Test 2: Geriatrics (pt 3/3)

Question 1

Generally, all medications given to an older adult are administered in a ______dose. (!!!)

Answer 1

Lower

Question 2

What are the pharmacokinetic changes that lead to exaggerated responses and a prolonged duration of action in the elderly?

Answer 2

Changes in volume of distribution, renal/hepatic clearance rates, compartmental redistribution, and elimination 1/2 lives

Question 3

What are the pharmacodynamic changes that lead to exaggerated responses and a prolonged duration of action in the elderly?

Answer 3

Altered receptor density and binding, changes in signal transduction, and impaired cellular responses

Question 4

The minimal alveolar concentration (MAC) of inhalational agents decreases roughly ____% per decade from the MAC value of 40-year-old adults

Answer 4

6.7%

Question 5

What is the NM blocking agent of choice for the older adult and why?

Answer 5

Cisatracurium, because it undergoes Hoffman elimination and ester hydrolysis and is not organ dependent.

Question 6

What are the anesthetic considerations associated with administering propofol to an older adult?

Answer 6

Hypotension, prolonged recovery, increased brain sensitivity

Question 7

What are the dose adjustments needed when giving propofol to an older adult?

Answer 7

-Decrease bolus and infusion by 50%
-Manufacturer recommends 1-1.5 mg/kg bolus for induction

Question 8

What are the anesthetic considerations associated with administering etomidate to an older adult?

Answer 8

Increased brain sensitivity, greater hemodynamic stability

Question 9

What are the dose adjustments needed when giving etomidate to an older adult?

Answer 9

Decrease bolus by 50%

Question 10

What are the anesthetic considerations associated with administering opioids to an older adult?

Answer 10

-Increased brain sensitivity
-profound physiologic effects
-slower onset and delayed recovery
-consider route of metabolism and metabolites
-avoid meperidine

Question 11

What are the dose adjustments needed when giving opioids to an older adult?

Answer 11

Decrease bolus by 50%

Question 12

What are the anesthetic considerations associated with administering Midazolam to an older adult?

Answer 12

Increased brain sensitivity, avoid per Beers Criteria

Question 13

What are the dose adjustments needed when giving Midazolam to an older adult?

Answer 13

AVOID
Decrease dose by 75%

Question 14

What are the anesthetic considerations associated with administering Nondepolarizing MRs to an older adult?

Answer 14

-Slower onset and delayed recovery
-consider route of metabolism and metabolites
-Avoid long-acting NDMRs

Question 15

What are the dose adjustments needed when giving Non-depolarizing MRs to an older adult?

Answer 15

No significant changes with intubating dose
Maintenance dose per PNS twitch response

Question 16

What are the anesthetic considerations associated with administering Depolarizing MRs to an older adult?

Answer 16

Slower onset and delayed recovery

Question 17

What are the dose adjustments needed when giving Depolarizing MRs to an older adult?

Answer 17

No dose adjustment

Question 18

What are the 4 basic principles in ethical decision making that apply to the older adult? (Same as for all patients)

Answer 18

1) Autonomy
2) Beneficence
3) Nonmaleficence
4) Justice

Question 19

What is autonomy?

Answer 19

The patient’s right to self-determination
-Informed consent, advanced directives (DNR)

Question 20

What is beneficence?

Answer 20

An obligation or responsibility to help the patient. To do good

Question 21

What is nonmaleficence?

Answer 21

To not intentionally harm the patient. Do no harm

Question 22

What is justice?

Answer 22

To treat the patient fairly (regardless of age, race, cultural beliefs, religion, disease process, resuscitation status, etc)

Question 23

A major neurocognitive disorder characterized by memory change or decline in memory, language, problem-solving, and other cognitive skills that affect a person’s ability to perform everyday activities.

Answer 23

Dementia

Question 24

What are common causes of dementia?

Answer 24

-Alzheimer’s Dz
-Vascular Dementia
-Parkinson’s Dz

Question 25

All types of dementia are associated with:

Answer 25

Behavioral, cognitive, and/or functional decline

Question 26

A comprehensive assessment of cognition includes:

Answer 26

-Assessment of decision-making capacity -Assess cognition using Mini-Cog test as per recent ACS/AGS guidelines or the MoCA -Identify risk factors for developing postoperative delirium -Identify reversible causes of dementia -Communication and coordination of care with geriatrician when appropriate

Question 27

A slowly progressive brain disease characterized by beta-amyloid protein deposits, intracellular neurofibrillary tangles, and loss of neurons. -Most common cause of dementia (60-80%)

Answer 27

Alzheimer's Dz

Question 28

-Risk factors: HTN and DM -10% of dementia cases -Location, number, and size of infarcts is directly r/t the degree of decline

Answer 28

Vascular Dementia

Question 29

What is mixed dementia?

Answer 29

Vascular infarcts found with Alzheimer's Dz

Question 30

A progressive degenerative disorder of the basal ganglia associated with a deficiency in dopamine -Behavioral, cognitive, and functional decline

Answer 30

Parkinson's Dz

Question 31

What are causes of reversible dementia?

Answer 31

-medications -alcohol -metabolic disorders -depression -CNS neoplasms -normal-pressure hydrocephalus

Question 32

The anesthetic plan should be based on what?

Answer 32

-patient condition -surgery -baseline neurologic impairment

Question 33

The use of benzodiazepines and antihistamines are associated with the development of _____, and should be avoided during the perioperative period.

Answer 33

Delirium

Question 34

Which patients may benefit from the use of Regional Anesthesia?

Answer 34

-Poorly controlled preop pain -Chronic opioid users -Anticipated high postop opioid requirements

Question 35

What are the most frequently occurring neurologic phenomena in older adults?

Answer 35

Postoperative Delirium and Postoperative Cognitive Dysfunction (POCD)

Question 36

Characterized by disruption of perception, thinking, memory, psychomotor behavior, sleep-wake cycle, consciousness, and attention.

Answer 36

Postoperative Delirium

Question 37

Postoperative Delirium is associated with an increased risk of:

Answer 37

-Periop mortality -Institutionalization -Dementia

Question 38

What are risk factors for postop delirium?

Answer 38

-Renal insufficiency -Metabolic derangements -Poorly controlled pain -Polypharmacy (psychoactive drugs) -Functional impairment -Urinary retention -Foley catheter -Use of benzos and antihistamines and anticholinergics

Question 39

A predictor for postoperative delirium. Associated with an increased risk for cardiac events and death. -Continue antidepressants perioperatively

Answer 39

Depression

Question 40

An array of cognitive impairments such as memory deficits, difficulty with concentration, impaired comprehension, and delayed psychomotor speed. -Subtle onset, deficits may not present for weeks to months after surgery -Inability to work, decline in ADLs, need for assisted care

Answer 40

Postoperative Cognitive Dysfunction

Question 41

How do you prevent postoperative cognitive dysfunction?

Answer 41

-Maintain oxygenation & cerebral perfusion -Surgeries should be as short or as minimally invasive as possible -Multimodal pain mgmt plan