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Co-existing Test 1 > Disease of Aging > Flashcards

Disease of Aging Flashcards

1
Q

What percentage of all surgeyr and inpatient procedures are performed on elderly patients?

What is elderly?

A

40%

age >65

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2
Q

True/Flase Medical care for elderly threatens to bankrupt the nation

A

true

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3
Q

What percentage of US medical costs are spent on elderly?

A

35%

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4
Q

What are contrubutors to the aging process?

A

gene (only 25%)

nutrtiion

lifestyle

environment

chance

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5
Q

What warrants a tailored anesthetic management for elderly patients?

A

diminished physiologic reserve

long-term persistence of diseases

comorbid conditions

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6
Q

What is functional reserve

A
  • body’s ability to respond to additional stress such as sx and infection
    • reduced ability is often termed farilty
    • seemingly minor issues produce significant impacts on persons with decreased reserve
  • attention to detail is rarely as important as when taking care of patientw ith extremes of age
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7
Q

What increases perioperative morbidity and mortality?

A
  • >80 yo
  • male
  • decreased albumin levels
  • inability to perform ADLs
  • ASA >3
  • emergency surgery
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8
Q

What are some nervous system changes seen in elderly? (specifically in brain)

A
  • brain mass decrease by 15%
    • gray matter srinkage
  • compensatory increase in CSF
  • decreased CBF d/t reduction in CMR–> susceptible to metabolic stress

From table in stoelting

  • amyloid accumulation- plaque in hippocampus and cortex
  • neuronal ion homeostasis- decreased ACh, dopa, glutamine
    • increased NE
  • Cytoskeletal/synaptic- synaptic remodeling. increase glial fibrillar acidic protein
  • Energy metabolism- decreased glucose use, decreased CMRO2, impairment of glucose transporter protein,
  • NT signaling= decrease activity of plasma Ca ATPase, decrease Ca binding proteins, increase voltage gated Ca channel
  • CNS endocrine- changes in diurnal variation of glucocorticoids. increased levels glucocorticoids
  • Blood flow- decreased CBF
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9
Q

What are some neurodegenerative effects of aging?

A

changes in cellular signaling

  • decreased dopamine
  • increased NE
  • decreased GABA binding sites
  • pathologic processes r/t amyloid plaques accumulation
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10
Q

What are some CV changes in aging person?

A
  • loss of elastin–> decreased tissue elasticity
  • increased collagen cross-links–> stiffness

leads to significant vascular damage (stiffening and artherosclerosis)

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11
Q

What is atherosclerosis?

A
  • Inflammation is hallmark of atherosclerosis- damage to vascular endothelium
  • causes occlustion of arteries
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12
Q

What are age-related changes in arteries

/

A
  • Dilation in arteries despite occlusion from atherosclerosis
  • aortic lumen increases in diameter
  • arteries become less responsive to vasodilators/constrictors
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13
Q

What kinds of issues can stiff arteries cause?

A
  • Increase SVR–> Increased SBP–> LVH–> Increased LV end diastolic pressure–> HF
  • Vent hypertrophy and increased workload predisposes heart to ischemia
  • diastolic pressure stays same
  • pulse pressure widens
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14
Q

What does heartfailure do to B1 and B2 adrenergic receptors?

A

alters ratio of B1 to B2 receptors

  • without HF- LV has 80% AB1 and 20% B2
  • With HF- LV has 60% B1 and 40% B2
    • Less response from B1 meds
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15
Q

What are some changes in the heart’s electrical system with age?

A
  • # pacemaker cells reduced by 90%
  • resting HR decreased
  • peak HR decreased
  • peak CO decreased

diminished response to atropine (50%)

reliance on atrial kick for maintenance of CO

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16
Q

What are some respiratory changes in the elderly?

A
  • Chest wall becomes stiffer
  • Lung tissue loses its elastic recoil
    • chest wall compliance decreases
      • chest wall becomes stiffer
    • lung compliance increases
      • lungs loos elasticity
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17
Q

What happens to residural volume with age?

VC?

Pao2?

A

RV- increases

VC- decreases

Pao2- decreases

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18
Q

What is closing volume? How does it change with age?

A

Closing volume is volume needed in lungs to keep alveoli open

CV increases with age

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19
Q

What happens to work of breathing with age?

Protective reflexes? FEV?

