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SEE/NCE Boards CoreConcepts > AGE RELATED CHANGES > Flashcards

AGE RELATED CHANGES Flashcards

1
Q

Post operative delirium vs Post Operative Cognitive Dysfunction : What is the difference?

A

Unlike POD, the onset of POCD is subtle and neurocognitive deficits may not present themselves
until weeks to months after surgery.

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2
Q

How to help POCD?

A

Establishing baseline cognitive function is critical because preoperative cognitive impairment may be present prior to surgery.

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3
Q

By what age-related physiologic functions

in humans have peaked and gradually decline thereafter.

A

age of 30 years,

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4
Q

Heart and vascular system compliance in the elderly

A

the heart and vascular system is less compliant,

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5
Q

Afterload + Systolic BP , in the elderly leading to

A

increase

in afterload, and an increase in systolic blood pressure,

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6
Q

What is the change that occurs in the elderly patients ventricles? what about ejection times?

A

ventricular thickening (hypertrophy) and prolonged ejection times

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7
Q

Diastolic function in the elderly?

A

ventricular hypertrophy and slower myocardial relaxation

often results in late diastolic filling and diastolic dysfunction.

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8
Q

What is the screening tool for Cognitive Ability Capacity

A

Mini-Cog 3 Item Recall and clock draw

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9
Q

What is the screening tool for Alcohol and Substance abuse?

A

Modified CAGE

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10
Q

When assessing for Slowness, Weight loss, Grip weakness, Exhaustion, Decrease in physical activity: What are you assessing for

A

Frailty.

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11
Q

Levels of catecholamines is _______In the elderly?

A

higher amounts of circulating catecholamines, they

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12
Q

Adrenergic responsiveness in the elderly?

A

exhibit decreased end-organ adrenergic responsiveness.

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13
Q

Therefore the older adult has a reduced capacity to increase heart rate in response to

A

hypotension, hypovolemia, and hypoxia.

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14
Q

Causes a faster induction time with inhalation agents but

A

Prolonged circulation time

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15
Q

In the elderly what delays the onset of intravenous drugs.

A

Prolonged circulation time

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16
Q

Prolonged circulation time effect on elderly 2

A

Faster induction with inhalation agents

Slower induction with IV agents

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17
Q

Elderly patients are at risk for which cardiac arrhythmias and why?

A

loss of sinoatrial node cells, which predisposes the elderly to atrial fibrillation, sick sinus syndrome, first- and second-degree heart blocks, and arrhythmias

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18
Q

Loss of _____node cells predisposes elderly to afib, sick sinus syndrome, 1st and 2nd HB and arrhythmias.

A

Sinoatrial node cells

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19
Q

Calcification of these valves primarily in the elderly

A

valves (primarily aortic and mitral),

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20
Q

Pulse pressure in the elderly? and why?

A

With aging the pulse pressure widens because of a greater proportionate increase in systolic blood pressure
compared with diastolic blood pressure.

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21
Q

Baroreceptors in the elderly? which results in?

A

decreased sensitivity of baroreceptors in the aortic arch and carotid sinuses in response to blood pressure changes, which results in increased episodes of hypotension.

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22
Q

Ejection phase in the elderly is

A

prolonged.

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23
Q

Elderly and heart’s regulation of calcium?

A

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.

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24
Q

Phase of the cardiac cycle that is prolonged?

A

Systolic phase of the cardiac cycle.

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25
Q

Older adults have a higher blood pressure because of ______Vascular resistance

A

Increased Peripheral vascular resistance. decreased arterial elasticity.

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26
Q

What is the cause of stiff veins and arteries in elderly

A

Loss of elastin; increased collagen; glycosylation cross-linking of collagen

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27
Q

Elastin is ____ in elderly while collagen is _____

A

Loss of elastin, increased collagen

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28
Q

What is the effects of stiff veins in elder and consequences on anesthesia?

