Geriatrics Flashcards

Question

Renal System

Answer 1

``` Kidney parenchymal tissue atrophy ↓RBF & renal mass ↓drug clearance ↓GFR 1mL/yr Dilute urine (unable to maximally concentrate) Tubular frailty - more susceptible to hypoxic or nephrotoxic injury Impaired Na+ conservation ↓renin/aldosterone production Prone to fluid overload or dehydration Unable to accommodate hemodynamic changes - more susceptible to injury ↓sensitivity to volume/osmoreceptor Diminished thirst response Bladder dysfunction/incontinence ```

Answer 2

Creatinine clearance

Answer 3

1. Fluid overload 2. Metabolite & drug accumulation 3. ↓drug elimination 4. Prolonged anesthetic drugs & adjuncts effects 5. Electrolyte imbalances 6. Arrhythmias

Answer 4

↓liver mass 20-40% ↓hepatic blood flow & functional hepatic reserve Altered drug metabolism & protein binding ↓metabolism → prolonged half-life ↓↑↓↓↓↑↑↓↑ →

Answer 5

Variable Oxidation, reduction, & hydrolysis CYP450 enzyme

Answer 6

Not significantly altered | Conjugation, sulfonic acid, or acetylation

Answer 7

Decreases & increases

Answer 8

↓motility & colonic function ↓GI immunity & drug metabolism Liver function impact on NPO status

Answer 9

``` Innate & adaptive changes ↓immune cells bactericidal activity ↑cytokine & chemokine levels Low-grade chronic inflammatory process ↓T & B cell function Impaired ability to fight infection & control cancers ```

Answer 10

Endocrine gland atrophy ↓hormone production Impaired endocrine function & glucose homeostasis Insulin, thyroxine, growth hormone, renin, aldosterone, & testosterone deficiencies Chronic electrolyte abnormalities Diabetes, hypothyroidism, impotence, & osteoporosis ↓lean body mass

Answer 11

↓1% per year after 30yo Total energy expenditure ↓ *↑energy expenditure w/ multiple comorbidities & chronic illness Unable to tolerate ↓O2 demand

Answer 12

↓pancreatic islet β cells number & function ↓insulin secretion & peripheral insulin resistance ↑hepatic glucose production Impaired fat/protein production

Answer 13

Diabetes - Risk periop & postop complications - Impaired cognition/dementia

Answer 14

↓intracellular fluid & blood volume → hypotension ↓muscle mass & reduced strength ↑fat % per total body weight Atrophy → 1° impact fast-twitch muscle fibers Loss body protein & motor neurons ↑waist circumference Fat accumulation w/in muscles ↓collagen, elastin, SQ fat, dermal/epidermal skin thickness Prone to skin tears & nerve injuries ↑↓↑↓↑↑↓↑ → ↑↓↑ → ↔ α ⋅ β Ø λ π η

Answer 15

Careful positioning

Answer 16

Impaired ↓hypothalamus function Hypothermia more pronounced & lasts longer Less effective peripheral vasoconstriction Prolonged recovery from anesthesia Impaired coagulation & immune function Blunted ventilatory response to CO2 ↑shivering incidence → O2 consumption & basal metabolic rate → hypoxia, acidosis, & CV compromise

Answer 17

Reduced physiologic reserve - associated w/ ↑disability susceptibility ↑vulnerability to adverse outcomes d/t ↓resistance to stressors 1° or 2° Weight loss, fatigue, impaired grip strength, low physical activity, & slow gait Decompensate more quickly Frailty index predicts outcomes in non-surgical elderly population (preop risk assessment) Periop risk factor r/t postop complications ↑LOS & discharge to skilled/assisted living facility

Answer 18

Intellectual decline Changes in cognitive, behavioral, or health status Degenerative brain diseases often incurable Supportive therapy/treatment

Answer 19

``` Chronic drug intoxication Vitamin deficiency Subdural hematoma Major depression Hydrocephalus Hypothyroidism ```

Answer 20

``` Unstable gait Poor muscle strength Neural damage in basal ganglia & cerebellum Peripheral neuropathy Fall history → evaluate gain & balance ```

Answer 21

``` Polypharmacy Loss neuronal tissue & receptor changes ↑sensitivity ↓anesthesia requirements Consider BIS monitor Anesthetic toxicity & cognitive dysfunction ```

Answer 22

``` ↓Vd ↑plasma concentration ↑body fat ↓muscle mass ↓plasma albumin Impaired renal function ↑serum concentration & prolonged drug effects (renal dependent elimination) ```

Answer 23

↓MAC 6% per decade after 40yo | N2O ↓8% per decade

Answer 24

↓induction dose 50% ↓infusion 20% ↑effect on hemodynamics ↓clearance (women > men)

Answer 25

``` Ideal drug (CV stable) Less hemodynamic instability ↓Vd ↓clearance ↑sensitivity ↓induction dose NO analgesic properties ```

Answer 26

↓total dose 50-80% ↓Vd Delayed recovery d/t ↓central Vd

Answer 27

↑sensitivity MOA unknown ↑DOA Contributes to postop delirium Hydroxymidazolam metabolite potential accumulation w/ ↓renal function

Answer 28

↑sensitivity ↓hepatic metabolism ↓renal excretion Metabolites (pharmacologically active Codeine, Morphine, & Meperidine) → analgesia & side effects

Answer 29

↑potency 50% > 80yo ↑sensitivity ↓dose PD > PK

Answer 30

