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APEX > Unit 11 - Geriatrics > Flashcards

Unit 11 - Geriatrics Flashcards

1
Q

most significant risk factor for developing cancer

A

old age

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2
Q

metabolic equivalent =

A

metabolic rate of a specific physical activity / metabolic rate at rest

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3
Q

1 MET = ____ mL O2/kg/min

A

3.5

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4
Q

a “yes” to what 2 questions indicates the patient is ok for surgery without the need for additional cardiac testing

A
  1. Can you walk up a flight of steps without stopping?
  2. Are you able to walk 4 blocks without stopping?
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5
Q

activities that = 1 MET

A
  • self care activities
  • working at computer
  • walking 2 blocks slowly
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6
Q

activities that = 2 METs

A
  • climbing a flight of stairs w/o stopping
  • walking 1-2 blocks uphill
  • light housework
  • raking leaves
  • gardening
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7
Q

approx oxygen consumption assoc with 4 METs

A

~1000 mL O2/min

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8
Q

approx oxygen consumption assoc with 4 METs

A

~1000 mL O2/min

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9
Q

METs assoc with poor, good, and outstanding functional capacity

A

1 MET = poor
4 METs = good
10 METs = outstanding

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10
Q

may be a better tool to predict functional status vs. METs

A

DSA - duke activity status index

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11
Q

how is frailty characterized

A

decreased reserve coupled with reduced resistance to stress (physiologic, physical, or psychosocial)

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12
Q

for every MET a patient can achieve, mortality decreases by:

A

11%

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13
Q

why do geriatric patients have an increased Vm

A

increased dead space necessitates an ↑ Vm to maintain a normal PaCo2

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14
Q

key resp changes in geriatric patients:
* Vm
* lung compliance
* lung elasticity
* chest wall compliance
* response to hypercarbia & hypoxia
* protective reflexes
* upper airway tone

A
  • Vm & lung compliance increased
  • the rest are decreased
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15
Q

why are geriatric patients at increased risk of respiratory failure

A

decreased PaO2, lung elasticity, and chest wall compliance all decrease pulmonary reserve

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16
Q

consequences of loss of elastic recoil in elderly pts

A

promotes small airway collapse

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17
Q

consequences of small airway collapse in geriatric patients

A

↑ dead space
↓ alveolar surface area
↑ V/Q mismatch
↑ A-a gradient
↓ PaO2
Altered lung volumes & capacities

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18
Q

what causes gas trapping in geriatric patients

A

The aged lung tissue has high compliance (it’s easy to inflate) BUT it has low elasticity (it’s harder for it to return to its original shape)

RV increases

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19
Q

what causes decreased chest wall compliance in geriatric pts

A

↑ Calcification of joints
↑ Diaphragmatic flattening
↑ A-P diameter
↓ Intervertebral disc height
↓ Respiratory muscle strength (↓ muscle mass)
↓ Lung elastic recoil

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20
Q

why are geriatric patients less responseive to hypercarbia & hypoxia

A

The chemoreceptors are less sensitive to changes is pH, PaCO2, and PaO2

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21
Q

why are geriatric patients at increased risk of aspiration

A

Reduced efficiency of cough and swallowing
* Greater stimulus is required to elicit the cough reflex
* ↑ Risk of aspiration

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22
Q

consequences of decreased upper airway tone in geriatric patients

A

Decreased respiratory muscle strength
↑ Risk of respiratory failure
↑ Risk of upper airway obstruction

Consider PAP or BiPAP in at-risk patients

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23
Q

why do geriatric patients have an increased FRC

A
  • reduced elastic recoil allows lungs to overfill with gas
  • increases RV and therefore FRC

