AGE RELATED CHANGES Flashcards
Post operative delirium vs Post Operative Cognitive Dysfunction : What is the difference?
Unlike POD, the onset of POCD is subtle and neurocognitive deficits may not present themselves
until weeks to months after surgery.
How to help POCD?
Establishing baseline cognitive function is critical because preoperative cognitive impairment may be
present prior to surgery.
By what age-related physiologic functions
in humans have peaked and gradually decline thereafter.
age of 30 years,
Heart and vascular system compliance in the elderly
the heart and vascular system is less compliant,
Afterload + Systolic BP , in the elderly leading to
increase
in afterload, and an increase in systolic blood pressure,
What is the change that occurs in the elderly patients ventricles? what about ejection times?
ventricular thickening (hypertrophy) and prolonged ejection times
Diastolic function in the elderly?
ventricular hypertrophy and slower myocardial relaxation
often results in late diastolic filling and diastolic dysfunction.
What is the screening tool for Cognitive Ability Capacity
Mini-Cog 3 Item Recall and clock draw
What is the screening tool for Alcohol and Substance abuse?
Modified CAGE
When assessing for Slowness, Weight loss, Grip weakness, Exhaustion, Decrease in physical activity: What are you assessing for
Frailty.
Levels of catecholamines is _______In the elderly?
higher amounts of circulating catecholamines, they
Adrenergic responsiveness in the elderly?
exhibit decreased end-organ adrenergic responsiveness.
Therefore the older adult has a reduced capacity to increase heart rate in response to
hypotension, hypovolemia, and hypoxia.
Causes a faster induction time with inhalation agents but
Prolonged circulation time
In the elderly what delays the onset of intravenous drugs.
Prolonged circulation time
Prolonged circulation time effect on elderly 2
Faster induction with inhalation agents
Slower induction with IV agents
Elderly patients are at risk for which cardiac arrhythmias and why?
loss of sinoatrial node cells, which predisposes the elderly to atrial fibrillation, sick sinus syndrome, first- and second-degree heart blocks, and arrhythmias
Loss of _____node cells predisposes elderly to afib, sick sinus syndrome, 1st and 2nd HB and arrhythmias.
Sinoatrial node cells
Calcification of these valves primarily in the elderly
valves (primarily aortic and mitral),
Pulse pressure in the elderly? and why?
With aging the pulse pressure widens because of a greater proportionate increase in systolic blood pressure
compared with diastolic blood pressure.
Baroreceptors in the elderly? which results in?
decreased sensitivity of baroreceptors in the aortic arch and carotid sinuses in response to blood pressure changes, which results in increased episodes of hypotension.
Ejection phase in the elderly is
prolonged.
Elderly and heart’s regulation of calcium?
include changes in the heart’s regulation of calcium, which causes the myocardium to generate force over a longer period after excitation, and prolongs the systolic phase of the cardiac cycle.
Phase of the cardiac cycle that is prolonged?
Systolic phase of the cardiac cycle.
Older adults have a higher blood pressure because of ______Vascular resistance
Increased Peripheral vascular resistance. decreased arterial elasticity.
What is the cause of stiff veins and arteries in elderly
Loss of elastin; increased collagen; glycosylation cross-linking of collagen
Elastin is ____ in elderly while collagen is _____
Loss of elastin, increased collagen
What is the effects of stiff veins in elder and consequences on anesthesia?
Changes in blood volume cause exaggerated
changes in cardiac fillin
Stiff arteries lead to impaired
Diastolic relaxation in the elderly
Stiff arteries in the elderly leads to impaired diastolic relaxation which leads to
Labile BP; diastolic dysfunction; sensitive to volume
status
Effect of myocardial hypertrophy in the elderly
Increased ventricular stiffness; prolonged
contraction; and delayed relaxation
Age related change: Reduced β-receptor
responsiveness: Anesthetic implications
Hypotension from anesthetic blunting of sympathetic tone;
altered reactivity to vasoactive drugs; increased dependence on
Frank-Starling mechanism to maintain CO; labile
BP, more hypotension
Altered reactivity to vasoactive drugs in the elderly is due to
Age related Reduced β-receptor responsiveness:
Elderly have increase dependence on ______to maintain CO
increased dependence on
Frank-Starling mechanism to maintain CO
Age related change: Reduced β-receptor
responsiveness: Consequences: comment on catecholamines, HR and contractility, baroreceptor control of BP
Increased circulating catecholamines; limited increase in HR and contractility in response to endogenous and exogenous catecholamines; impaired baroreflex control of BP
In Elderly; density of β-receptors
decreased density of β-receptors
Why is Ventricular filling dependent on atrial pressure in the elderly?