A

Changes in blood volume cause exaggerated changes in cardiac filling

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29
Q

Stiff arteries lead to impaired

A

Diastolic relaxation in the elderly

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30
Q

Stiff arteries in the elderly leads to impaired diastolic relaxation which leads to

A

Labile BP; diastolic dysfunction; sensitive to volume

status

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31
Q

Effect of myocardial hypertrophy in the elderly

A

Increased ventricular stiffness; prolonged

contraction; and delayed relaxation

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32
Q

Age related change: Reduced β-receptor

responsiveness: Anesthetic implications

A

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

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33
Q

Altered reactivity to vasoactive drugs in the elderly is due to

A

Age related Reduced β-receptor responsiveness:

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34
Q

Elderly have increase dependence on ______to maintain CO

A

increased dependence on

Frank-Starling mechanism to maintain CO

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35
Q

Age related change: Reduced β-receptor

responsiveness: Consequences: comment on catecholamines, HR and contractility, baroreceptor control of BP

A 
Increased circulating catecholamines;
limited increase in HR and contractility
in response to endogenous and
exogenous catecholamines; impaired
baroreflex control of BP
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36
Q

In Elderly; density of β-receptors

A

decreased density of β-receptors

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37
Q

Why is Ventricular filling dependent on atrial pressure in the elderly?

A

Myocardial stiffening

Increased interstitial fibrosis; amyloid deposition

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38
Q

What happens to the myocardium of the elderly ?

A

Myocardial stiffening

Increased interstitial fibrosis; amyloid deposition

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39
Q

2 cardiac changes combined adversely affects the compensatory mechanisms of the older adult under the stress of anesthesia and surgery?

A

decreased cardiac reserve AND decreased maximum heart rate

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40
Q

In the elderly, what is the most common cardiac complication and the leading cause of death in the postoperative period.

A

Myocardial infarction

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41
Q

The most frequently associated cardiovascular coexisting diseases in the older adult are

A

HTN
HLD
CAD
CHF

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42
Q

Elderly patients and chest wall

A

calcifications of the chest wall,

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43
Q

Elderly chest wall compliance

A

decreased intercostal muscle mass, contributes to a decrease in chest wall compliance

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44
Q

Intercostal muscle mass in the elderly is

A

Decreased

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45
Q

Change in the spine affected chest wall compliance in the elderly

A

changes in spinal lordosis, which may further diminish chest wall compliance.

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46
Q

Lung parenchyma changes in the elderly,

A

loss of elastic tissue recoil of the lung.

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47
Q

Gas exchange and ALVEOLAR surface area in the elderly

A

Reduced functional alveolar surface area available for

gas exchange

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48
Q

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.

A

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

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49
Q

Closing volume in the elderly is

A

Increased

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50
Q

Why does closing volume increase in the elderly?

A

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

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51
Q

The closing volume exceeds functional residual capacity (FRC) at approximately (E before S)

A

65 years of age in the erect (sitting) position and at age 45 years in the supine position

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52
Q

In the supine position The closing volume exceeds functional residual capacity (FRC) at approximately ___years of age

A

45

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53
Q

In the sitting position, The closing volume exceeds functional residual capacity (FRC) at approximately ___years of age

A

65

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54
Q

Vital capacity in the elderly is_____ with ______in inspiratory reserve volume and expiratory reserve volume.

A

decrease; decreases

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55
Q

Residual volume in elderly

A

INCREASE

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56
Q

FRC in elderly is

A

INCREASE

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57
Q

Inspiratory and Expiratory volume in the elderly

A

DECREASE

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58
Q

Total Lung capacity in the elder

A

Total lung capacity remains UNCHANGED or may slightly decrease

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59
Q

The forced vital capacity (FVC) and the forced

expiratory volume in 1 second (FEV1) are both decreased in the elderly why?

A

decreased as a result of the loss of lung elastic recoil, decrease in small airway diameter, and
subsequent airway collapse with forced expiration

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60
Q

Small airway diameter in the elderly is

A

decreased

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61
Q

Overall the elderly have______ efficiency of gas exchange.

A

impaired

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62
Q

Why is there impaired oxygenation ?

A

Impaired oxygenation is reflected by a decline in resting arterial oxygen tension (PaO2),

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63
Q

PaO2 is what level after 75

A

83 mm Hg, after 75 years of age.

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64
Q

PaO2 is 83 mmHg after

A

75 years of age

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65
Q

The decline in PaO2 in the elderly is due to

A

premature closing of small airways and the reduction in the alveolar surface area.

