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Geriatric Anesthesia > Apex- Geriatrics > Flashcards

Apex- Geriatrics Flashcards

1
Q

A 70kg patient can walk up two flights of stairs without stopping. How much oxygen is consumed per minute during this activity?

A. 250mls
B. 500mls
C. 1000mls
D. 1500mls

A

C. 1000mls

1 MET (metabolic equivalent) corresponds to o2 consumption of 3.5ml/kg/min

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2
Q

One metabolic equivalent (MET) corresponds to an oxygen consumption of what?

A

3.5ml/kg/min

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3
Q

Inability to achieve how many METs is associated with increased periop risk

A

4 METS
(climbing two flights of stairs without stopping)

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4
Q

Patients of what age and older are considered geriatric or elderly

A

65 and greater

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5
Q

Raking leaves = how many METS

A

4

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6
Q

T/F- getting older is the most significant risk factor for developing cancer

A

True

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7
Q

Light housework = how many mets

A

4

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8
Q

strenous sports ( running, swimming, basketball) = how many mets

A

10 +

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9
Q

For every MET a patient can achieve, mortality decreases by what %

A

11 %

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10
Q

Which factor increases in the elderly:

A. Dead space
B. lung elasticity
C. PaO2
D. Chest wall compliance

A

A. Dead space

(air, no blood)

Increased dead space necessitates increased minute ventilation to maintain a normal PaCO2

Aging is associated with a reduction in PaO2, lung elasticity, and chest wall compliance

Taken together, these changes reduce pulm reserve and increase risk of respiratory failure

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11
Q

T/F: reduced PaO2 is a normal change associated with aging

A

True

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12
Q

Increased or Decreased in the elderly:

Minute ventilation

A

increased

due to increased dead space

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13
Q

Increased or Decreased in the elderly:

lung compliance

A

increased

decreased elasticity - can fill the baloon up easier

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14
Q

Increased or Decreased in the elderly:

lung elasticity

A

decreased

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15
Q

Increased or Decreased in the elderly:

chest wall compliance

A

decreased

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16
Q

Increased or Decreased in the elderly:

response to hypercarbia and hypoxia

A

decreased

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17
Q

Increased or Decreased in the elderly:

protective airway reflexes

A

decreased

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18
Q

Increased or Decreased in the elderly:

upper airway tone

A

decreased

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19
Q

2 main lung paramters that are INCREASED in the elderly

A
  1. minute ventilation (to compensate for increased dead space)
  2. lung compliance
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20
Q

Why do the elderly have increased dead space?

A

loss of elastic recoil promotes small airway collapse

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21
Q

Increases/Decreases/no change with age:
upper airway tone

A

Decreases

decreased resp muscle strength

consider CPAP/BiPAP in at risk patients

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22
Q

Increases/Decreases/no change with age:
A-a gradient

A

Increased

decreased lung elasticity > increased small airway collapse >

increased dead space, vq mismatch and A-a gradient

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23
Q

Increases/Decreases/no change with age:

A:P diameter

A

increases

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24
Q

Which volumes and capacities are increased in the 70yo patient (select 3):

  • Closing capacity
  • Residual volume
  • Total lung capacity
  • Vital capacity
  • Expiratory reserve volume
  • Functional residual capacity
A

Closing capacity
Residual volume
FRC

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25
Q

geriatric lung volumes/capacities
IRV:
ERV:
RV:

IRC:
FRC:

VC:
TLC:

A

↓ IRV (due to increased RV)
↓ERV: (due to increased RV)
** ↑RV: (due to increased CC and gas trapping) **

↓ IRC: (due to increased FRC)
** ↑FRC: (due to increased RV)**

↓ VC: (due to increased chest wall stiffness, decreased recoil and strength)
* TLC: NO CHANGE (increased RV + decreased VC = net change for TLC) *

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26
Q

Closing capacity surpasses FRC at about what age in the supine position vs standing

A

45 yo supine
65 yo standing

i still dont know wtf this means

apparently it means that the small airways will collapse during tidal breathing, setting the stage for V/Q mismatch, increased anatomic dead space, and a reduction in PaO2

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27
Q

T/F: FEV and FEV1 are not affected by aging

A

False - they are both decreased

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28
Q

Why does the older patient have an increased FRC?

A

bc the aged lungs lose elastic recoil → lungs become overfilled with gas → increased RV (the volume that remains in the lungs after a full exhalation)

FRC = ERV + RV

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29
Q

why do the small airways in the old pt have a greater tendency to collapse during expiration?