RV = volime that remains in lugns after full exhalation

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24
Q

at what age does Closing capacity surpasses FRC in supine position

A

~45 yrs

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25
at what age does CC surpass FRC when standing
~65 yrs
26
consequence of CC surpassing FRC in geriatric pt
small airways will collapse during tidal breathing ## Footnote sets the stage for V/Q mismatch, increased anatomic dead space, and a reduction in PaO2
27
consequence of CC surpassing FRC in geriatric pt
small airways will collapse during tidal breathing ## Footnote sets the stage for V/Q mismatch, increased anatomic dead space, and a reduction in PaO2
28
lung volumes that are increased in geriatric pts
RV FRC CC
29
lung volumes that are decreased in geriatric pts
VC ERV
30
TLC in geriatric patients
unchanged | ↑ RV + ↓ VC = 0 net change
31
what causes decreased VC in geriatric patients
* reduced lung elastic recoil * increased chest wall stiffness * weaker respiratory muscles
32
FRC is determined by the balance between what 2 things
1. lung elastic recoil 2. chest wall compliance
33
what causes chest wall stiffness in geriatric pts
* arthritic changes in costovertebral joints * intercostal cartilage calcification * atrophy of intercostal muscles
34
IRV in geriatric patients
decreased | ↑ FRC reduces IRV
35
ERV in geriatric patients
decreased | ↑ RV reduces ERV
36
ERV in geriatric patients
decreased | ↑ RV reduces ERV
37
FEV & FEV1 in geriatric patients
decreased
38
most common coexisting disease in the elderly
cardiac disease
39
4 most common CV conditions in geriatric pts
1. hypertension 2. CAD 3. CHF 4. myocardial ischemia
40
2 best indicators of cardiac reserve
* Exercise tolerance * ability to perform daily living activities
41
lung volumes that are decreased with age
VC ERV IRV FEV FEV1
42
lung volumes that are increased in geriatric pts
RV FRC CC
43
causes of increased BP in geriatric pts related to aging
* loss of elastin and increased collagin * increased SVR and afterload
44
hypertrophy assoc with aging
concentric | increased LV thickness
45
hypertrophy assoc with aging
concentric | increased LV thickness ## Footnote myocytes that die are not replaced - cells that remain increase in size
46
why do geriatric patients experience greater BP lability with induction or acute blood loss
vascular stiffness = decreased venous capacitance
47
why does diastolic dysfunction develop with age
impaired relaxation
48
what increases risk of A-fib in geriatric patients
Atria **generate higher pressure** to prime the non-compliant ventricle = atrial enlargement and risk of atrial fibrillation
49
why are geriatric patient at increased risk of dysrhythmias
* fibrosis of conduction system * loss of SA node tissue
50
dysrhythmias geriatric pts are at increased risk for
* A-fib * 1st degree block * 2nd degree block * sick sinus syndrome
51
BP changes in geriatric patients
* increased SBP, DBP, and PP * Arterial stiffness increases SBP to a greater degree than DBP
52
why is aging assoc with reduced exercise tolerance and cardiac reserve
diminished ability to increase stroke volume | leads to decreased CO
53
HR changes in geriatric patients
* ↓ Responsiveness to catecholamines * ↓ Response to hypotension, hypovolemia, and hypoxia * Decrease in maximal HR
54
maximal HR calculation
220 - age
55
VTE risk in geriatric patients
increased - meet all 3 components of Virchow's triad ## Footnote 1. Venous stasis 2. Hypercoagulability 3. Endothelial dysfunction
56
response to catecholamines with age
decreased
57
why are geriatric pts at increased risk of orthostatic hypotension
decreased baroreceptor responsiveness
58
SNS and PNS tone in geriatric pts
SNS = increased PNS = decreased
59
why is SNS tone increased in geriatric pts
Higher norepinephrine concentration in the plasma ## Footnote This effect is blunted by reduced beta receptor sensitivity and reduced coupling with adenylate cyclase
60
beta receptors in geriatric population
reduced sensitivity d/t reduced receptor affinity & changes in signal transduction
61
change in MAC with age
decreases 6% every decade after age 40
62
consequences of decreased baroreceptor responsiveness in geriatric pts
increases risk of: * Orthostatic hypotension
 * Syncope * Greater degree of hemodynamic compromise following sympathectomy
63
why are geriatric pts at increased risk of hypothermia
impaired thermoregulation
64
neurotransmitter activity changes in geriatric pts
Reduced activity of Ach, NE, DA, and GABA | Number of receptors may be reduced
65
neurotransmitter activity changes in geriatric pts
Reduced activity of Ach, NE, DA, and GABA | Number of receptors may be reduced
66
changes in peripheral nerves with age
* Reduced number of myelinated nerves * Degeneration of nerves that remain reduces function
67
onset of postop delirium