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66
Q

What predisposes the elderly to apnea

A

ventilatory response to hypoxemia and hypercarbia is decreased, predisposing them to increased episodes of apnea.

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67
Q

Elderly airway changes (laryngeal) include

A

decrease in laryngeal and pharyngeal support that accompanies aging, which can result in airway obstruction

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68
Q

Protective airway reflexes in the elderly?

A

protective airway reflexes (i.e., coughing and swallowing) are decreased

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69
Q

What put the elderly patients at increased risk of aspiration

A

In addition, protective airway reflexes (i.e., coughing and swallowing) are decreased

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70
Q

Age related changed : Increased lung compliance Consequences and anesthetic implications?

A

Consequences –> Increased V ̇/Q̇ mismatch

Anesthetic Implications–> Avoid high pressure/large TV

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71
Q

Increased small airway closure consequences on dead space, alveolar surface area, PCBF and PaO2

A

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

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72
Q

Increase small airway closure in the elderly, what are your anesthetic considerations?

A

Consider alveolar recruitment maneuvers (PEEP)
Limit High inspired O2
Maintain PaCo2 near normal value

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73
Q

Limit this as far as O2 for elderly

A

Limit High inspired O2

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74
Q

Decreased airway reflexes , anesthetic considerations

A

Consider RSI with GA
Ensure fully reversed prior to extubation
Consider postoperative CPAP or BiPAP

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75
Q

WOB in elderly be careful with

A

Careful use of NDMRs, opioids, and benzodiazepines

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76
Q

3 main respiratory parameters DECREASE In elderly

A

IRV
ERV
VC

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77
Q

2 main respiratory parameters that INCREASE in the elderly? Because those two parameters increase, what effect is there on TLC?

A 
residual volume (RV’) and functional residual capacity (FRC’) such that the total lung capacity
remains approximately the same
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78
Q

Why does the TLC remains the same

A

IRV , ERV, VC decrease

FRC and RV increases

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79
Q

Increase risk of this post-op for elderly patients

A

Increase risk of post op pulmonary complications

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80
Q

Top Patient risk factors for Postoperative pulmonary complications

A

Age greater than 60 years
• Chronic obstructive pulmonary disease
• ASA class II or greater
• Functional dependence

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81
Q

Top surgery related risk factors for postop pulmonary complications

A 
Surgery-Related Factors
• Prolonged operation (> 3 hours)
• Surgical site
• Emergency operation
• General anesthesia
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82
Q

For example, smoking cessation at

least

A

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

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83
Q

4 main renal changes in the elderly

A

atrophy of kidney parenchymal tissues
Deterioration of renal vascular structures
Decreased renal blood flow
Decrease in renal mass

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84
Q

Renal mass is

A

Decreased

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85
Q

Renal blood flow in the elderly

A

decreased

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86
Q

Decrease in renal blood flow and renal mass leads to what changes in the GFR?

A

Decrease glomerular filtration rate (GFR) resulting in decreased renal drug clearance and decreased renal blood flow from age 20 years to age 90 years

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87
Q

GFR decline %

A

(approximately a 25%–50% decline).

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88
Q

Decrease GFR effect on drugs

A

diminished renal clearance of hydrophilic agents

and hydrophilic metabolites of lipophilic agents

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89
Q

If overzealous administration of fluid

A

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.

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90
Q

Segment of the kidney that is impaired in the elderly

A

Diluting segment of the nephron

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91
Q

Sodium conservation in the elderly

A

The production of renin and aldosterone is decreased with age, causing impairment of sodium conservation

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92
Q

Renin production in elderly is

A

Decreased

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93
Q

Aldosterone production in elderly

A

decreased

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94
Q

Sodium conservation in the elderly is

A

decreased

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95
Q

Hydrogen ion excretion in elderly

A

Decreased

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96
Q

Impaired ability of the kidneys to respond to

A

changes in electrolyte concentrations, intravascular volume, and free water

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97
Q

Why does the serum creatinine remains unchanged with aging?

A

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.

