interested in that, again, just go on the website, look at, just do a search for the clean SP podcast. If you want to begin, if you're taking your exams around that period, I believe you'd find that to be really helpful. And even for those taking the exams now, it's not out of place to listen to those clean SP podcasts, right? Because again, they kind of intertwined with some stuff that the MBM is already testing, right? So you might as well go and learn those things. And again, God willing, over the next few days to weeks, I'm going to start making more podcasts in that clean SP curriculum pretty aggressively, right? And then as I round up, I do offer, if you're taking step 2, see you anytime soon. I'm having a comprehensive step 2, see you course next Saturday, the 17th, right? It's a 10 hour course. If you're interested, again, shoot me an email through the contact button on the website. And I'll give you some more details. And I also have like a test ticket strategy course from 2 to 4 30 pm, Pacific Standard Time next week Friday, right? So that's the 16th of October, right? And then if you're preparing for the USML, step 3 exam, again, I'm having a 2 D course. It's 12 hours total from the 13th to the 14th of November next month. And then also I'm also bringing in a bio statistics ethics and like new USML changes course, right? So again, I'm making final plans for that. It's probably going to be about a four hour course.

We're going to be covering a lot of bio stats, a lot of ethics, right? And again, in question format, these changes that are coming to the USM Ls, right? Again, like right around November. And please subscribe to the podcast. You can find these podcasts on Apple podcasts on Google Play on Spotify. So please subscribe. At least the most recent 150 will be on those podcasts platforms, right? But if you want the older podcasts or all the podcasts, just go to the website, divineinterventionpodcast.com. You can actually subscribe to that website. Whenever I make a new podcast, you're going to get it. You're going to get a notification, right? And then also please subscribe to the You Tube channel. It's called divineintervention, USML podcast and videos. And again, my schedule has opened up some words. So if you're looking for one of one tutoring for the USML exams, right? So like any of the USML exams, although I'll say maybe USML tutoring for now is a little limited for me. But I'll say more in terms of like ira's advice. Like polishing up your personal statement, mocking reviews, rec letters, stuff like that, right? Like help with writing those things. Just reach out to me through the contact button and we'll take things from there. So thank you for listening. My life lesson in today that I want to talk about is something that I've kind of talked about before. But it's something I've seen destroy many people. And I feel like I should talk about it again.

And this life lesson relates to keeping your mind, keeping your mind. I feel like in these days that we live in, right? Most institutions, like even the media, social media, whatever, they are all based on trying to formulate opinions in your mind, trying to formulate your mindset. The thing is your mind is the most important part of you, right? I mean, literally there's a part of the Bible that says they should guard your heart with all diligence, right? Because out of it, right, proceeds the issues of life. I feel like many people these days really pollutes their minds. And unfortunately, and again, I'm not going to mention any specific examples here. Because I'm not going to call out any resource or anything like that. No, no, no, no, that's not my goal here. But I want you to be able to think for yourself with this life. That's one of the reasons I talk about these life lessons. Well, there are many things that pollute people's minds that are out there. And the thing is once your mind is colored, right? Then it's almost like surgical, right? So you hear like, oh, if the US is attacking this country, descend a surgical strike to destroy blah, blah, blah, blah. It's literally the same thing. If your mind is polluted, if your mind is destroyed, that's almost like a surgical way to destroy a person's life, right?

Like many times when you see people like almost like essentially self-destructing life, it didn't just start suddenly, it did not just wake up in the morning and say, oh, I'm going to self-destruct or oh, I'm going to commit suicide or anything like that. No, it started as a thought in the mind. It started as a mindset of despair, right? And the reason I keep seeing this is medicine, the rigors of medicine, the challenges of medicine, right? Sometimes can really burn a person out from a mental perspective, right? So I will encourage you what to what to feed your mind with, what's the kind of music you listen to, what's the kind of TV shows you input into your mind, right? What's the kind of friends you keep? Like what kind of, like if you're with a person that just always puts you down, always complains about how studying for the USML is sucks and how the program director of my program is the worst person in the world, as you keep feeding your mind with those things, then there is no way your mind, there's no way your life will be good, right? Remember the Bible says as a man think it is in his heart, so he is, right? I mean, if you even look at the Bible when the Israelites were trying to make it to the promised land, right? When they sent spies to Canaan to spy out the land, right? What happened? Some of those spies, you know, except like Joshua and Caleb, when they got back, what did they do? They delivered an evil report, right?