Myocardial stiffening
Increased interstitial fibrosis; amyloid deposition
What happens to the myocardium of the elderly ?
Myocardial stiffening
Increased interstitial fibrosis; amyloid deposition
2 combined adversely affects the compensatory mechanisms of the older adult under the stress of anesthesia and surgery
decreased cardiac reserve and decreased maximum heart rate
In the elderly, what is the most common cardiac complication and the leading cause of death in the postoperative period.
Myocardial infarction
The most frequently associated cardiovascular coexisting diseases in the older adult are
HTN
HLD
CAD
CHF
Elderly patients and chest wall
calcifications of the chest wall,
Elderly chest wall compliance
decreased intercostal muscle mass, contributes to a decrease in chest wall compliance
Intercostal muscle mass in the elderly is
Decreased
Change in the spine affected chest wall compliance in the elderly
changes in spinal lordosis, which may further diminish
chest wall compliance.
Lung parenchyma changes in the elderly,
loss of elastic tissue recoil of the lung.
Gas exchange and ALVEOLAR surface area in the elderly
Reduced functional alveolar surface area available for
gas exchange
In elderly patients, even in the absence of disease, Lung compliance________ which impairs what ______? Physiologic shunt is __________ and results in the ________of oxygen exchange at the alveolar level.
increase in lung compliance impairs the matching of ventilation and perfusion, increases physiologic shunt, and results in the reduction of oxygen exchange at the alveolar level
Closing volume in the elderly is
Increased
Why does closing volume increase in the elderly?
It loses lung elastic recoil. Lung elastic recoil is necessary for maintaining small airway caliber, an increased lung compliance causes small airway diameter to narrow, and eventually increases the closing volume
The closing volume exceeds functional residual capacity (FRC) at approximately (E before S)
65 years of age in the erect (sitting) position and at age 45 years in the supine position
In the supine position The closing volume exceeds functional residual capacity (FRC) at approximately ___years of age
45
In the sitting position, The closing volume exceeds functional residual capacity (FRC) at approximately ___years of age
65
Vital capacity in the elderly is_____ with ______in inspiratory reserve volume and expiratory reserve volume.
decrease; decreases
Residual volume in elderly
INCREASE
FRC in elderly is
INCREASE
Inspiratory and Expiratory volume in the elderly
DECREASE
Total Lung capacity in the elder
Total lung capacity remains UNCHANGED or may slightly decrease
The forced vital capacity (FVC) and the forced
expiratory volume in 1 second (FEV1) are both decreased in the elderly why?
decreased as a result of the loss of lung elastic recoil, decrease in small airway diameter, and
subsequent airway collapse with forced expiration
Small airway diameter in the elderly is
decreased
Overall the elderly have______ efficiency of gas exchange.
impaired
Why is there impaired oxygenation ?
Impaired oxygenation is reflected by a decline in resting arterial oxygen tension (PaO2),
PaO2 is what level after 75
83 mm Hg, after 75 years of age.
PaO2 is 83 mmHg after
75 years of age
The decline in PaO2 in the elderly is due to
premature closing of small airways and the reduction in the alveolar surface area.
What predisposes the elderly to apnea
ventilatory response to hypoxemia and hypercarbia is decreased, predisposing them to increased episodes of apnea.