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98
Q

Skeletal muscle mass is

A

Decreased

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99
Q

Why is Creatinine production decreased in the elderly

A

from the overall declining skeletal muscle mass associated with aging.

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100
Q

Best indicator of drug clearance?

A

Creatinine clearance

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101
Q

What is a common formula for estimating creatinine clearance, which in turn estimates GFR (eGFR) in the healthy older adult

A

The Cockroft–Gault equation

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102
Q

Formula of Cockroft–Gault equation for GFR?

A

eGFR mL/min = (140-age) X weight (kg) / 72 x serum creatinine (mg/dL)

the whole thing x 0.85 for female patients.

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103
Q

Age related Renal changes put the older patient at risk for 4 things

A

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

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104
Q

The aging adult liver decreases in mass by approximately

A

20% to 40 % and may be attributed to the decrease in its blood flow.

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105
Q

As far as liver changes what affects liver more than the age related changes?

A

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.

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106
Q

Phase 2 drug metabolism involves

A

conjugation reactions, sulfonic acid, or acetylation.

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107
Q

The liver produces key proteins such as

A

albumin and α1-acid glycoprotein (AAG).

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108
Q

In the elderly, serum albumin and AAG

A

decreases ; increases

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109
Q

Low albumin, Theoretically this may result in adverse drug effects especially when?

A

when malnutrition is present.

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110
Q

Protein binding changes with aging do not routinely require alterations in drug dosing why?

A

Because the protein binding on free plasma concentration is rapidly counteracted by clearance

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111
Q

The most notable endocrine organ to impact the aging adult patient and postoperative morbidity is the

A

pancreas.

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Perfectly
112
Q

Major endocrine changes

A

decline in number and function of the pancreatic islet beta cells that results in decreased insulin secretion.

113
Q

Insulin and the elderly:
What happens to insulin resistance?
What happens to hepatic production of glucose?
What happens to fats and proteins?

A

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.

114
Q

Hepatic production of glucose in the elderly

A

increase

115
Q

Fas and protein breakdown in the elderly

A

Decrease or IMPAIRED

116
Q

Diabetes has an effect on brain aging and is associated

with playing a role in

A

impaired cognition and Alzheimer’s dementia

117
Q

Basic metabolic rate and elderly

A

There is a decrease in the basal metabolic rate (BMR) as a result of decreased physical activity.

118
Q

Elderly: Serum testosterone and growth hormone levels.

A

decreases

119
Q

Skeletal muscle mass and strength in the elderly

What % is loss by what age?

A

Skeletal muscle mass and strength declines with aging

50% of skeletal mass being lost by the age of 80 years.

120
Q

What is one of the causes of functional decline and independence in the elderly?

A

The loss of skeletal muscle tissue (sarcopenia)

121
Q

Elderly have sarcopenia, what does that mean?

A

The loss of skeletal muscle tissue (sarcopenia)

122
Q

Body protein in the elderly

A

Decrease

123
Q

Body fat in the elderly

A

increases

124
Q

The total body water loss is mostly;

A

intracellular and somewhat in the extracellular compartment

125
Q

Blood volume and elderly

A

blood volume decreases approximately 20% to 30 % by age 75 years.

126
Q

As a result of decrease in total body water, older adults

are more vulnerable to what?

A

hypotension and have difficulty compensating for positional changes.

127
Q

Thermoregulation and older adults is _______ and why>

A

Thermoregulation in the elderly patient is impaired, because in the older adult there is a decrease in the function of the hypothalamus.

128
Q

Explain hypothermia in the elderly

A

Hypothermia is more pronounced and lasts longer because of a :

  1. Lower basal metabolic rate
  2. high ratio of surface to body area mass, and less effective peripheral vasoconstriction in response to cold
129
Q

Ratio of SURFACE to BODY MASS AREA in the elderly

A

HIGH

130
Q

Hypothermia is particularly detrimental in the elderly patient because it
* effect on anesthetic

A

slows anesthetic elimination,

131
Q

Hypothermia is particularly detrimental in the elderly patient because it *effect on recovery from anesthesia

A

prolongs recovery from anesthesia,

132
Q

Hypothermia is particularly detrimental in the elderly patient because it * effect on coagulation and immune system

A

impairs coagulation, impairs immune function

133
Q

Hypothermia on ventilatory response to CO2

A

, blunts the ventilatory response to CO2 and increases

the chance that the patient will shiver

134
Q

Why you don’t want elder to shiver?