A

bc of the reduction in elastic recoil

  • small airways collapse before the lung can fully deflate
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30
Q

The following CV changes occur in response to aging EXCEPT:

A. diastolic dysfunction
B. loss of elastin in arterial wall
C. fibrosis of the cardiac conduction system
D. increased venous capacitance

A

D.

our veins become stiffer as we age and this reduces venous capacitance (the volume of blood the veins can hold)

in the OR this manifests as greater BP lability with anesthetic induction or during acute blood loss

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31
Q

Cardaic disease is the most common coexisisting disease in the elderly. What are the 4 most common coniditions

A

HTN, CAD, CHF, Myocardial ischemia

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32
Q

What are the 2 best indicators of cardiac reserve?

A
  1. exercise tolerance
  2. the ability to perform ADLs
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33
Q

Aging effects on CV: (increased/decreased/no change)

Arterial compliance
Venous compliance
Myocardial compliance
Conduction
Myocardial mass

A

ALL DECREASED EXCEPT MYOCARDIAL MASS (INCREASED)

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34
Q

T/F: in the postop period, MI is the most common cause of death in the elderly population

A

True!

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35
Q

T/F: filling pressures will underestimate chamber volume

A

False - overestimate

often have impaired relaxation -> diastolic dysfunction
diastolic dysfunction = chambers require a greater pressure to fill a given volume
so a certain filling pressure that normally would indicate a normal volume would be over-estimatimating this volume

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36
Q

why is tachycardia bad in the elderly population?

A

diastolic dysfunction = inability to relax
tachycardia = reduced filling time
reduced filling time = less blood able to get through -> backs up (CHF)

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37
Q

Why is afib usually not well tolerated in the older adults

A

bc they usually have some degree of diastolic dysfunction - chambers cant relax and require a higher pressure to fill (provided by the atria) - loss of that extra pressure → hypotension

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38
Q

If you have an old patient and notice they have a 1st or 2nd degree block - why would that be?

A

as you age, the cardiac system gets fibrosed and puts you at risk for dysrhythmias as you get older (afib, SSS, 1st and 2nd degree blocks)

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39
Q

The risk of venous thromboembolism (increases/decreases) with age

why or why not

A

increases exponentially

bc all 3 components of virchows triad affect the elderly

when you think venous thromboembolism risk –> think virchows triad:
1. venous stasis
2. hypercoagulability
3. endotheilal dysfunction

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40
Q

Virchow’s triad describes and consists of what

A

risk of venous thromboembolism
1. venous staasis
2. hypercoagulability
3. endothelial dysfunction

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41
Q

Is pulse pressure increased or decreased with age

A

increased due to loss of elastin (stiffer arteries, reduced compliance, increased SVR and SBP much greater than DBP )

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42
Q

SVR increased or decreased with age

A

increased - loss of elastin = stiffer, less compliant arteries

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43
Q

Which factor remains unchanged in the healthy geriatric patient?

A. Pulse pressure
B. Systolic heart function
C. SVR
D. Lusitropy

A

B. Systolic heart function

*SBP INCREASES , systolic function = unchanged

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44
Q

Increased/decreased/ no change in the geriatric patient:
Lusitropy

A

decreased

the aged heart is slower to return calcium into the sarcoplasmic reticulum during diastole, slowing the rate of myocardial relaxation

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45
Q

Increased/decreased or no change:
Heart rate

A

decreased

fibrosis of conduction system

*decreased responsiveness to catecholamines
*decreased ability to respond to hypotension, hypovolemia, and hypoxia

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46
Q

Increased/decreased/no change:
cardiac output

A

decreased

decreased SV and HR

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47
Q

T/F: older patients have no change in systolic function

A

TRUE

(increased SBP though)

im assuming bc of the adaptive mechanisms of the heart and this is at the cost of reduced diastolic function

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48
Q

How is stroke volume affected by age?

A

decreased due to diminished ability to increase stroke volume (stiff arteries/veins/decreased venous capitance)

*results and reduced exercise tolerance and cardiac reserve

49
Q

Which factor decreases as a result of hte aging proces?