And once that evil report came out, right, that polluted information, it made the Israelites that feeling down, right? They felt crappy, they felt terrible, they said they're complaining to Moses and everything, right? Again, because their minds had been worked on, they lost all hope for the future. So again, watch what you feed your mind with. If you feed your mind with good and you think good, your life will be good. But if you feed your mind with crap and you think crap, your life will be crap, right? So again, just be very careful. I'm telling you, I'm telling you like in our schools, on TV, on social media, pretty much even ads on TV, all those things I'm trying to do is to try to frame your mind, right? Because again, once the mind is framed in a certain way, then you can pretty much control everything that comes from there, right? So again, remember, guard your heart without diligence, right? As you're studying for the USMELY exams, stay away from Reddit, stay away from SDN, because you know what? If you reach stories of people that are like, ooh, I feel like I failed my exam. I just came out of my exam, oh, I've been crying, crying, crying. Oh, I can immediately see that I got 30 questions wrong. Guess what? You're going to pollute your mind, you're going to color your mind, you're going to get a ton of anxiety, right? And then you're not going to feel confident going into your exam, right? In fact, there is one strategy that I recommend for people.

This is actually something I did quite a bit of when I was studying for my USMELY exams. There is a document that I used to have in those days, this is way back in the day, where I could... These were things like, qualifed months in advance, right? Where I qualifed stories of people that got really high scores on the USMELY exams, that people that got like 275s, 2 A.Bs and stuff like that, I qualifed those documents, and then whenever I'm like, I need motivation, I go and read those documents that I've saved, right? And I'm like, wow, okay, this person did this, this, this, and that, he got into the 270s. Okay, this person, wow, this person has such a positive outlook. And guess what? Those things became my reality after I was said and done, right? So again, I will encourage you, watch what you feed your mind with. Like if you're like, man, I got to look at it already and SDN. Let me tell you what to do. Copy and paste pages or screenshot pages of like people that have had positive USMELY experiences, right? And then whenever you're feeling down, go and read those experiences, right? I'm telling you like, those things make a big, big, big impact, right? Many of the mentors I have in life, like, I don't just select people as my mentors, like willingly. Like I really, really look at this person, like is this person a positive person, as this person achieved great things in their lives, right?

Before I get advice from those people, because I know that people can frame a person's mind. And the framing of your mind, if you can win, like literally like in church, like maybe like a few weeks ago, I preached a message on the battle of the mind, right? If you can win the battle in your mind, you've won the battle of life. I'm telling you right now, right? If you can decide in your hearts, like great things that you will achieve in life will not come because you were a hard working person. No, don't get me wrong. Hard work helps and all those things help, right? But the thing is that hard working meant that hard working persona or that is that's, oh, I'm going to, I'm going to persevere through the challenging situations that I face. It all starts because you've made up your mind to be that kind of person, right? So when that battle in your mind first, get your mind straight first before you study any major thing. Once your mind is well set, then those major things will come very easy. Those major things will come very easy. So again, I know I've kind of rumbled for a bit, but I think it's a lesson that's very important for, especially for medical professionals and whoever is listening to this podcast. So thank you for listening. I'll see you next time. God bless you and thank you.

Anosmia (loss of smell) and ageusia (loss of taste).

Systolic blood pressure increases due to arterial stiffening, while diastolic blood pressure decreases.

Mild proteinuria or increased urinary frequency/incontinence.

Elastic recoil of the lungs and ability to clear mucus (mucociliary clearance).

Parathyroid Hormone (PTH) secretion.

It raises suspicion for ovarian pathology or cancer.

Anosmia (loss of smell) and ageusia (loss of taste).

Loss of elasticity/compliance, making them less elastic.

$1-\alpha$-hydroxylase activity (leading to decreased active Vitamin D).

Decreased fibroblast activity, leading to reduced collagen synthesis.

Due to fibrosis/changes in the conductance system and a decline in heart rate.

Thyroid hormones and adrenal steroid hormones.

Anosmia (loss of smell) and ageusia (loss of taste).

Loss of elasticity/compliance, making them less elastic.

$1-\alpha$-hydroxylase activity (leading to decreased active Vitamin D).

Decreased fibroblast activity, leading to reduced collagen synthesis.

Due to fibrosis/changes in the conductance system and a decline in heart rate.

Thyroid hormones and adrenal steroid hormones.