Elderly airway changes (laryngeal) include
decrease in laryngeal and pharyngeal support that accompanies aging, which can result in airway obstruction
Protective airway reflexes in the elderly?
protective airway reflexes (i.e., coughing and swallowing) are decreased
What put the elderly patients at increased risk of aspiration
In addition, protective airway reflexes (i.e., coughing and swallowing) are decreased
Age related changed : Increased lung compliance Consequences and anesthetic implications?
Consequences –> Increased V ̇/Q̇ mismatch
Anesthetic Implications–> Avoid high pressure/large TV
Increased small airway closure consequences on dead space, alveolar surface area, PCBF and PaO2
Increased anatomic dead space (leading to an increased in MV to maintain a normal PaCO2)
Decreased alveolar surface area
Decreased PCBF (Pulmonary capillary blood flow)
Decreased PaO2
Increase small airway closure in the elderly, what are your anesthetic considerations?
Consider alveolar recruitment maneuvers (PEEP)
Limit High inspired O2
Maintain PaCo2 near normal value
Limit this as far as O2 for elderly
Limit High inspired O2
Decreased airway reflexes , anesthetic considerations
Consider RSI with GA
Ensure fully reversed prior to extubation
Consider postoperative CPAP or BiPAP
WOB in elderly be careful with
Careful use of NDMRs, opioids, and benzodiazepines
3 main respiratory parameters DECREASE In elderly
IRV
ERV
VC
2 main respiratory parameters INCREASE There is a corresponding increase in
residual volume (RV’) and functional residual capacity (FRC’) such that the total lung capacity remains approximately the same
Why does the TLC remains the same
IRV , ERV, VC decrease
FRC and RV increases
Increase risk of this post-op for elderly patients
Increase risk of post op pulmonary complications
Top Patient risk factors for Postoperative pulmonary complications
Age greater than 60 years
• Chronic obstructive pulmonary disease
• ASA class II or greater
• Functional dependence
Top surgery related risk factors for postop pulmonary complications
Surgery-Related Factors • Prolonged operation (> 3 hours) • Surgical site • Emergency operation • General anesthesia
For example, smoking cessation at
least
8 weeks prior to surgery, implementing inspiratory muscle training and lung expansion maneuvers via incentive spirometry, and medically optimizing patients with COPD and/or asthma
4 main renal changes in the elderly
atrophy of kidney parenchymal tissues
Deterioration of renal vascular structures
Decreased renal blood flow
Decrease in renal mass
Renal mass is
Decreased
Renal blood flow in the elderly
decreased
Decrease in renal blood flow and renal mass leads to what changes in the GFR?
Decrease glomerular filtration rate (GFR) resulting in decreased renal drug clearance and decreased renal blood flow from age 20 years to age 90 years
GFR decline %
(approximately a 25%–50% decline).
Decrease GFR effect on drugs
diminished renal clearance of hydrophilic agents
and hydrophilic metabolites of lipophilic agents
If overzealous administration of fluid
decrease in GFR and impairment of the diluting segment of the nephron can easily predispose the patient to fluid overload if overzealous intravenous fluid is administered.
Segment of the kidney that is impaired in the elderly
Diluting segment of the nephron
Sodium conservation in the elderly
The production of renin and aldosterone is decreased with age, causing impairment of sodium conservation
Renin production in elderly is
Decreased
Aldosterone production in elderly
decreased
Sodium conservation in the elderly is
decreased
Hydrogen ion excretion in elderly
Decreased
Impaired ability of the kidneys to respond to
changes in electrolyte concentrations, intravascular volume, and free water
Why does the serum creatinine remains unchanged with aging?
The serum creatinine is often unchanged if there is no renal failure because of decreased creatinine production from the overall declining skeletal muscle mass associated with aging.
Skeletal muscle mass is
Decreased
Why is Creatinine production decreased in the elderly
from the overall declining skeletal muscle mass associated with aging.
Best indicator of drug clearance?
Creatinine clearance
What is a common formula for estimating creatinine clearance, which in turn estimates GFR (eGFR) in the healthy older adult
The Cockroft–Gault equation
Formula of Cockroft–Gault equation for GFR?
eGFR mL/min = (140-age) X weight (kg) / 72 x serum creatinine (mg/dL)
the whole thing x 0.85 for female patients.