A. Baroreceptor sensitivity
B. Incidence of orthostatic hypotension
C. Plasma norepinephrine concentration
D. Sympathetic tone

A

A. Decreased baroreceptor sensitivity

50
Q

Would you expect an old person to have a more or less exaggerated sympathectomy - why

A

more exaggerated

-aging is associated with decreased baroreceptor sensitivity and theyll be unable to compensate for the reduction BP with HR

51
Q

aging is associated with an increased/decreased sympathetic tone

A

increased

52
Q

aging is associated with an increased/decreased plasma norepinephrine concentration

A

increased

think heart doesnt respond as much to catecholamines so the body is gonna produce more to try and stimulate it more

53
Q

PNS tone: increased/ decreased/ unchanged

A

decreased

54
Q

T/F: the ability to thermoregulate is decreased in the elderly population

A

True

55
Q

T/F: the elderly have higher norepinephrine concentration in the plasma

A

True –> increased SNS tone

56
Q

higher, lower, unchanged:

SNS tone

A

higher –> higher levels of NE concentration in the plasma

57
Q

higher/lower/unchanged:

PNS tone

A

decreased

-may affect the ability of anticholinergics to increased hr

(increased SNS tone, decreased PNS tone)

58
Q

Do elderly have an increased or decreased response to catecholamines

A

decreased

  • decreased adrenergic receptor density
  • impaired B-receptor and adenylate cyclase coupling
  • increased circulating catecholamines as partial compensation
  • decreased ability to increase HR during hypotension or times of stress (decreased baroreceptor function)
59
Q

T/F: elderly have decreased baroreceptor function

A

true

-reduced ability to increase HR during hypotension or times of stress
-increased risk of orthorstaitic hypotension, syncope, and greater degree of hemodynamic compromise following sympathectomy

60
Q

T/F: elderly are at increased risk of hypothermia

A

True

due to impared thermoregulation

shivering increases VO2
vasoconstriction increases afterload and MVO2
risk of wound infection
increased blood floss
coaguloapthy
impaired drug metagolism

61
Q

6 adverse effects of hypothermia

A
  1. shivering - increases VO2 400%
  2. vasoconstriction increases afterload and myocardial o2 consumption
  3. risk of infection
  4. increased blood loss
  5. coagulopathy
  6. impaired drug metabolism (all metabolic processes slow down)
62
Q

MAC decreases what % each decade of life after how many years of age?

in the 80yo patient- how much is MAC reduced by?

A

6% every decade after 40yo

~25% (6x4=24)

63
Q

increased/decreased/unchanged:

neurotransmitter activity in the brain

A

decreased

64
Q

increased/decreased/unchanged:
brain mass

A

decreased

65
Q

increased/decreased/unchanged:
peripheral nerve quantity and function

A

decreased

66
Q

what is the most common perioperative CNS complication in the elderly?

A

postop delirium

67
Q

timing of postop delirium vs postop cognitive dysfunction (POCD)

A

delerium - early in postop period
POCD - weeks to months after surgery

68
Q

T/F- most cases of postop cognitive dysfunction are mild and tend to resolve after 3 months

treatment?

A

True!

none

69
Q

dose of IV induction agent should be reduced what % in the elderly?

A

30-40%

70
Q

Alzheimers vs PD

A

Alzhemiers = ↓ACH
Parkinsons = ↓Dopamine in the basal ganglia

71
Q

T/F: decreased brain mass that’s associated with aging affects mental capaacity

A

false

72
Q

what atrophies at a faster rate- gray or white matter

A

gray

73
Q

Risk factors for postop delirium mneumonic

A

DELIRIUMM

Drugs (anesthetic agents? - use rapidly metabolized drugs)
Electrolyte imbalance
Lack of drugs (withdrawal)
Infection (UTI/Resp)
Reduced sensory input
Intracranial dysfunction
Urinary retention and fecal impaction
Myocardial event, male gender

74
Q

T/F: postop delirium can be caused by a myocardial event

A

True

75
Q

what is the most significant risk factor for postop cognitive dysfunction?

A

advanced age

76
Q

t/f: myelinated nerves decreased with age

A

true - myelinated nerves and function

77
Q

t/f: acetylcholine activity increases with age

A

false- decreases

78
Q

How is dopamine activity affected by age?

A

decreasd dopamine activity

79
Q

Is a long surgery more likely to produce postop delirium or postop cognititive dysfunction?