early postop
68
most common periop CNS complication in geriatric pts
postop delirium
69
presentation of postop delirium
Disordered behavior, perception, memory, psychomotor skills
70
presentation of Postoperative Cognitive Dysfunction
Impaired concentration, comprehension, psychomotor skills
71
risk factors for postop delirium
DELIRIUM: * **D**rugs (use rapidly metabolized drugs) * **E**lectrolyte imbalance * **L**ack of drugs (withdrawal) * **I**nfection (UTI and respiratory) * **R**educed sensory input * **I**ntracranial dysfunction * **U**rinary retention and fecal impaction * **M**yocardial event, male gender
72
risk factors for postop cognitive dysfunction
Advanced age (most significant) Pre-existing cognitive deficit Cardiac surgery Long duration of surgery High ASA status Low level of education Anesthetic agents ???
73
treatment of postop delirium in geriatric pts
Treat underlying cause Antipsychotics Minimize polypharmacy
74
treatment of postop cognitive dysfunction
No specific treatment Most cases are mild and tend to resolve after ~ 3 months
75
onset of postop cognitive dysfunction
weeks to months postop
76
changes in geriatric pts that affect neuraxial anesthesia
* ↓ CSF volume * ↓ volume of epidural space * ↓ diameter of dorsal & ventral nerve roots * ↑ permeability of dura
77
peripheral changes in geriatric pts that affect neuraxial anesthesia
* ↓ inter Schwann cell distance * ↓ conduction velocity
78
why are geriatric patients at risk for greater block height with epidural anesthesia
* decreased epidural space volume = greater LA spread * dura is more permeable to LAs
79
why are geriatric pts at risk of greater block height with spinal anesthesia
* decreased CSF volume = greater spread * dura more permeable to LAs ## Footnote give ↓ dose
80
why are geriatric patients at increased risk of false negative response to epidural test dose
↓ myocardial sensitivity to catecholamines
81
why are geriatric pts predisposed to fluid overload and dehydration
**impaired:** * sodium handling * ability to concentrate urine * capacity to dilute urine
82
serum Cr changes in elderly pts
**no change** * GFR decreases with age (theoretically should ↑ serum Cr) * Muscle mass also decreases with age (less Cr produced) These 2 processes cancel each other out (net = unchanged Cr)
83
RBF changes with age
Decreases 10% per decade
84
what contributes to decreased renal mass in elderly
* decreased nephrons (cortex > > > medulla) * loss of functioning glomeruli
85
why does ability to concentrate urine decrease with age
* Increased flow through medullary nephrons washes out solute, reducing osmolarity in this region * ↓ Concentration gradient necessary to produce concentrated urine
86
reduced CrCl in elderly is a function of what 2 things
* ↓ Renal blood flow brings less creatinine to the nephron per unit time * There are less nephrons to clear creatinine
87
most sensitive indicator of renal function and drug clearance in the elderly
CrCl
88
normal GFR in adult male
~125 mL/min
89
changes in GFR with age
decreases by 1 mL/min/year after age 40
90
why are elderly patients at increased risk of fluid overload
**↓ GFR** less plasma delivered to nephrons per unit time
91
why do elderly patients have a reduced response to acid load
reduced capacity of the renal tubules to secrete ammonium
92
why does ability to conserve sodium decrease with age
decreased aldosterone sensitivity
93
alpha 1 glycoprotein levels in elderly
increased ## Footnote Increased reservoir for basic drugs Insignificant in clinical practice
93
alpha 1 glycoprotein levels in elderly
increased ## Footnote Increased reservoir for basic drugs Insignificant in clinical practice
94
alpha 1 glycoprotein levels in elderly
increased ## Footnote Increased reservoir for basic drugs Insignificant in clinical practice
95
albumin production level in elderly
decreased ## Footnote Decreased reservoir for acidic drugs Insignificant in clinical practice
96
hepatocellular function with age
**no change** less total enzymes produced but they function normally
97
what causes decreased periop hepatic function
* Reduced as a function of ↓ blood flow & ↓ liver mass * NOT because of impaired hepatocellular function
98
changes in first pass metabolism with age
decreased d/t reduced hepatic mass and liver blood flow
99
pseudocholinesterase production in elderly
decreased ## Footnote Prolonged duration of succs and ester LAs Men > women
100
consequences of decreased muscle mass in elderly
* ↓ Basal metabolic rate * ↓ Total body water * ↓ Blood volume * ↓ Plasma volume
101
why do elderly patients have prolonged elimination of lipophilic drugs
↑ total body fat = ↑ increased Vd of lipophilic drugs
102
Vd for lipophilic and hydrophilic drugs in elderly
increased for lipophilic decreased for hydrophilic

APEX (54 decks)

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