Renal changes put the patient at risk for 4 things
1/ fluid overload;
(2) accumulation of metabolites and drugs that are excreted by the kidneys;
(3) decreased drug elimination, which can prolong the
effects of a wide range of anesthetic drugs and adjuncts;
(4) electrolyte imbalances, which can lead to arrhythmias by affecting cardiac conduction
The aging adult liver decreases in mass by approximately
20% to 40 % and may be attributed to the decrease in its blood flow.
As far as liver changes what affects liver more than the age related changes?
it is the combination of coexisting diseases (i.e., hepatitis, drug-induced liver injury, cirrhosis) and lifestyle habits (i.e., smoking, alcohol consumption, poor nutrition) that affect liver function more so than the physiologic aging
liver.
Phase 2 drug metabolism involves
conjugation reactions, sulfonic acid, or acetylation.
The liver produces key proteins such as
albumin and α1-acid glycoprotein (AAG).
In the elderly, serum albumin and AAG
decreases ; increases
Low albumin, Theoretically this may result in adverse drug effects especially when?
when malnutrition is present.
However, protein binding changes with aging do not routinely require alterations in drug dosing why? as
the protein binding on free plasma concentration is rapidly counteracted by clearance
The most notable endocrine organ to impact the aging adult patient and postoperative morbidity is the
pancreas.
Major endocrine changes
decline in number and function of the pancreatic islet beta cells that results in decreased insulin secretion.
Insulin and the elderly
insulin resistance occurs peripherally, which contributes
to increased hepatic production of glucose and impaired
breakdown of fats and proteins making the elderly glucose tolerant or diabetic.
Hepatic production of glucose in the elderly
increase
Fas and protein breakdown in the elderly
Decrease or IMPAIRED
Diabetes has an effect on brain aging and is associated
with playing a role in
impaired cognition and Alzheimer’s dementia
Basic metabolic rate and elderly
There is a decrease in the basal metabolic rate (BMR) as a result of decreased physical activity and/or
Serum testosterone and growth hormone levels.
decreases
Skeletal muscle mass and strength in the elderly
Skeletal muscle mass and strength declines with aging with 50% of skeletal mass being lost by the age of
80 years.
What is one of the causes of functional decline and independence in the elderly?
The loss of skeletal muscle tissue (sarcopenia)
Elderly have sarcopenia, what does that mean?
The loss of skeletal muscle tissue (sarcopenia)
Body protein in the elderly
Decrease
Body fat in the elderly
increases
The total body water loss is mostly;
intracellular and somewhat in the extracellular
compartment
Blood volume and elderly
blood volume decreases approximately 20% to 30 % by
age 75 years.
As a result of decrease in total body water, older adults
are more vulnerable to
hypotension and have difficulty compensating for positional changes.
Thermoregulation and older adults
Thermoregulation in the elderly patient is impaired. In the older adult there is a decrease in the function of the hypothalamus.
Explain hypothermia in the elderly
Hypothermia is more pronounced and lasts longer because of a :
- Lower basal metabolic rate
- high ratio of surface to body area mass, and less effective peripheral vasoconstriction in response to cold
Ration of surface to body area mass in the elder
HIGH
Hypothermia is particularly detrimental in the elderly patient because it
* effect on anesthetic
slows anesthetic elimination,
Hypothermia is particularly detrimental in the elderly patient because it *effect on recovery from anesthesia
prolongs recovery from anesthesia,
Hypothermia is particularly detrimental in the elderly patient because it * effect on coagulation and immune system
impairs coagulation, impairs immune function
Hypothermia on ventilatory response to CO2
, blunts the ventilatory response to CO2 and increases
the chance that the patient will shiver
Why you don’t want elder to shiver?
Shivering drastically increases oxygen consumption, which leads to hypoxia, acidosis, and cardiac
compromise
It is known that inhaled anesthetics
inhibit the temperature regulating centers in the hypothalamus; thus, the aging adult has this added insult to an already inhibited hypothalamus.
