Geriatrics Flashcards
(106 cards)
1
Q
What physiological change of aging occurs in the autonomic nervous system?
A. decreased beta receptor responsiveness.
B. decrease norepinephrine levels.
C. Increased acetylcholine release in response to vagal stimulation.
D. increased baroreceptor sensitivity.
A
A. decreased beta receptor responsiveness d/t decreased receptor affinity in altered signal transduction.
2
Q
How is autonomic nervous system function altered with aging?
A
-Increase sympathetic nervous system activity (Decreased parasympathetic nervous system activity)
-Decreased beta receptor responsiveness
-Increased no epinephrine concentrations in the plasma
3
Q
Elderly patients have decreased barrel receptor responses, this increases the risk of:
A
Orthostatic hypotension
Syncope
Increased hypotension with sympathectomy
4
Q
How does atrial compliance and filling pressures change with aging?
A
Feeling pressure should increase due to the less compliant heart and vascular system. Diastolic function is decreased due to reduce compliance and increased wall, stiffness, impairing, myocardial relaxation.
5
Q
True or false: aging patients have no change in systolic function.
A
True (assuming no prev severe cardiac events)
6
Q
What is ischemic preconditioning?
A
When a short period of myocardial ischemia will lessen the effects of a prolonged ischemic event that occurs after. Weird.
7
Q
What are some cardiovascular changes in the older adult?
A
-Reduction in arterial compliance
-Increased systemic, vascular resistance
-Increase in arterial stiffness, increasing the systolic blood pressure to a greater degree than the diastolic pressure.
!However, there is no change in systolic function!
8
Q
What physiological change of aging occurs in the cardiovascular system?
A. increased vascular system compliance.
B. decreased mean arterial pressure.
C. Decrease pulse pressure.
D. left ventricular wall thickening.
A
Left ventricular wall thick
9
Q
What medication in the elderly can increase risk of seizures?
A
Tramadol (weak opioid)
10
Q
Medication in the elderly can increase the risk of central anticholinergic symptoms
A
Scopolamine
11
Q
Compared to a 25-year-old woman, what will most likely be observed in a 65-year-old woman when rocuronium is used for neuromuscular blockade?
A. Increase duration of redosing
B. Increase initial dosing requirements
C. Onset of action will be unaffected by age
D. Onset of action will be shorter
A
A. Increase duration of redosing
You don’t have to redose as much.
There is not a shortened onset of action in elderly patients
12
Q
What are some pharmacokinetic changes that alter the duration and elimination of NMBA’s in the elderly??
A
Increased total body fat
Decreased total body water
Decrease lean body mass
Decreased renal and hepatic blood flow
Decreased hepatic function
Decreased GFR
Decrease CO
13
Q
What are elderly patients more prone to d/t their increase in age?
A
Age-related comorbid disease
Progessive decline of baseline function
Increase in ASA physical status
14
Q
What are factors that influence perioperative outcomes in the elderly?
A
Emergency surgery
Number of comorbidities
Type of surgical procedure
15
Q
What are the three most common postoperative complications in the elderly? (broad think body systems)
A
Cardiac
Pulmonary
Neurologic
16
Q
The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) and the American Geriatrics Society (AGS) developed Best Practice Guidelines for Optimal Preoperative
Assessment for the elderly surgical patient. What are the categories? (12)
A
- Cognitive Ability Capacity
- Decision Making Capacity
- Depression
- Risk for postoperative delirium
- Alcohol and Substance Abuse
- Cardiac
- Pulmonary
- Frailty
- Functional Status
- Nutritional Status
- Medications (Beers Criteria),
Review RX, herbal or OTC meds - Patient Counseling
17
Q
Beer’s Criteria from the American Geriatric Society should be used for?
A
populations aged 65 and older in the US
18
Q
What is the purpose of Beer’s Criteria?
A
Improve medication selection,
educate clinicians and patients,
reduce adverse drug events and
serve as a tool for evaluating quality of care,
cost, and patterns of drug use of older adults
19
Q
What are the Beer’s Criteria?