A

POCD

80
Q

T/F: low level of education is a risk factor for postop cognitive dysfunction

A

True

81
Q

Identify the statements that MOST accurately describe neuraxial anesthesia in the elderly patient (select 2):

-spinal anesthesia is associated with a lesser spread of local anesthetic
- CSF volume is increased
- Epi test dose ahs a higher rate of a false-negative result
- Epidural anesthesia is asssociated wit ha greater spread of local anesthetic

A
  • Epi test dose ahs a higher rate of a false-negative result
  • Epidural anesthesia is asssociated wit ha greater spread of local anesthetic

  • decreased beta-receptor sensitivity in the myocardium reduces the efficacy of an epi test dose
    • epidural = greater spread of LA because of a reduction in epidural space volume

-spinal anesthesia is associated wtih a greater spread of LA because of a reduction in CSF volume

82
Q

why would you want to reduce the dose of spinal vs epidural anesthetics in the elderly population

A

they have decreased CSF volume which results in a greater spread of LA in the spinal space
and decreased epidural space volume –> greater spread of LA in the epidural space

+

dura is more permeable to local anesthetics

83
Q

is the dura more or less permeable to local anesthetics as we age

A

more permeable (reduce dose)

84
Q

increased or decreased myocardial sensitivty to catecholamines

A

decreased

(but increased concentration of catecholamines in the plasma)

85
Q

Which factor is unchanged in the geriatric patient:
A. creatinine clearance
B. Serum creatinine
C. GFR
D. Aldosterone

A

B. Serum creatinine

↓ muscle mass (body produces less creatinine) + ↓, GFR (less creat excreted) = no change

86
Q

GFR decreases how many mL/min/year after age 40

A

1mL/min/year

87
Q

how is aldosterone affected by aging

A

decreased aldosterone sensitivity → impaired ability to conserve sodium

88
Q

why might hyponatremia not be unusual in the older person

A

decreased aldosterone sensitivity → impared ability to conserve sodium

89
Q

T/F: perioperative renal failure is associated with very high mortality

A

True

90
Q

T/F: serum creatinine is a poor indicator of renal function in the elderly

A

True

91
Q

How much does renal blood flow decrease per decade?

A

10%

92
Q

How is renal mass affected by aging?

A

decreased renal mass = loss of functioning glomeruli

93
Q

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

A

creatinine clearance

94
Q

T/F: creatinine clearance is not affected by the aging process

A

false -it’s reduced

decreased renal blood flow brings less creatinine to the nephron per unit of time + there are less nephrons (loss of renal mass) to clear the creatinine

95
Q

Is GFR affected by aging?

normal rate in the adult male

A

yes decreases 1ml/min/year after age 40

125ml/min

96
Q

3 consequences of decreased GFR in the elderly

at what age should you consider dose adjustments?

A
  1. risk of fluid overload (less plasma delivered to nephrons per unit of time)
    *decreased renal blood flow
  2. decreased elimination of hydrophilic drugs
  3. decreased hydrophilic metabolites of lipophilic drugs

> 60 yo

97
Q

Why are the elderly at risk of dehydration?

A
  • decreased aldosterone = decreased ability to conserve sodium (and water)
98
Q

The following decrease as a normal response to aging EXCEPT:
A. Albumin
B. Pseudocholinesterase
C. alpha 1-acid glycoprotein
D. hepatic blood flow

A

C. alpha 1-acid glycoprotein

*binds basic drugs- production is increased

99
Q

increased/decreased/nochange:

alpha 1-acid glycoprotein

A

increased

binds basic drugs

100
Q

increased/decreased/nochange:

Albumin

A

decreased

binds aciditc drugs

101
Q

increased/decreased/nochange:
pseudocholinesterase

A

decreased

*can prolong the durtion of sux

102
Q

increased/decreased/nochange:
hepatic blood flow

A

decreased

*consequently, less drug is delivered to the liver per unit of time
*this can prolong the elmination of drugs with a high hepatic extraction ratio

Opioids, Induction agents, Locals, Betablockers, CCBs

High ER = > 0.7
low ER = <0.3 (PTT and MLD scores)

phenytoin, theophylline, thiopental, methadone, lorazepam, diazepam

intermidiate = MMVA - methohexital, midaz, vec, alfentanyl

103
Q

T/F: there is no change in hepatocellular function with aging

A

true!

but there is less hepatic mass → less total enzyme produced
+ less hepatic blood flow→ less drug or toxin delivered to the liver per unit of time