Once temperature decreases in the elderly patient, it is difficult to
restore normal body temperature
Ways to avoid hypothermia in the elderly
Administration of all fluids and blood transfusions
through a warming device
Thermal mattress or forced air warmer,
and an environmental humidity higher than 50%
Elderly: Collagen and elastin
The elderly have a decrease in dermal and epidermal thickness of the skin, which is caused by a loss of collagen and elastin
Subcutaneous fat in the elderly
decrease in subcutaneous fat and thinness of the
skin, the aging adult is prone to skin tears and nerve injuries with positioning.
CNS changes in the elderly
progressive loss of neurons and neuronal substance,
decrease in neurotransmitter activity, and decreased brain volume.
CNS changes in the brain are more prominents inthe
These losses are most prominent in the cerebral cortex, particularly the frontal lobes.
CSF and older adults? nerve conduction velocity?
decrease in cerebrospinal fluid, a decrease in nerve conduction velocity,
CNS changes and anesthetic agents
increased sensitivity to anesthetic agents
Brain function monitoring (bispectral index monitoring)
may be beneficial in the elderly surgical patient. It may assist in guiding)
the titration of medications and inhalation agent, thus speeding recovery times and perhaps decreasing the incidence of POD and postoperative cognitive dysfunction (POCD
May assist in preventing POD or POCD
BIS monitoring
The older patient may experience increased sensitivity to drugs
because the number of receptors available are decreased
BBB and elderly
The blood brain barrier becomes more permeable, which may also contribute to the sensitivity of medications in addition to neurocognitive disorders such as Alzheimer dementia and delirium.
The dose of induction agents should be
decreased by as much as 50% in older patients, arguing for very meticulous titration.
Benzodiazepines and older adults
Benzodiazepines should be avoided in older
adults because they contribute to adverse events (i.e., falls, confusion, POD)
Number of myelinated nerves are
decreased
Changes in elderly :_______intervertebral disc height,
_______Of the intervertebral foramina,,
decreased; narrowing of
Older people and
decreased space between the posterior spinous processes
contribute to difficulties associated with patient positioning and spinal or epidural needle placement.
presence of calcifications, and changes in normal
lordosis,
Dura and older adults?
is more permeable to local anesthetics and that the CSF specific gravity increases, whereas its volume decreases.
CSF specific gravity in the elderly_____and CSF volume _____
Increases: decreases
When doing neuraxial analgesia in the elderly, what is your concern about sympathectomy
Because elderly patients have an impaired baroreceptor response, severe hypotension refractory to adrenergic stimulation may result from postspinal sympathectomy. This could potentially be detrimental in the presence of impaired cardiac function.
Spread of LA in the elderly
Enhanced spread of local anesthetics with
epidural blockade
Test dose of LA and the elderly
In addition, the use of an epinephrine “test dose”
for identification of intrathecal injection is less reliable in the elderly because of the decreased end-organ adrenergic responsiveness
Elderly dose of LA should be
Reduced
Several screening tools are available, but the_____
can be rapidly administered, is highly sensitive and specific for dementia, and is unbiased by variances in education or language. It consists of a
Mini-Cog; three-item recall and a clock draw algorithm
Mini Cog consists of
three-item recall and a clock draw algorithm
The four legally–relevant criterion for decision making capacity are
(1) understandingtreatment options;
(2) appreciating and acknowledging medical condition and likely outcomes;
(3) exhibiting reasoning and engaging in a rational discussion of surgical treatment options;
4) clearly choosing a preferred treatment option.
Primary frailty vs secondary frailty
Primary frailty occurs as part of the intrinsic process of aging.Secondary frailty is related to the end-stage of chronic illnesses
Aging and senses
Aging is associated with decreases in all the senses; thus it is speculated that the decrease in smell and taste may cause foods to be less appetizing.
Aging and lean body mass
aging cause decreased lean body mass that may mimic or be confused with malnutrition.