A
- D/C meds that have potential reaction with anesthesia
- D/C nonessential meds that increase surgical risk
- Identify meds on Beer’s criteria
- Avoid Ketorolac (GI bleed, AKI)
- Avoid Meperidine for analgesia (delirium)
- Use caution with antihistamines or with strong anticholinergic effects
20
Q
True or False: Aging not synonymous with poor physiological health
A
True
21
Q
True or False: Chronological age no longer an indicator of morbidity and mortality
A
True
22
Q
At what age do we “peak”, then gradually decline?
A
30 :(
23
Q
What is the most common cardiac complication and leading cause of death in
the postoperative period? Torabi Red Item
A
MI
24
Q
Most common CV diseases in the elderly?
A
HTN
HLD
CAD
CHF
25
The perioperative risk calculator provides an estimate of perioperative cardiac risk and should be completed for elderly patients before non-– cardiac surgery. What five questions/categories are reviewed.?
Age
Creatinine
ASA
Preop functional status
Procedure site
26
How does ventricular ejection time change in the elderly? Why?
Prolonged Ejection Time
A thicker ventricular wall reduces chamber size and makes the heart less flexible.
When it contracts, it takes longer to squeeze the blood out because the thickened muscle isn't as coordinated and can't contract as quickly and efficiently.
Also, because the afterload is higher, more force and time are needed to eject blood from the left ventricle.
27
Prolonged circulation time in the elderly, due to CV changes, cause what sort of induction of anesthetic changes?
Faster induction time with inhalation agents, but delays the onset of IV drugs
28
Why do inhalation agents have a relatively faster onset in the elderly?
Prolonged circulation time leads to:
-Blood lingers longer in the pulmonary capillaries.
-It absorbs more anesthetic gas per unit of time while it's in the lungs.
-This increases the partial pressure of anesthetic in the blood more quickly.
-Faster rise of alveolar and arterial anesthetic partial pressures (FA/Fi) → faster delivery to the brain → faster induction.
29
What sort of conduction system changes occur in the elderly due to calcification?
Afib
Sick Sinus Syndrome
Heart Blocks
- more likely to need pacemaker
30
In an arterial BP tracing, why is there a faster propagation of the pulse pressure waveform?
D/t arterial stiffening
(Pressure tracing per beat more narrow/shorter)
31
List the age-related CV changes seen in the elderly
Myocardial Hypertrophy
Myocardial Stiffening
Reduced LV Relaxation
Reduced Beta Receptor Responsiveness
Conduction Abnormalities
Stiff Arteries
Stiff Veins
32
The elderly CV change, myocardial hypertrophy, causes a failure to maintain?
Preload (CHF)
(Can't relax > reduced diastolic filling > reduced preload > reduced SV > reduced CO)
33
The elderly CV change, myocardial stiffening, makes ventricular failure dependent on?
Atrial Pressure
[Normally, blood flows passively from the atrium into the ventricle during early diastole — no major force needed.
-But in a stiff ventricle, passive filling is impaired because the ventricle resists expansion.
-Therefore, the ventricle relies heavily on the "atrial kick" — the active contraction of the atrium — to push extra blood into it.
-Higher atrial pressure (and a strong atrial contraction) becomes necessary to overcome the ventricular stiffness and achieve adequate filling.]
34
The elderly CV change, reduced Beta-Receptor Responsiveness, leads to?
Hypotension (less response to catecholamines) and more dependent on the Frank Starling Law (Preload)
35
The elderly CV change, stiff arteries and veins, leads to?
Labile BP and Changes in Blood Volume - more exaggerated changes in cardiac filling
36
The elderly are more dependent on ________ _________ d/t decreased beta receptor resopnsiveness.
Frank Starling Law
37
Elderly patients have an increase in catecholamine levels, what downstream effects does this cause?
decreased end-organ adrenergic response
38
How does HR in the elderly response to hypotension, hypovolemia, and hypoxia?