*leading to decreased perioperative hepatic function

104
Q

increased reservoir for basic drugs or aciditic drugs

A

basic drugs

  • basic drugs bind to A1A GP (increased levels)
  • acid drugs bind to albumin (decreased levels)
105
Q

how is sux altered in the elderly

A

prlonged duration due to decreased pseudocholinesterate production

men > women

(also prolonged duration of ester LAs)

106
Q

how are phase 1 vs phase 2 reactions altered in the elderly

A

decreased phase 1 (HOR)
no change in phase 2 (conjugation and acetylation)

107
Q

t/f: older patients have a slowed first pass metabolism

A

true

due to reduced hepatic mass and liver blod flow

108
Q

How does aging affect the pharmacokinetics of anesthetic drugs (select 2):

-Faster induction with etomidate
-Faster induction with sevoflurane
-increased volume of distribution of propofol
-increased volume of distribution of rocuronium

A

increased Vd of propofol → increase in total body fat = large Vd for lipophilic drugs
faster induction with sevo → decreased cardiac output = faster inh induction and slower Iv induction (prolonged circ time)

total body water and blood volume are decreased accounting for a smaller Vd for hydrophlic drugs (roc)

109
Q

increased/decreased/unchanged:
Circulation time

A

increased

reduced CO prolongs the time of drug delivery from the side of administration to hte site of action :

slower IV induction
-faster inhalational induction

110
Q

increased/decreased/unchanged:
Surface area to body mass ratio

significance?

A

increased

decreased lean body mass

111
Q

increased/decreased/unchanged:
lean body mass

A

decreased

decreased surface area to body mass ratio

112
Q

increased/decreased/unchanged:
total body fat

A

increased

*increased Vd of lipohilic drugs -may prolong their elmination

113
Q

effects of reduced lean body mass in the elderly (4)

what kind of drugs are affected?

A
  1. decreased BMR
  2. decreased total body water
  3. decreased blood volume
  4. decreased plasma volume

smaller vD for hydrophilic drugs –> higher than expected plasma concentration of a given dose

114
Q

how are hydrophilic drugs affected in the elderly?

A

smaller Vd (decreased total body water) –> increased plasma concentration for a given dose

*reduce dose!

115
Q

T/F: age does not affect pharmacodynamic effects of neuomusuclar blockers

A

true

but increased DOA of steroidal NMDs if renal or hepatic clearence is reduced

116
Q

In the elderly patient, consequences of decreased lung elasticity include an increased: (select 2):

-dead space
-alveolar surface area
-PaO2
-A-a gradient

A

Dead space & A-a gradient

the aged lung tissue has high compliance (easy to inflate) but low elasticity (harder to return to origina lshape). Loss of elastic recoil promotes small airway collapse, which ahs the following consequences:
-increased dead space
-increased VQ mismatch
-increased A-a gradient
-decreased alveolar surface area
-decreased PaO2

117
Q
what is represented by the Y axis?
A

Age

TLC

The aged lug has a reduction in elastic recoil, causing it to become overfilled with gas.
this process: increases RV and increased RV explains why FRC is increased

the reduction in elastic recoil cause the small airways to collapse during expiration which is why closing capacity increases as we age: concenquences = VQ mismatch, decreased PaO2, and increased deadd space

vital capacity decreases as a result of decreased lung elastic recoil, increased chest wall stiffness, and weakness of respiratory musculature.

TLC stays about the same, respresented by the Y-axis

118
Q

Mneumonic for things at increased closing volume

c

what is closing capacity?

A

CLOSE-P

COPD
LV failure
Obesity
Supine position
Extremes of age
Pregnancy

CC = CV + RV

119
Q

In the PACU, a patient with parkinsons is experienceing an exacerbation of exgrapyramidal symptoms. What is hte MOST appropriate drug to administer at this time?

A. Droperidol
B. Diphenhydramine
C. Metoclopramide
D. Chlorpromazine

A

B. Diphenhydramine

PD = loss of dopaminergic neurons in the substantia niagria in the basal ganglia
DA inhibits the firing rate of extrapyramidal neurons
loss of DA fibers creates a realtive in crease in ACH activity in the extrapyramideal neurons
pts often exhibit motor excitation: resting tremor and rigidity

knowing hte pathophys makes the treatment obvious: There are 2 pharmacologic broad options:
1. reduce Ach with an anticholinergic such as benztropine or diphendyramine
2. increase DA with levodopa or selegiline

If hte patient experiences an exacerbation of parkinsonian signs during the periop period, the most approriate choice is a drug with anticholinergic properties

Geriatric Anesthesia (2 decks)

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