A

Shivering drastically increases oxygen consumption, which leads to hypoxia, acidosis, and cardiac
compromise

135
Q

Temperature regulating centers and inhaled anesthetics effect on them?

A

inhibit the temperature regulating centers in the hypothalamus; thus, the aging adult has this added insult to an already inhibited hypothalamus.

136
Q

Once temperature decreases in the elderly patient, it is difficult to

A

restore normal body temperature

137
Q

Ways to avoid hypothermia in the elderly

A

Administration of all fluids and blood transfusions
through a warming device
Thermal mattress or forced air warmer,
and an environmental humidity higher than 50%

138
Q

Elderly: Collagen and elastin

A

The elderly have a decrease in dermal and epidermal thickness of the skin, which is caused by a loss of collagen and elastin

139
Q

Subcutaneous fat in the elderly

A

decrease in subcutaneous fat and thinness of the

skin, the aging adult is prone to skin tears and nerve injuries with positioning.

140
Q

CNS changes in the elderly

A

progressive loss of neurons and neuronal substance,

decrease in neurotransmitter activity, and decreased brain volume.

141
Q

CNS changes in the brain are more prominents where in the brain?

A

In the cerebral cortex, particularly the frontal lobes.

142
Q

CSF and older adults? nerve conduction velocity?

A

decrease in cerebrospinal fluid, a decrease in nerve conduction velocity,

143
Q

CNS changes and anesthetic agents

A

increased sensitivity to anesthetic agents

144
Q

Brain function monitoring (bispectral index monitoring)

may be beneficial in the elderly surgical patient. It may assist in guiding)

A

the titration of medications and inhalation agent, thus speeding recovery times and perhaps decreasing the incidence of POD and postoperative cognitive dysfunction (POCD

145
Q

May assist in preventing POD or POCD

A

BIS monitoring

146
Q

The older patient may experience increased sensitivity to drugs

A

because the number of receptors available are decreased

147
Q

BBB and elderly

A

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.

148
Q

The dose of induction agents should be

A

decreased by as much as 50% in older patients, arguing for very meticulous titration.

149
Q

Benzodiazepines and older adults

A

Benzodiazepines should be avoided in older

adults because they contribute to adverse events (i.e., falls, confusion, POD)

150
Q

Number of myelinated nerves are

A

decreased

151
Q

Changes in elderly :_______intervertebral disc height,

_______Of the intervertebral foramina,,

A

decreased; narrowing of

152
Q

Older people and

A

decreased space between the posterior spinous processes

153
Q

contribute to difficulties associated with patient positioning and spinal or epidural needle placement.

A

presence of calcifications, and changes in normal

lordosis,

154
Q

Dura and older adults?

A

is more permeable to local anesthetics and that the CSF specific gravity increases, whereas its volume decreases.

155
Q

CSF specific gravity in the elderly_____and CSF volume _____

A

Increases: decreases

156
Q

When doing neuraxial analgesia in the elderly, what is your concern about sympathectomy

A

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.

157
Q

Spread of LA in the elderly

A

Enhanced spread of local anesthetics with

epidural blockade

158
Q

Test dose of LA and the elderly

A

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

159
Q

Elderly dose of LA should be

A

Reduced

160
Q

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

A

Mini-Cog; three-item recall and a clock draw algorithm

161
Q

Mini Cog consists of

A

three-item recall and a clock draw algorithm

162
Q

The four legally–relevant criterion for decision making capacity are

A

(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.

163
Q

Primary frailty vs secondary frailty

A

Primary frailty occurs as part of the intrinsic process of aging.Secondary frailty is related to the end-stage of chronic illnesses

164
Q

Aging and senses

A

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.

165
Q

Aging and lean body mass

A

aging cause decreased lean body mass that may mimic or be confused with malnutrition.

166
Q

Can be implemented to establish mobility and gait

A

The Timed Up and Go Test (TUGT)

167
Q

What is timed up and Go test

A

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.