Can be implemented to establish mobility and gait
The Timed Up and Go Test (TUGT)
What is timed up and Go test
This entails having the older adult patient rise from
a standard chair, walk approximately 10 feet, turn back, and return to the chair and sit down again. If it takes longer than 20 seconds to complete the test, the patient is determined to be at risk for falls.
The most important goals in the perioperative care of older adults are the
Avoidance of functional decline, and maintenance of independence postoperatively.
Drugs actions that are often seen in the elderly
Exaggerated responses to anesthetic drugs and a prolonged duration of action
In elderly, A decreased blood volume results
in a
decrease in initial volume of distribution which leads to higher-than-expected initial concentration of drug with an intravenous bolus injection
Vd of hydrophillic drug
decrease for hydrophilic drugs
Vd of lipophillic drug
Increase for lipophillic drugs
Plasma protein in the elderly
Decreased plasma protein binding in the elderly theoretically results in an increase in the free plasma concentration for drugs that are highly protein bound.
Older adults phase I and phase II
Phase I metabolism may be reduced, but phase II metabolic pathways are not affected by aging
Older people, RBF, GFR and tubular secreation
Decrease in blood flow, glomerular filtration, and tubular secretion leads to increased serum concentration and prolonged effects of drugs dependent on renal elimination.
The minimal alveolar concentration (MAC) of inhalational agents
decreases roughly 6.7% per decade from the MAC value of 40-year-old adults
Neuromuscular blocking drugs are not affected by the _______changes of the older adult.
pharmacodynamics
What pharmacology parameters of NMB is altered by aging?
Pharmacokinetics
For all neuromuscular blocking drugs, the onset
of action is usually
prolonged
The neuromuscular blocking medication of choice for the older adult is ______why?
Cisatracurium; because it undergoes Hoffman elimination and ester hydrolysis and is not organ dependent.
Older adults anesthetic considerations of propofol
Hypotension; prolonged recovery; increased brain sensitivity
Dosing of propofol older adults considerations
bolus and infusion by 50% (manufacturer
recommends 1–1.5 mg/kg bolus for induction
Midazolam in the elderly
Avoid per BEER CRITERIA OR ↓ dose by 75%
Avoid THIS OPIOIDS in the elderly
MEPERIDINE
Considerations with opioids in the elderly
slower onset and delayed recovery; consider route of
metabolism and metabolites;
AVoid this medication per BEER”S CRITERIA
Midazolam
What is Autonomy?
Patient’s right to self-determination
What is Beneficence:
An obligation or responsibility to help the patient; “to do good”
What is Nonmaleficence:
To not intentionally harm the patient; “do no harm”
What is justice
• Justice: To treat the patient fairly
Is the cornerstone for upholding the practice
of autonomy.
The informed consent
Autonomy is also exercised through
an advanced directive (AD).
In 1991, legislation enacted the ____what is it?
Patient Self-Determination Act (PSDA), which
requires hospitals and other health organizations that receive Medicare funds to provide information to patients regarding their right and refusal of care (i.e., ADs).
When was the Patient Self-Determination Act (PSDA) established>
1991
ASA suggests that specific resuscitation alternatives during the surgical procedure be presented and discussed with the patient. These three alternatives include
(1) the full suspension of the DNR status intraoperatively and postoperatively,
(2) the acceptance or refusal of specific resuscitative interventions (i.e., chest compressions, defibrillation, vasopressor administration) with full documentation of these in the medical record, and
(3) resuscitation procedures will be determined by the anesthesia provider and the surgeon based on clinical judgment, while keeping in mind the patient’s values and wishes
The ethical principle of social justice is NOT
providing the greatest good for the greatest number of people; it is treating people equally, regardless of their age, race, cultural beliefs, religion, disease
processes, or resuscitation status.
should not be regarded as a reason to exclude an older adult for any procedure.
age, as an independent factor,
The most frequently occurring neurologic phenomena in older adults
POD and postoperative cognitive dysfunction (POCD)
POD and symptoms
Symptoms typically manifest acutely within
the first few days after surgery and can last for several days or weeks.