Decreased capacity/ability to respond with an increase in HR.
-Barorecpetor responsiveness reduced
39
How does age related calcification in the elderly affect the heart?
Calcification of conduction system leads to loss of SA node cells --> arrhythmias
Calcification of the valvular system: aortic and mitral stenosis/regurg
40
How does the sympathetic nervous system activity change in the elderly?
Increase sympathetic, nervous system activity due to increased amounts of catecholamines
41
how is emergence changed in the elderly?
Slower, due to lower cardiac output
42
What lung volume changes are seen in the elderly?
Increase in residual volume
Increase in FRC
Decrease vital capacity,
Decrease inspiratory reserve volume
Decrease expiratory reserve volume.
43
How does closing volume change as we age? *red item Torabi*
Closing volume exceeds FRC at 45 years in the supine position
Closing volume exceeds FRC at 65 years in upright position
44
How does closing capacity change as we age?
Gradually increases as we age
45
What two volumes make up closing capacity?
Closing volume + residual volume
46
How do calcifications in the elderly affect the MSK system?
Calcification of the chest wall, intervertebral and intercostal joints
-Leads to decreased intercostal mass
-Decrease chess wall compliance
-Flattening of diaphragm
-Loss of intervertebral height, changes in spinal lordosis
47
How does PaO2 change with age?
Overall, impaired gas exchange, therefore PaO2 declines with age
PaO2= 100 - (0.4 x Age)
48
How do central and peripheral chemo receptors change with age? What are the consequences and anesthetic considerations?
Decreased chemo receptor sensitivity
Leads to increased hypoventilation, increased apnea, and therefore a decreased ventilator response.
Consider postop CPAP or BiPAP
Vigilant monitoring
Supplemental O2 postop
Encourage cough deep breathe/IS
49
How does pulmonary muscle strength change with age? Consequences and anesthetic considerations.
Decreased muscle strength
Increased work of breathing and decreased protective airway reflexes. Risk for resp failure and aspiration
Adequate hydration, consider RSI with GA, ensure fully reverse prior to extubation, consider CPAP or BiPAP postop, vigilant monitoring, cough/deep, breathing postop
50
How do the small airways change as we age? What are the consequences and anesthetic considerations?
There is an increase in small airway closures
Increased anatomic, dead space, decreased alveolar surface area, decreased pulmonary capillary blood flow, decreased PaO2
Consider viola recruitment maneuvers, limit high FiO2, maintain PaCO2 near normal preop value, consider regional/local with sedation
51
What are some airway anatomic changes that occur as we age along with their consequences? (red item Torabi)
Decrease in laryngeal and pharyngeal support: higher risk of obstruction
Edentulous: poor mask, ventilation
Arthritis: decreased ROM
Decrease in protective laryngeal reflexes: increased risk of aspiration
52
Postop pulmonary complications seen in the elderly
Atelectasis
Bronchospasm
Exacerbation of underlying disease
Pneumonia
Prolonged mechanical ventilation
Postop respiratory failure
53
Age alone + coexisting, pulmonary disease increases the chance of what in the elderly?
Postoperative pulmonary complications
54
Patient related risk factors for postop pulmonary complications (a lot)
Age greater than 60
COPD
ASA class two or greater
Functional dependence
CHF
OSA
Pulmonary hypertension
Current cigarette use
Preop sepsis
Weight loss in the past six months
Serum albumin less than 3.5
BUN greater than or equal to 21
Serum creatinine greater than 1.5
55
Surgery related factors that increase the risk for postoperative pulmonary complications
Prolonged operation greater than three hours
Surgical site
Emergency operation
General anesthesia
Perioperative transfusion
Residual neuromuscular blockade
56
How does creatinine change in the elderly? (red item Torabi)
Creatinine stable however, a normal level in the elderly should not be interpreted as an absence of renal impairment
57
How does renal function change in the elderly? (red item Torabi)
Progressive atrophy of renal tissue, ↓ renal mass and sclerosis of vascular structures:↓ renal blood flow and glomerular
filtration rate.
