9. Geriatric Considerations Flashcards by J L

Geriatric Considerations
Introduction – Life expectancy
• When the United States was founded, life expectancy was about ____ years.
• By the mid-1800s it increased to 42 years.
• In 1950 it jumped to 68 years.
• By 1991 the average was 75.5 years.
• In 2016, the most recent year for which life expectancy statistics are available, the average life expectancy in the United States was ____ years (81.1 years for females, 76.1 years for males).

78.6

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Geriatric Considerations
Introduction
• Classically, age ____ is considered the beginning of the geriatric period.
• Adults age 65 and older are the ____- growing segment of the United States population.
• Based on several variables, including fertility rate, mortality rate, immigration activity, and the aging of the baby boomer generation, the United States Census Bureau projects that the elderly will constitute ____% of the population by 2050.

65
fastest
20.4

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Geriatric Considerations
Introduction
• Aging causes changes at a ____ and ____ system level that must be recognized and compensated for so that effective management and treatment of an elderly patient can proceed safely.

cellular

organ

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Geriatric Considerations

Introduction
• The aging process involves both ____ and ____ changes that may alter a patients’ ability to respond to stress as well as their response to drug administration.

physiologic

pathologic

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Geriatric Considerations

Medications
• Adverse drug interactions are more common in ____ patients than in younger patients.
• One reason is that geriatric patients take more ____.
-More than one-third of prescriptions drugs used in the US are taken by elderly patients.
-The ambulatory elderly fill between 9-13 prescriptions a year (new prescriptions and refills).
-The average elderly patient is taking more than ____ prescription medications.
-The average nursing home patient is taking ____ medications.

elderly
medications
prescription
five
seven

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Geriatric Considerations

Medications
• Since its publication in 1991 the Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults has been the most consulted source of information about the safety of prescribing medications for older adults.

• There have been several updates and it uses a comprehensive, systematic review and grading of the evidence on drug-related problems and ____ in older adults.

adverse drug events (ADEs)

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Geriatric Considerations
Evaluation
• The aging process affects all ____ systems.
• Of greatest concern are the effects of aging and the insufficient response to stress within the ____, pulmonary, renal, hepatic, and neurological systems.

organ

cardiovascular

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Common Health Care Issues in the Geriatric Population
Body mass
• Changes that occur with aging include:
 -A \_\_\_\_ in lean body mass
-An \_\_\_\_ in body fat
-A \_\_\_\_ in total body water

decrease
increase
decrease

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Common Health Care Issues in the Geriatric Population

Body mass – Volume of drug distribution
• The central compartment is smaller (decreased total body water) = ____ peak concentration.
• The rapidly equilibrating compartment is smaller (decreased lean body mass) = ____ drug effect.
• The slowly equilibrating compartment is larger (increased body fat) = ____ volume of distribution and ____ drug effect.

higher
longer
increased
longer

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Common Health Care Issues in the Geriatric Population

Neurologic
• Pharmacodynamic sensitivity ____ with age for all drugs that act within the central nervous system.
• There is an age-related decrease in the ____ at 1 atmosphere preventing ____ in 50 percent of patients exposed to a surgical incision (termed “MAC”) for all volatile anesthetic agents.
• The normal ventilatory response of the central nervous system to hypercapnia, and especially to hypoxemia, is ____ with age.

increases
minimum alveolar concentration
movement
diminished

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Common Health Care Issues in the Geriatric Population
Neurologic
• The respiratory depressant effects of opioids, benzodiazepines, and volatile anesthetics are ____ in older adults and may further impair the response to ____ and hypoxemia.
• Changes in the peripheral nervous system include a reduction in ____ fibers, with potential alterations in pain perception.
• ____ pain thresholds have been observed in older patients and may contribute to ____ presentation for painful conditions.

exaggerated
hypercapnia
myelinated
higher
delayed

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Common Health Care Issues in the Geriatric Population

Respiratory
• Although the overall ____ of alveoli does not change with age, ____ changes affect gas exchange.
• Alveolar ducts enlarge and septa collapse due to a loss of elastic tissue, resulting in reduced ____ area.
• The reduction in elastic lung tissue and increased calcifications at rib articulations results in a stiff, less ____ lung.
• The effort to expand the lung increases ____% from 20 to 60 years of age.

number
structural
total alveolar
compliant
30

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Common Health Care Issues in the Geriatric Population

Respiratory
• These changes reduce the ____ recoil of the lungs and lead to premature airway closure, air trapping, and increased ____.
• The increase in ____ of the larger central airways (10% from youth to elderly age) also contributes to the overall physiologic ____.
• Due to earlier ventilatory muscle fatigue, the geriatric patient may not be able to ____ the ventilation rate efficiently to address a hypoxic event.