Common theory of POCD is
Common theories include cerebral hypoperfusion
(severe hypotension and embolic events), the inflammatory process associated with surgery, and general anesthetics
The treatment of POD begins with
prevention
Risk Factors for Postoperative Cognitive Dysfunction
•
Genetic disposition • Lower educational level • High alcohol intake or alcohol abuse • Increasing age • High ASA status • Preexisting mild cognitive impairment • History of cerebrovascular accident • Major operations, redo operations • Cardiac surgery • Longer duration of surgery and anesthesia • Intraoperative cerebral desaturation • Postoperative delirium • Postoperative infection
The use of pharmacologic interventions should be reserved for those who are highly agitated and are threatening harm to self and/or others.5,
(i.e., haloperidol, lorazepam)
In the elderly patient, total body water_____ while total body fat _____Thus, the volume of distribution for water-soluble drugs such as (3)_______; while the volume of distribution for lipid-soluble drugs such as (3) _____
decreases; increases. glycopyrrolate, succinylcholine, and gentamicin; decreases
barbiturates, benzodiazepines, and volatile anesthetics ;increases.
The geriatric population is more susceptible to decreases in core temperature primarily because
autonomic peripheral vasoconstriction decreases with age
Elderly ; insulin and glucose loads
They exhibit a lower insulin response to glucose loads
Hypothermia in the elderly is known to increase the risk for (select two)
Myocardial ischemia
Coagulopathy
Elderly are more prone to this endocrine disorder
Hypothyroidism
The elimination of hydrophilic agents in the elderly is prolonged primarily because of
a decrease in renal clearance
Vd of water soluble drugs is_____; Water soluble drugs examples are GGS
Decreased; Gentamycin, Glycopyrrolate, Succinylcholine.
Vd of lipid soluble drugs is ______; Lipids soluble drugs examples are BBV
Barbiturates, Benzodiazepines and volatile anesthetics
Systolic function of geriatric according to apex
No change
The most significant risk factor to developing cancer is
Old age
Lung Compliance describes how
Easy it is to inflate (distend) the lungs
Lung elasticity describes how
Elastic recoil which is the tendency of the lung to return to original shape after exhalation.
Older people compliance and elasticity
High compliance
Low elasticity
Loss of elastic recoil and effect on respiratory system:
Dead space, alveolar surface area, V/Q mismatch, A-a gradient, PaO2
Increased dead space
Decreased alveolar surface area
Increased VQ mismatch
Decreased PaO2
RV in the elderly _______Which is similar to what happen to what disease process?
Increases; Emphysema
Cough reflex in the elderly
A greater stimulus is required to initiate the cough reflex
The reason why the small airways have a greater tendency to collapse during expiration.
The reduction in elastic recoil is
Total lung capacity is unchanged, because of the.
increase in RV and the reduction in VC
Because the total lung capacity is unchanged, a change in one
volume or capacity usually causes a change in another.
Increased FCR
Functional Residual capacity
Closing volume
RV
Vital Capacity is
decreased
Why does total lung capacity remains unchanged in the elderly?
Increased RV
Decreased VC
Venous capacitance in the elderly is______meaning?
Decreased; Greater lability of BP with anesthetic induction
The best indicator of cardiac reserve are
Exercise tolerance
Ability to perform ADLs
Most common cause of death of the elderly in the postop period?
MI
Change in _______can cause drastic changes in preload
blood volume
Very important for the noncompliant ventricle
Atrial kick is needed to prime the noncompliant ventricle
During Atrial fibrillation and ventricular priming
Unable to prime because AFIB patients lack atrial kick
Systolic function ________ ; SBP ______
Systolic FUNCTION remains the same
SBP increase
Pulse pressure in the elderly and why
Widens: BECAUSE SBP increases much more than DBP increases
Why does BP increases in the elderly?
Arterial compliance is REDUCED which increases SVR
Diastolic function changes in the elderly include
Reduced compliance and increased arterial wall stiffness impairs myocardial relaxation
Slower rate of Ca2+ removed from the cytoplasm
Diastolic function in the elderly is _____but does not mean ____
Reduced; failure
SV and elderly
Reduced ability to increase SV
HR and elderly
Decreased response to catecholamines
What is maximal HR and how is it in elderly?