``` Not dependent on liver or renal function ↓50% by 85yo ↓bolus dose 1/2 Infusion rate 1/3 Slower on & off ↑PD sensitivity ```

Answer 31

``` NOT RECOMMENDED Normeperidine = active metabolite Renal excretion Half-life 15-30 hours Associated w/ postop delirium Postop shivering ↓dose ```

Answer 32

PD & ED95 not significantly altered PK ↓onset maximal block ↓hepatic metabolism ↓renal excretion ↑recovery time 50% Residual blockade effect on pharyngeal function DOC = Cisatracurium - Hoffman elimination & ester hydrolysis - Not organ dependent

Answer 33

Decision-making capacity

Answer 34

1. Understanding treatment options 2. Appreciating & acknowledging medical conditions & outcomes 3. Exhibiting reasoning/rational discussion of treatment options 4. Clearly choosing a preferred treatment option

Answer 35

Patient right to self-determination

Answer 36

Obligation or responsibility to help the patient | Do Good

Answer 37

Not intentionally harm the patient | Do not harm

Answer 38

Treat the patient fairly

Answer 39

Suspension - full or partial | No suspension

Answer 40

Suspension - full or partial | No suspension

Answer 41

25% malnutrition - Associated w/ adverse health outcomes - Postop complications ETOH check vitamin B12 & folate levels ↓intake d/t taste loss & ↓appetite ↓lean body mass Slower protein turnover Severe nutritional risk: > 10-15% weight loss over 6mos BMI < 18.5kg/m^2 Serum albumin < 3g/dL

Answer 42

``` Poor functional status = surgical site infection & postop complications risk factor 25% > 65yo have impaired ADLs Up & go mobility test Review ADLs Assess hearing & vision ```

Answer 43

Assess cognitive ability, decision-making capacity, & postop delirium risk Dementia history - Mini cog = 3 item recall & draw a clock - Advanced directives or surrogate decision maker

Answer 44

Drugs potentially harmful AVOID: - Metoclopramide (extrapyramidal effects) - Meperidine - NSAIDs (GI bleed) - Transdermal Fentanyl → delirium & respiratory depression - Agonist-antagonist opioids - Methadone (long half-life → over-sedation or respiratory depression)

Answer 45

Risk of adverse events - Assess current medications - Chronic benzodiazepine - OTC or herbal supplements Anticholinergics associated w/ delirium & gait instability Discontinue when possible

Answer 46

Trauma, falls, hip fracture, intracranial bleeding, intra-abdominal, or vascular Assess acute heart failure, acute lung injury, dehydration ↑O2 requirements Worse outcomes than elective surgery - unable to optimize or perform full preop work-up

Answer 47

``` Regional anesthesia ↓DVT incidence ↓Anesthetic requirements ↓induction doses 25% Avoid benzodiazepines Skin breakdown & ulcerations risk - positioning considerations Hypothermia risk ```

Answer 48

Do not tolerate hypovolemia or hypervolemia Hypovolemia → hypotension & organ hypoperfusion Hypervolemia → HTN & CHF ↑Hgb/Hct goals

Answer 49

Postop delirium & POCD common after cardiac & non-cardiac surgery 15-55% hospitalized elderly patients

Answer 50

Rapid decline in LOC - difficulty focusing, shifting, or sustaining attention Incoherent speech, memory gaps, disorientation, hallucination not explained by pre-existing dementia or impairment Possible inflammatory response d/t surgical stress Haloperidol short-term to control symptoms

Answer 51

``` Genetic disposition Lower education ↑ETOH intake or abuse Elderly ASA status Pre-existing mild cognitive impairment CVA history Cardiac surgery Surgery & anesthesia duration Intraop cerebral desaturation Postop infection ```

Answer 52

Cardiac, pulmonary, or neurologic - Emergency surgery - # comorbidities - Surgical procedure type

Answer 53

Acute procedural pain vs. chronic pain Identify source or cause - distended bladder, incision, infection, inflammation, fracture, positioning, UTI, or constipation

Answer 54

1. Surgical procedure risk 2. Patient clinical risk factors ↑clinical risk factors ↑surgical procedure risk → overall poor outcomes risk ↑hospitalization $$$ Elderly = worse outcomes ↑complication risk w/ CV surgery 2-5x mortality cardiac & non-cardiac surgery Postop complication 60% Prolonged mechanical ventilation Atrial fibrillation more common Surgical wound infection Stroke 2x Neurocognitive dysfunction DELIRIUM COMMON AFTER MAJOR SURGERY Functional recovery Ø norm Patients commonly discharged to long-term rehab or nursing home

Answer 55

Pulmonary insufficiency or infection

Answer 56

Aging = progressive accumulation of random molecular defects ALL major cells types in brain undergo structural changes (neuronal cell death, dendritic changes, synaptic loss) ↓brain mass ↑CSF Blood vessels - stiff & thick + atherosclerosis ↑diastolic dysfunction w/ age (systolic dysfunction abnormal) Closing volume approach Vt → atelectasis Kidney susceptible to damage - unable to accommodate hemodynamic change or Na+/H2O imbalance Frailty ↑susceptibility to disability 1. Procedures surgical risk 2. Number clinical risk factors Delirium common after major surgery ↓anesthetic requirements

Geriatrics Flashcards

(80 cards)