168
Q

The most important goals in the perioperative care of older adults are the

A

Avoidance of functional decline, and maintenance of independence postoperatively.

169
Q

Drugs actions that are often seen in the elderly

A

Exaggerated responses to anesthetic drugs and a prolonged duration of action

170
Q

In elderly, A decreased blood volume results

in a

A

decrease in initial volume of distribution which leads to higher-than-expected initial concentration of drug with an intravenous bolus injection

171
Q

Vd of hydrophillic drug

A

decrease for hydrophilic drugs

172
Q

Vd of lipophillic drug

A

Increase for lipophillic drugs

173
Q

Plasma protein in the elderly

A

Decreased plasma protein binding in the elderly theoretically results in an increase in the free plasma concentration for drugs that are highly protein bound.

174
Q

Older adults phase I and phase II

A

Phase I metabolism may be reduced, but phase II metabolic pathways are not affected by aging

175
Q

Older people, RBF, GFR and tubular secreation

A

Decrease in blood flow, glomerular filtration, and tubular secretion leads to increased serum concentration and prolonged effects of drugs dependent on renal elimination.

176
Q

The minimal alveolar concentration (MAC) of inhalational agents

A

decreases roughly 6.7% per decade from the MAC value of 40-year-old adults

177
Q

Neuromuscular blocking drugs are not affected by the _______changes of the older adult.

A

pharmacodynamics

178
Q

What pharmacology parameters of NMB is altered by aging?

A

Pharmacokinetics

179
Q

For all neuromuscular blocking drugs, the onset

of action is usually

A

prolonged

180
Q

The neuromuscular blocking medication of choice for the older adult is ______why?

A

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

181
Q

Older adults anesthetic considerations of propofol

A

Hypotension; prolonged recovery; increased brain sensitivity

182
Q

Dosing of propofol older adults considerations

A

bolus and infusion by 50% (manufacturer

recommends 1–1.5 mg/kg bolus for induction

183
Q

Midazolam in the elderly

A

Avoid per BEER CRITERIA OR ↓ dose by 75%

184
Q

Avoid THIS OPIOIDS in the elderly

A

MEPERIDINE

185
Q

Considerations with opioids in the elderly

A

slower onset and delayed recovery; consider route of

metabolism and metabolites;

186
Q

AVoid this medication per BEER”S CRITERIA

A

Midazolam

187
Q

What is Autonomy?

A

Patient’s right to self-determination

188
Q

What is Beneficence:

A

An obligation or responsibility to help the patient; “to do good”

189
Q

What is Nonmaleficence:

A

To not intentionally harm the patient; “do no harm”

190
Q

What is justice

A

• Justice: To treat the patient fairly

191
Q

Is the cornerstone for upholding the practice

of autonomy.

A

The informed consent

192
Q

Autonomy is also exercised through

A

an advanced directive (AD).

193
Q

In 1991, legislation enacted the ____what is it?

A

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).

194
Q

When was the Patient Self-Determination Act (PSDA) established>

A

1991

195
Q

ASA suggests that specific resuscitation alternatives during the surgical procedure be presented and discussed with the patient. These three alternatives include

A

(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

196
Q

The ethical principle of social justice is NOT

A

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.

197
Q

should not be regarded as a reason to exclude an older adult for any procedure.

A

age, as an independent factor,

198
Q

The most frequently occurring neurologic phenomena in older adults

A

POD and postoperative cognitive dysfunction (POCD)

199
Q

POD and symptoms

A

Symptoms typically manifest acutely within

the first few days after surgery and can last for several days or weeks.

200
Q

Common theory of POCD is

A

Common theories include cerebral hypoperfusion

(severe hypotension and embolic events), the inflammatory process associated with surgery, and general anesthetics

201
Q

The treatment of POD begins with

A

prevention

202
Q

Risk Factors for Postoperative Cognitive Dysfunction

•

A 
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
203
Q

The use of pharmacologic interventions should be reserved for those who are highly agitated and are threatening harm to self and/or others.5,

A

(i.e., haloperidol, lorazepam)

204
Q

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) _____

A

decreases; increases. glycopyrrolate, succinylcholine, and gentamicin; decreases
barbiturates, benzodiazepines, and volatile anesthetics ;increases.