A

Work of breathign increases

Protective reglexes are decreased= susceptible to aspiration

FEV decreases

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20
Q

What are some changes to renal system with age?

A
  • Renal tissue atrophy
    • 50% decline of funcitoning nephrons by age 80
    • 1-1.5% decline in GFR
  • GFR decrease
  • Creatining clearance decrease
    • serum creatinin remains WNL
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21
Q

What UOp is necessary to prevent postop renal dysfunction?

A

>0.5 mL/kg/hr

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22
Q

What are some pharmacodynamic and pharmacokinetic alterations in elderly?

A
  • Increased body fat–> increased Vd for lipid soluble drug–> prolongation of drugs
    • FAT SOLUBLE DRUGS
  • Reduced plasma volume–> smaller Vd for hydrophillic drugs–< higher plasma concentration
  • reduced protein binding
  • slower hepatic conjugation
  • decreased renal elimination
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23
Q

What are renal, GI changes noted in elderly?

A
  • liver size decreases
  • hepatic blood flow decreases 20-40%
  • liver perfusion decreases
    • liver enzymes normal
      • need >70% drop in blood flow before you see on blood test
  • renal cortical mass decrease
    • glomeruli decrease by 50% by age 80
      *
24
Q

What are some immune related aging changes

A
  • Bactericidal substances decrease
  • cytokines and cehmokines increased
  • consistent with low-grade chornic inflammatory process
  • impact ability to fight infection and contorl cancer
25
What are some endocrine changes in the elderly?
* Endocrine glands atrophy * impaired glucose hemostasis--\> DM * Decreased thyroxine, GH, testosterone * metabolism decreases 1% / yr after age 30 * energy expenditure, in people iwth multipl comorbidities, goes up
26
How does TBW change with age? Weight? Lean body mass? Total fat? % fat per TBW?
decrease 10-15% * weight declines * lean body mass decreases * **total fat decreases but** % of fat per total body weight increases
27
What is osteoarthritis? Most susceptible? RIsk factors?
* Caucasian and asian ancestry * \>70 yo * Risk factors * estrogen deficiency * male hypogonadism * smoking * alchol consumption * calcium deficit * cancer * immobilization * long-term corticosteroid usage * obesity
28
Anesthesia significance of patient with OA?
Careful with positioning in OR * maybe position before going to sleep * pad bony prominences * thin skin--\> handle easily * pay attention to cervical spine * may consider awake intubation
29
What is the classic triad of parkinson's? What leads to the classic triad? What is cause of parkinsons?
* Cause of parkinsons- decreased dopamine in basal ganglia * Classic triad- tremor, bradykinesis, rigidity * What leads to classic triad- no inhibitory substance wth unopposed Ach * Treatment * increase dopamine or decrease affects Ach
30
What are drugs to treat parkinsons? Drugs that exacerbate parkinson's? EPS txmt?
* Mainstay= dopamine agonists * Drugs that preceipitate/exacertabe parkinsons * phenothiazines * butyrphenones (droperidol) * metoclopramide * Drugs that might treat EPS? * benadryl
31
Does choice of MR matter in parkinson's patient?
No
32
What is the theory behind postop delirium and cognitive dysfunction?
* Delirium affects 15-55% of older patient * surgical stress and associted inflammation--\> leukocyte migration to CNS where leukocytes play important role in pathophys of postop delirium
33
What are distinguising features of dementia? Symptoms? course?
* Distinguishing factors- memory impairment * symptoms- disorientaiton, agitation * course- slow onset, progressive, chronic * no cut/dry treatment
34
What is distinguishing factor/symptoms/course of delirium?
* Distinguishing features=fluctuating LOC, decreased attention * symptoms- disorientation, visual hallucinations, agitation, apathy, withdrawl, memorya nd attention impairment * course- acute, most cases remit with correction of underlying medical condition
35
Distinguishing features/symptoms/course of postoperative cognitive disorder?
* Dinstinguishing features- Memory deficits, difficulty concentraitng, delayed psychomotor speed * Symptoms- memory and attention impairment * Course- subtle, neurocognitive deficits may not be present until weeks- months after surgery
36
Distinguishing features, symptoms, course of depression?
* Distinguishing features- hopelessness, sadness, loss of interst and pleasure in activities * Symptoms- disturbances of sleep, appetite, concentration, low energy , feeling of hopelessness, suicidal ideation * Course- single or recurrent episode, may be chronic