elastic
dead space
diamete
dead space
increase

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Common Health Care Issues in the Geriatric Population

Renal
• After the age of 50 years, there is a significant decrease in ____ mass and functional nephron units.
• The glomerular filtration rate (GFR) gradually ____ through the age of 60 years (1% per year) and more abruptly thereafter.
• Coupled with decreasing ____ function, renal blood flow ____ by 10% per decade.
• This reduces the concentrating ability, impairs the ability to buffer ____ and base loads, and decreases the capacity to resorb ____ and conserve sodium.

renal
declines
cardaic
decreases
acid
glucose

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Common Health Care Issues in the Geriatric Population
Renal
• In patients 75 years of age, renal blood flow has decreased to less than ____ compared to a 30 year old.
• This decrease in renal perfusion is significant for drugs in which ____ excretion is a principal means of removing the drug from the body.
• Drugs such as ____, tetracycline, and ____ exhibit greatly increased terminal elimination half lives.

half
urinary
penicillin
digoxin

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Common Health Care Issues in the Geriatric Population
Hepatic
• Age-related declines in hepatic mass and function, as well as decreased hepatic blood flow, result in ____ metabolism of most drugs.

slower

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Common Health Care Issues in the Geriatric Population
Hepatic
• In addition, diminished albumin levels may result in ____ free-drug concentrations of highly protein bound drugs.

• For example:
Diazepam is approximately 98.5% bound (1.5% free to exert its effect) in younger individuals. In elderly individuals, it is only ____% bound.
This leaves ____ as much diazepam available (3% versus 1.5%) to produce its clinical actions.

larger
97
twice

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Common Health Care Issues in the Geriatric Population

Cardiovascular
• According to The American Heart Association (AHA), ____ is the primary cause of death in elderly patients.
• 16% of patients older than 65 have ischemic heart disease.
• 25% of patients older than 80 years have some degree of coronary disease.
• ____ affects 35% of people older than 65 years.
• Older patients with hypertension are 2-3 times more likely to have a ____ event than younger patients with similar hypertension.

ischemic heart disease
hypertension
cardiovascular

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Common Health Care Issues in the Geriatric Population
Cardiovascular
• The high prevalence of cardiovascular disease in the elderly is a direct result of the ____ related changes that occur in each component of the cardiovascular system.

• As the heart and blood vessels age, their ____ gradually declines due to a decrease in the content of elastic tissue and an increase in the amount of ____, calcium, and smooth muscle.

age
elasticity
collagen

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Common Health Care Issues in the Geriatric Population

Cardiovascular
• Collagen cross-linking increases with age and results in a stiffer, less ____ ventricle.
• The reduced elastic recoil of the large and medium size vessels coupled with atherosclerotic changes culminates in an increase in ____.
• Fibrosis and calcification of the aortic valve, is present in 20% of patients older than 65 years.

compliant

total peripheral vascular resistance

Common Health Care Issues in the Geriatric Population

Cardiovascular
• The combination of these effects of the heart: 
-\_\_\_\_ preload.
-\_\_\_\_ afterload.
• This causes:
- A decrease in \_\_\_\_.
-A decrease in \_\_\_\_.
-An increase in \_\_\_\_.

increased
increased
cardiac output
stroke volume
systolic blood pressure

Common Health Care Issues in the Geriatric Population

Cardiovascular
• The American College of Cardiology (ACC) and AHA have produced guidelines for cardiovascular disease. A task force published practice guidelines for perioperative cardiovascular evaluation for non- cardiac surgery.
• The ACC/AHA guidelines indicate that patients should be assessed with a ____ approach according to the clinical predictors, the risk of the proposed operation, and the patient’s functional capacity.

stepwise

Common Health Care Issues in the Geriatric Population
Cardiovascular
•
The ACC/AHA clinical predictors:

____ cardiovascular risk factors: Unstable coronary syndromes, decompensated congestive heart failure, significant arrhythmias, and severe valvular disease.

____ cardiovascular risk factors: Mild angina pectoris, previous myocardial infarction, compensated/prior heart failure, diabetes mellitus, and renal insufficiency.

____ cardiovascular risk factors: Advanced age, abnormal electrocardiographic findings history of stroke, and uncontrolled systemic hypertension.

major
intermediate
minor

• “Stressing the heart might not sound like a safe thing for someone with a
cardiovascular condition, but a cardiac stress test is an important tool for doctors (pumping function of the heart and vessels that supply blood to the heart.)
• There are two types of cardiac stress tests:
1. Most common and preferred approach is to ____.
2. The use of ____ to simulate exercise on the heart.
• Your doctor may order a stress test to diagnose a ____disease and hard arrhythmias and to determine treatments if you have already been diagnosed.”