↓ ability to correct alterations in electrolyte
concentrations, intravascular volume, and free water
58
A decrease in GFR can lead to?
↓ glomerular filtration rate leads to delayed
renal drug excretion(hydrophilic drugs), ↑ risk
of CKD
59
How does hepatic function change in the elderly?
Decreased liver mass and reduced portal and hepatic blood flows result in ↓ hepatic drug clearance
Cytochrome P-450 enzyme activity decreases with aging
Phase 1 (oxidation, reduction, hydrolysis) and phase 2 (conjugation, sulfonic acid, acetylation) reactions may be depressed with aging.
60
How does hepatic blood flow change per decade?
Approximately decreases 10% per decade
61
How does the endocrine system change in the elderly? (red itrm torabi)
Decreased pancreatic function (↓ insulin
secretion)
* Increased incidence of diabetes
* Decreased tolerance to glucose load: avoid IV glucose solutions
* ↑ risk of perioperative complications if history of DM > 10 years
62
How much muscle mass is lost by 80 years old? (red item torabi)
50%
63
How does basil metabolism and heat production change in the elderly?
Decrease due to scale to muscle atrophy, decrease physical activity, and decreased testosterone
64
Why do the elderly have a higher propensity for hypothermia?
Because of blunted central thermal regulation in body compositional changes such as a decrease in muscle mass, decreased total body water, coupled with increased body fat
65
How does the volume of distribution for water soluble and lipid soluble drugs change in the elderly?
Decrease Vd of water, soluble drugs
Increased Vd of lipid soluble drugs
66
What brain structure becomes impaired, resulting in a reduction in thermal regulation in the elderly?
Decrease in hypothalamus function
67
Hypothermia is more pronounced in last longer in the elderly due to?
Lower basal metabolic rate
Higher ratio of surface to body area mass
Less effective peripheral vasoconstriction in response to cold
68
how does impaired thermal regulation affect anesthesia?
Slows anesthetic elimination
Prolongs recovery
Impaired coagulation
Impaired immune system system
Blunt ventilator response to CO2
Increase risk of shivering
69
What area of the brain experiences the most prominent losses from aging
Cerebral cortex – frontal lobe
70
What are some neuraxial anesthesia considerations for the elderly?
* ↓ myelinated nerve fibers
* Dura is more permeable to LA
* CSF Volume ↓
* Time of onset ↓ with more enhanced spread * Epidural Test dose less reliable in elderly d/t beta adrenergic response
* Use ↓ dose of LA
71
Healthcare decision-making for older patients is autonomy. Autonomy implies?
Mental competence
72
What are the legal standards for competence?
ability to communicate a choice, understand relevant information, appreciate the current situation and its consequences, and manipulate information rationally.
73
What are the components of frailty syndrome?
Mobility
Muscle weakness
Poor exercise tolerance
Unstable balance
Factors related to body composition, such as weight loss, malnutrition, and muscle wasting
74
Frailty can be diagnosed if there is the presence of three or more of the following criteria:
‣ muscle weakness, *
‣ slow walking speed,
‣ exhaustion,*
‣ low physical activity, and
‣ unintentional weight loss.*
75
What is thought to be the key drivers in the underlying pathophysiology of frailty?
Chronic inflammation and endocrine dysregulation
76
Frailty is a prognostic factor for?
Poor outcomes
77
What degree of weight loss suggests frailty?
Unintentional 10 pound weight loss within a year
78
What is the incidence of malnutrition in elderly inpatients?
20 to 40%
79
What are some reason reasons for a decline in nutritional status in the elderly?
Change in taste, smell, and reduced income
80
What are some predisposing factors of malnutrition?
Heart failure
COPD
Cancer
81
Indications of malnutrition include:
Weight loss
Low BMI
Nutrient related disorders, example, anemia
Albumin less than 3.5
82
Polypharmacy occurs in what percent of acutely hospitalized, older adults
61%
83
The number of medications being used by a patient is directly proportional to?