205
Q

The geriatric population is more susceptible to decreases in core temperature primarily because

A

autonomic peripheral vasoconstriction decreases with age

206
Q

Elderly ; insulin and glucose loads

A

They exhibit a lower insulin response to glucose loads

207
Q

Hypothermia in the elderly is known to increase the risk for (select two)

A

Myocardial ischemia

Coagulopathy

208
Q

Elderly are more prone to this endocrine disorder

A

Hypothyroidism

209
Q

The elimination of hydrophilic agents in the elderly is prolonged primarily because of

A

a decrease in renal clearance

210
Q

Vd of water soluble drugs is_____; Water soluble drugs examples are GGS

A

Decreased; Gentamycin, Glycopyrrolate, Succinylcholine.

211
Q

Vd of lipid soluble drugs is ______; Lipids soluble drugs examples are BBV

A

Barbiturates, Benzodiazepines and volatile anesthetics

212
Q

Systolic function of geriatric according to apex

A

No change

213
Q

The most significant risk factor to developing cancer is

A

Old age

214
Q

Lung Compliance describes how

A

Easy it is to inflate (distend) the lungs

215
Q

Lung elasticity describes how

A

Elastic recoil which is the tendency of the lung to return to original shape after exhalation.

216
Q

Older people compliance and elasticity

A

High compliance

Low elasticity

217
Q

Loss of elastic recoil and effect on respiratory system:

Dead space, alveolar surface area, V/Q mismatch, A-a gradient, PaO2

A

Increased dead space
Decreased alveolar surface area
Increased VQ mismatch
Decreased PaO2

218
Q

RV in the elderly _______Which is similar to what happen to what disease process?

A

Increases; Emphysema

219
Q

Cough reflex in the elderly

A

A greater stimulus is required to initiate the cough reflex

220
Q

The reason why the small airways have a greater tendency to collapse during expiration.

A

The reduction in elastic recoil is

221
Q

Total lung capacity is unchanged, because of the.

A

increase in RV and the reduction in VC

222
Q

Because the total lung capacity is unchanged, a change in one

A

volume or capacity usually causes a change in another.

223
Q

Increased FCR

A

Functional Residual capacity
Closing volume
RV

224
Q

Vital Capacity is

A

decreased

225
Q

Why does total lung capacity remains unchanged in the elderly?

A

Increased RV

Decreased VC

226
Q

Venous capacitance in the elderly is______meaning?

A

Decreased; Greater lability of BP with anesthetic induction

227
Q

The best indicator of cardiac reserve are

A

Exercise tolerance

Ability to perform ADLs

228
Q

Most common cause of death of the elderly in the postop period?

A

MI

229
Q

Change in _______can cause drastic changes in preload

A

blood volume

230
Q

Very important for the noncompliant ventricle

A

Atrial kick is needed to prime the noncompliant ventricle

231
Q

During Atrial fibrillation and ventricular priming

A

Unable to prime because AFIB patients lack atrial kick

232
Q

Systolic function ________ ; SBP ______

A

Systolic FUNCTION remains the same

SBP increase

233
Q

Pulse pressure in the elderly and why

A

Widens: BECAUSE SBP increases much more than DBP increases

234
Q

Why does BP increases in the elderly?

A

Arterial compliance is REDUCED which increases SVR

235
Q

Diastolic function changes in the elderly include

A

Reduced compliance and increased arterial wall stiffness impairs myocardial relaxation
Slower rate of Ca2+ removed from the cytoplasm

236
Q

Diastolic function in the elderly is _____but does not mean ____

A

Reduced; failure

237
Q

SV and elderly

A

Reduced ability to increase SV

238
Q

HR and elderly

A

Decreased response to catecholamines

239
Q

What is maximal HR and how is it in elderly?

A

220 - HR

Decreased in the elderly

240
Q

SNS tone and elderly

A

Higher NE concentration in the plasma

241
Q

Coupling is

A

Reduced with adenylate cyclase

242
Q

PNS tone is decreased therefore

A

May have difficulty increasing HR with anticholinergics

243
Q

Dehydration in the elderly increases the risk of

A

Fluid and electrolyte imbalance

244
Q

Parkison’s disease is ________ in what part of the brain?