• •
Idea of a stress test is that youre hooking someone up to an ____, putting them on a treadmill, and seeing if they’re getting ____.
Based on the EKG, you can see which ____ it is, and determine treatment.

exercise
medication
coronary artery
EKG
ischemia
vessel

Common Health Care Issues in the Geriatric Population Cardiovascular • The ACC/AHA task force determined that functional status has been shown to be reliable for perioperative and long term prediction of ____. • If the patient has not had an exercise stress test, functional status can be estimated from their ability to perform activities of ____. • Functional capacity can be expressed in ____ levels.

cardiac events daily living metabolic equivalent (MET)

Common Health Care Issues in the Geriatric Population Cardiovascular • The oxygen consumption (VO2) of a 70-kg, 40-year- old man in a resting state is ____ mL/kg/min or ____ MET. • Functional capacity is considered excellent when the patient can participate in activity rated greater than ____ METs. • Poor functional capacity is associated with less than ____ METs.

3.5 1 10 4

Common Health Care Issues in the Geriatric Population Cardiovascular • The Duke Activity Status Index contains questions that can be used to estimate the patient's ____. • In these guidelines, surgical procedures are are also classified as high, intermediate-, or low-risk. • All dental procedures are considered ____-risk. Hospital based OMS procedures may be ‘____.’

functional capacity low intermediate

Common Health Care Issues in the Geriatric Population Cardiovascular • ACC/AHA task force concludes that patients with moderate-to-excellent functional capacity (>4 METs), generally can undergo low/intermediate-risk surgery with ____ likelihood of perioperative death or myocardial infarction. • The task force also concludes that patients with poor functional capacity should be considered for further ____ testing (Stress Test/Echocardiogram).

little | noninvasive

Common Health Care Issues in the Geriatric Population Wound healing • Age-related effects have been reported at all phases of ____ healing. • Overall, the wound healing process in the elderly patient is ____ compared with younger individuals.

wound | delayed

Common Health Care Issues in the Geriatric Population Psychosocial • The elderly patient frequently exhibits cognitive, emotional, and behavioral changes that may significantly alter the outcome and recovery. • These changes are usually secondary to the normal aging process. • ____ caused by Alzheimer disease is the leading cause of disability in the elderly population and represents the most common reason for institutionalization.

dementia

Common Health Care Issues in the Geriatric Population Psychosocial • This can result in poor compliance with preoperative and postoperative management, including ____ with prescribed medications and obtaining an ____ for treatment. • Completing an objective assessment of the patient’s cognitive abilities via ____ interaction with the patient or family members enables the clinician to identify psychosocial issues that may compromise care.

compliance informed consent direct

Anesthetic Considerations Inhalation sedation: N2O • Highly recommended technique for sedation of the geriatric patient due to its ____. • It offers the advantage of providing a ____ (minimal to moderate) sedative technique with the benefits of supplemental ____. • Given the lower MAC for older patients, it will generally have a more ____ effect.

titrability light oxygenation profound

Anesthetic Considerations Oral (Enteral) Sedation Age does not affect ____ of oral medications, but age related changes can have a significant impact on how the drug ____ in the elderly population. Because orally administered drugs cannot be precisely ____, it is recommended that drugs be used in ____ dosages on the initial visit and then ____ by appointment as necessary.

``` absorption acts titrated smaller titrated ```

Anesthetic Considerations Oral (Enteral) Sedation • Medications such as benzodiazepines and the newer nonbarbiturate sedative- hypnotics (ex: zolpidem) are useful in managing mild ____. • Due to increased duration of action of these medications, ____ acting medications are preferred. • ____ are not recommended. • ____ may also be used as antianxiety medications.

anxiety short barbiturates antihistamines

Anesthetic Considerations Intramuscular (Parenteral) Sedation • ____ sedation is generally not recommended in the geriatric population because of the inability to titrate the medication. • This technique is usually reserved for the induction of anesthesia in ____ patients. • When required, ____ is the medication of choice, keeping in mind the need to ____ the dose of drug in the elderly patient (____ is not preferred in the geriatric population because of the stimulation of the CV system).

``` intramuscular (IM) uncooperative midazolam decrease ketamine ```

Anesthetic Considerations Intravenous (Parenteral) Sedation • Intravenous (IV) sedation is highly recommended due to the ability to ____. • Vascular access in the older patient may be more difficult because of the loss of ____ and increase in fragility of the veins. • Titration should occur even more ____ in the geriatric individual because of the pharmacokinetic changes that occur.

titrate elasticity slowly

Anesthetic Considerations General Anesthesia • The use of outpatient general ____ depends on the overall health of the patient. • The elderly patient with ____ may require outpatient general anesthesia for dental care. • Consult the patient’s primary care physician for recommendations.

anesthesia | dementia

Anesthetic Considerations Medications - Summary • This figure is adapted from the Beers Criteria and lists sedative/anesthetic drugs considered to be deserving of careful scrutiny before being administered to elderly patients. • This chart shows that MAC is decreasing by ____% per decade of increasing age ◦ You need ____ drug to get the clinical effect • Need to be very careful with ____ ◦ Ex) Morphine - 50% reduction in dose DON’T NEED TO MEMORIZE DOSES but just have in mind that everything you give to older patients is going to behave differently due to pathologic and physiologic changes.