The likelihood of having an adverse drug reaction and potential interactions with anesthetic meds
84
What is postoperative delirium?
A transient disorder of cognition and consciousness characterized by an acute onset and fluctuating course.
85
When does postop delirium usually manifest?? (Torabi Red Item)
Manifest acutely within first few days after surgery and it last for several days/weeks
86
Symptoms of postoperative delirium
Agitation
Somnolence
Social withdrawal
Psychosis
87
Risk factors for postoperative delirium
Advanced age
Male gender
Dementia
History of alcohol, abuse
Depression
Duration of anesthesia
Poor functional status
Abnormal electrolytes and glucose
88
Treatment for postoperative delirium
Treat any underlying disorder
Encourage interaction with family members
Encourage normal sleep – wake cycles
Avoid restraints if possible
89
What are two medications that can be used to try and control or prevent postop delirium
Haloperidol (PO or IM) for acute agitation control
Dexmedetomidine Intraoperative
90
What surgical procedures have a higher incidents of postop delirium?
Aortic heart surgery
Hip surgery
91
What is postoperative cognitive dysfunction?
A subtle deterioration in memory, attention in speed of information processing associated with anesthesia and surgery
92
when does postoperative cognitive dysfunction usually present? What are some causes?
Presents weeks to months after surgery. May not recover to preop cognitive state.
Causes: cerebral hypo perfusion, general anesthetics
93
What is dementia what is the most common cause of dementia?
Persistent and progressive impairment of cognition that interferes with activities of daily living
Alzheimer's disease is the most common cause in the elderly and affects 30 to 50% of people by age 85
94
How does dementia influence anesthesia?
Delayed emergence
Alters BIS baseline values
95
Alzheimer's disease is characterized by?
Diffuse amyloid-rich senile plaques and neurofibrillary tangles are the hallmark pathologic findings
* Changes in synapses and in the activity of several major neurotransmitters, especially synapses involving acetylcholine and CNS nicotinic receptors.
96
What are the two types of Alzheimer's disease?
* Early Onset: presents before age 60 (d/t mutation in genes)
* Late Onset: develops after age 60
97
Besides progressive, cognitive impairment and memory, what other symptoms can be seen in Alzheimer's disease?
Apraxia -Inability to perform purposeful movements or tasks
Aphasia - Loss or impairment of the ability to communicate
Agnosia - Inability to recognize or interpret sensory information (objects, sounds, smells), despite normal sensory function
98
When is a definitive diagnosis of Alzheimer's disease made?
Usually postmortem
99
What are some symptom management medication options for Alzheimer's?
cholinesterase inhibitors such as:
tacrine,
donepezil,
rivastigmine
galantamine
memantine
100
What sort of agents are preferred in patient with Alzheimer's or dementia? What should be avoided?
Shorter acting sedative-hypnotic drugs, anesthetics, and opioids.
Avoid pre-oxidation and centrally acting anticholinergics
101
If a patient is taking a cholinesterase inhibitor to help Alzheimer's symptoms, how might this affect one of your anesthesia drugs?
Prolongation of the effect of succinylcholine and relative resistance to
nondepolarizing muscle relaxants resulting from the use of
cholinesterase inhibitors.
102
The most significant anesthetic consideration, impatience with osteoarthritis is?
Cervical spine changes
103
How do MAC requirements change as we age?
➢MAC of inhalation agents ↓ by 6 % each decade after age 40
104
How should your dose of propofol accommodate an opioids change in the elderly?
Reduce bolus by 50%
105
How should your nondepolarizing and depolarizing neuromuscular blocking agent dose change for the elderly?
No significant dose adjustment
106
How does acute postoperative pain change in the elderly?
Age-related decrease in pain perception
* Alzheimer disease is associated with a decrease in reported pain
* Pain tolerance increases with the severity of dementia
* MULTI-MODAL