220 - HR
Decreased in the elderly
SNS tone and elderly
Higher NE concentration in the plasma
Coupling is
Reduced with adenylate cyclase
PNS tone is decreased therefore
May have difficulty increasing HR with anticholinergics
Dehydration in the elderly increases the risk of
Fluid and electrolyte imbalance
Parkison’s disease is ________ in what part of the brain?
Decrease DOPAMINE in the BASAL GANGLIA
Dose of IV anesthetic agent should be decreased by
30-40%
In the elderly , reduced activity of what neurotransmitters?
Ach, NE, DA, GABA
Gray matter vs white matter?
Gray atrophies at a faster rate than white matter
Pain, Temperature and Crude sensation travel via the
LATERAL AND Anterior SPINOTHALAMIC TRACT
PTC –> LAST
POST OP DELIRIUM RISK FACTORS Mnemonic DELIRIUM
Drugs? *use rapidly metabolized drugs Electrolyte imbalance Lack of drugs Infection (UTI or resp) Reduced sensory input Intracranial dysfunction Urinary retention , fecal impaction Myocardial event Male gender
Impaired comprehension , concetration and psychomotor skills is associated with
POCD
6 risk factors for POCD : AP CHALL
Advanced age Pre-existing cognitive deficit Cardiac surgery High ASA Anesthetic agensts Long duration surgery Low level education
Post op delirum treatment vs POCD treatment
POST DELIRIUM –> Treat underlying cause, Antipsychotics, minimize polypharmacy
POCD –> resolve after 2-3 months
Epidural LA is associated with ______spread of LA due to
GREATER; REDUCTION in the epidural space
Spinal LA is associated with ______spread of LA due to
GREATER; REDUCTION in the CSF volume
Dura and elderly
Dura is more permeable to LA (reduce dose)
Myelinated nerve changes
Decrease in number, diameter and conduction velocity
Associated with very high mortality
perioperative renal failure
Aldosterone in the elderly and effect
Decrease, decrease ability to conserve sodium which lead to increase risk of dehydration
CrCl in elderly
less nephrons to clear creatinine
What is the most sensitive indicator of renal function and drug clearance in the elderly?
Creatinine Clearance
When to consider dosage adjustments?
Age> 60
ADH and elderly
Decrease reponse to ADH
RBF and elderly
Decrease 10% per decade
Concentration gradients?
Decrease concentration gradient necessary to produce concentrated urine
Loss of nephrons where does is occur
CORTEX»_space;>MEDULLA
Why is there no change in serum creatinine ?
GFR decreases with age, in theory, this should increase in serum creatinine
Muscle mass also decreases with age, this means, less creatinine is produced.
Pseudocholinesterase production and elderly
Reduced
Drugs with HiGH HEPATIC EXTRACTION RATIO
fentanyl, lidocaine, metoprolol
Hepatic blood flow is ______in the elderly
Decreased
Low Hepatic Extraction Ratio drugs
Theophylline and Diazepam
Alpha 1 Acid Glycoprotein is
Increased
increase reservoir for basic drugs.
Free fraction of drugs bound to albumin is
Increased, because albumin levels are decreased
THINGS THAT increase closing volume CLOSE-P
COPD LV failure Obesity Supine position Extreme of age Pregnancy.
Closing capacity is
Closing volume + Residual volume
One of the most cardinal signs of parkisons’
Bradykinesia
If the patient with Parkinson’s disease start exhibiting parkinsonian syndrome, best way to treat is with
Drugs with anticholinergic properties (reduces ACH)
EPS treat with
Benztropine or diphenhydramine
Summary: respiratory parameters that increases with age
Lung Compliance Closing Capacity Minute Ventilation Residual volume FRC
Summary: respiratory parameters that decreases with age (VIECEL)
Vital , Forced VC Inspiratory Reserve Capacity Expiratory reserve volume Chest wall compliance Elasticity of the lung Lung mass