A

Decrease DOPAMINE in the BASAL GANGLIA

245
Q

Dose of IV anesthetic agent should be decreased by

A

30-40%

246
Q

In the elderly , reduced activity of what neurotransmitters?

A

Ach, NE, DA, GABA

247
Q

Gray matter vs white matter?

A

Gray atrophies at a faster rate than white matter

248
Q

Pain, Temperature and Crude sensation travel via the

A

LATERAL AND Anterior SPINOTHALAMIC TRACT

PTC –> LAST

249
Q

POST OP DELIRIUM RISK FACTORS Mnemonic DELIRIUM

A 
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
250
Q

Impaired comprehension , concetration and psychomotor skills is associated with

A

POCD

251
Q

6 risk factors for POCD : AP CHALL

A 
Advanced age
Pre-existing cognitive deficit
Cardiac surgery
High ASA
Anesthetic agensts
Long duration surgery
Low level education
252
Q

Post op delirum treatment vs POCD treatment

A

POST DELIRIUM –> Treat underlying cause, Antipsychotics, minimize polypharmacy
POCD –> resolve after 2-3 months

253
Q

Epidural LA is associated with ______spread of LA due to

A

GREATER; REDUCTION in the epidural space

254
Q

Spinal LA is associated with ______spread of LA due to

A

GREATER; REDUCTION in the CSF volume

255
Q

Dura and elderly

A

Dura is more permeable to LA (reduce dose)

256
Q

Myelinated nerve changes

A

Decrease in number, diameter and conduction velocity

257
Q

Associated with very high mortality

A

perioperative renal failure

258
Q

Aldosterone in the elderly and effect

A

Decrease, decrease ability to conserve sodium which lead to increase risk of dehydration

259
Q

CrCl in elderly

A

less nephrons to clear creatinine

260
Q

What is the most sensitive indicator of renal function and drug clearance in the elderly?

A

Creatinine Clearance

261
Q

When to consider dosage adjustments?

A

Age> 60

262
Q

ADH and elderly

A

Decrease reponse to ADH

263
Q

RBF and elderly

A

Decrease 10% per decade

264
Q

Concentration gradients?

A

Decrease concentration gradient necessary to produce concentrated urine

265
Q

Loss of nephrons where does is occur

A

CORTEX&raquo_space;>MEDULLA

266
Q

Why is there no change in serum creatinine ?

A

GFR decreases with age, in theory, this should increase in serum creatinine
Muscle mass also decreases with age, this means, less creatinine is produced.

267
Q

Pseudocholinesterase production and elderly

A

Reduced

268
Q

Drugs with HiGH HEPATIC EXTRACTION RATIO

A

fentanyl, lidocaine, metoprolol

269
Q

Hepatic blood flow is ______in the elderly

A

Decreased

270
Q

Low Hepatic Extraction Ratio drugs

A

Theophylline and Diazepam

271
Q

Alpha 1 Acid Glycoprotein is

A

Increased

increase reservoir for basic drugs.

272
Q

Free fraction of drugs bound to albumin is

A

Increased, because albumin levels are decreased

273
Q

THINGS THAT increase closing volume CLOSE-P

A 
COPD
LV failure
Obesity
Supine position
Extreme of age
Pregnancy.
274
Q

Closing capacity is

A

Closing volume + Residual volume

275
Q

One of the most cardinal signs of parkisons’

A

Bradykinesia

276
Q

If the patient with Parkinson’s disease start exhibiting parkinsonian syndrome, best way to treat is with

A

Drugs with anticholinergic properties (reduces ACH)

277
Q

EPS treat with

A

Benztropine or diphenhydramine

278
Q

Summary: respiratory parameters that increases with age

A 
Lung Compliance
Closing Capacity
Minute Ventilation
Residual volume
FRC
279
Q

Summary: respiratory parameters that decreases with age (VIECEL)

A 
Vital , Forced VC
Inspiratory Reserve Capacity
Expiratory reserve volume
Chest wall compliance
Elasticity of the lung
Lung mass

SEE/NCE Boards CoreConcepts (49 decks)

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