6 less opioids

Anesthetic Considerations Delirium • ____ is perhaps the most significant age- related postoperative complication of sedation and general anesthesia. • It is characterized by an ____ decline in ____ function and attention, with evidence from the patient’s history that this is due to ____ derangement, a medication, or is multifactorial. It’s a diagnosis of ____ Delirium is much more common in elderly patients Sedation can be medications you give to reduce anxiety in dental clinic Patients come in for a dental procedure and you give them some type of medication and then afterwards, they are not themselves. their family members will call and say they are staying up, they keep going and checking refrigerator, they are drifting off. - sign of delirium • It’s in a DSM how you diagnose it but important thing is that you have to be aware of side effects from medications, particularly general anesthesia • Delirium is not ____

``` delirium acute cognitive physiologic exclusion ``` physiologic

Anesthetic Considerations Delirium • The prevalence of postoperative delirium ranges from ____%, with the highest rates observed after high-risk procedures, such as ____ surgery, vascular surgery, and ____ surgery.

9 to 44 cardiac hip fracture

Anesthetic Considerations Delirium • In order for delirium to be diagnosed, patients should undergo an assessment of the following: disturbance of ____, a change in cognition, acute onset, and evidence from the history that this is due to ____ derangement (for example, hypoxia, hypoglycemia, electrolyte abnormality, acid– base abnormality), an intoxicant, medications, or more than one cause. • One of the most widely used instruments for assessing postoperative cognitive impairment is the ____

consciousness physiologic confusion assessment method (CAM)

Anesthetic Considerations Delirium • Remember: Delirium is a diagnosis of ____. Must rule out: - Uncontrolled ____ - Pneumonia - Infection - ____ abnormalities - Urinary retention - ____ impaction - Medications - Hypoglycemia

exclusion pain electrolyte fecal

Anesthetic Considerations Delirium • The recommended 1st-line treatment of delirium following sedation or general anesthesia includes: -Frequent ____ -A calm environment -Avoiding the use of ____ restraints -Having familiar persons in close proximity to the patient -Ensuring that ____ and hearing aids are readily available

reorientation physical glasses

Geriatric Emergency Scenarios Syncope • Syncope may represent a symptom of underlying pathology of the ____, neurologic, or pulmonary system. • ____ syncope is the most common cause of syncope in younger patients. In the elderly population this only represents ____% of the cases. • Cardiac causes include: ____, aortic stenosis, dysrhythmias. All episodes of syncope in the elderly must be considered ____ until proven otherwise.

``` cardiac vasovagal 1-5 MI cardiac ```

Geriatric Emergency Scenarios Syncope • Management: ____. If patient has pulse and is breathing, recline the chair, give ____ and monitor vital signs. • Strongly consider calling ____ given possible underlying causes in the elderly population.

ABCs oxygen EMS

Geriatric Emergency Scenarios Syncope • ____ may produce an episode of syncope if you sit the patient up too fast. • Common causes of orthostatic hypotension in the elderly: Medication related and ____ due to ____/malnutrition.

orthostatic hypotension hypovolemia dehydration

Geriatric Emergency Scenarios Altered Mental Status • If the baseline mental status of a patient changes acutely, therapy should be directed at identifying life threatening and easily treatable conditions. • Assess ABCs and give supplemental ____. Have family/____ come to the room to assess the patient as well. • Call ____ as common conditions that produce altered mental status include: MI, hypoglycemia, dehydration, electrolyte disturbance, and infection.

oxygen caretaker EMS

Special Patient Populations Patient Scenarios – Alzheimer’s • The five-minute recall of Alzheimer's patients is often quite ____, patients may need frequent reminders during procedure as to your identity and instruction on how to cooperate. • ____ patients may fail to understand spoken word (receptive aphasia) or may have difficulty communicating (expressive aphasia). • These patients may require a little extra time to elicit clinical symptoms and may not understand all the questions about their care.

limited | aphasic

Special Patient Populations Patient Scenarios – Alzheimer’s • The family caregiver should be ____ during the clinical assessment to assure accurate history. • Patients may not be able to express their pain appropriately. Discuss changes in ____ and eating habits with the caregivers as this could point to a painful condition. • Non-verbal communication with significantly aphasic patients is helpful. A frequent ____, a calm, gentle voice and touch, as well as pointing and mimicking can assist with communication in the patient with receptive aphasia.

present diet smile