37
What is the confusion assessment method diagnostic algorithm?
1. Acute change in mental status and fluctuating course * is there evidence of acute change in cognition from baseline * does abnormal behavior fluctuate during the day 2. Inattention * does the patient have dififculty focusing attention 3. Disorganized thinking * does the patient have rambling or irrelevant conersations, unclear or illogicla flow of ideas, or unpredicatlbe switching from subject ot subject 4. Abnormal LOC * is patient anything besides alert- hyperalert, lethargic, stupurous Diagnosing delirium requires features 1 and 2 and either 3 or 4
38
What is an early hallmark of dementia?
intellectual decline
39
What is the mini-cog?
* 3 item recall and clock drawing * Scoring * 1 point fo each item recalled * 2 points for normal appearing clock * Results * 0-2 points indicates positive screening for dementia
40
What causes increase sensitivity to anesthesia in elderly?
loss of neuronal tissue changes in receptor function
41
What is the affect on TBW in elderly? Drug implication? BOdy fat? Drug implications?
* Reduction of TBW--\> Decreased centrla compartment volume--\> increased plasma concentration with IV admin * Increased body fat and decreased muscle mass--\> Large VD (lipid soluble)--\> prolonged drug actions
42
What are some changes in serum proteins in elderly?
* Plasma albuin decrease * alpha acid glycoprotein increase However, weight and lean body mass has more impact on drugs
43
Metabolism of ehich drugs may be affected?
Those dependent on CYP 450 may see reduced clearane up to 30-40%
44
Affect of MAC on aging?
decrease 6% per decade after 40 for VA
45
ALteration in propfol with age?
* Need 20% reduction in induction dose * Age related changes * deeper levels of anesthesia * increased timeto reach deeper stages of anesthesia * prolonged recovery time
46
Changes in etomidate with age?
* Ideal drug for elderly d/t hemodynamic stability * lower dose recommended *
47
Changes for midazolam with elderly?
* Elderly much more sensitive * DOA prolonged * might contribute to post op delirium * midazolam--\> hydrozymidazolam (active metabolite)--\> excreted by kidneys * need **75%** dose reduction form 20--\>90yo * do not recommend in patient over 70
48
Changes for opioid for elderly?
* Phamacodynamic changes present within opioid receptor * increased sensitivity to opioids * Pharmcokinetics change especially opioid metabolism affect the choice of opioids in elderly * liver metabolizes opioids * kidney excrete metabolite
49
What should we do to fentanyl for aging?
* 50% increase in potency * increased sensitivity * decrease dose
50
Remifentanil changes in elderly?
* Ultrashort acting med metabolized by tissue esterases * perhaps ideal (d/t utilizing tissue esterases for metabolism) * however, still need to reduce the dose * dosage is 1/2 bolus dose of younger patient * reduce drip by 1/3
51
Demerol in elderrly?
* very long half life * metabolized to normeperidine (active metabolite) excreted by kidneys * associated with postop delirium * NOT RECOMMENDED IN ELDERLY
52
NMB agents in elderly?
* Pharmacodynamics not significantly altered * ED 95 essnetially the same * Pharmcokinetics ARE significantly altered * onset to max blockade is LONGER * metabolism and excretion prolonged in pts with hepatic and or renal dysfunction * recovery prolonged by as much as 50%
53
What NMB agent would be agent of choice in elderly?
Cisatracurium or atracurium (less atra. d/t histamine release) short acting and don't need liver/renal metabolism
54
Preop assessment of elderly?
* Review of geriatric syndromes * evaluation of frailty * nutritional status * albumin \<3 * BMI \<18.5 * 10-15% wt loss over 6 months \<\<\< red flagS!! * assessment of functional status (hearing and vision impariment) * baseline cognitive status and document preop findings * review of meds- polypharmacy * goals of care
55
What should determine need for additional intraop monitoring?
based in potential risk/benefits potential massive blood loss patient ASA comorbidities planned sx
56
Summary of anesthetic plan changes for elderly?
* Pronounced hemodynamic effects * smaller doses to achieve same anes. depth * doses of induction agnets/opioids decrease 25% * benzodiazpeine should be avoided * meperidine should not be used in elderly
57
Which drugs should we avoid in elderly?
* benzodiazepines * transderm fentanyl in opioid naive * agonist-antagonist * methadone * 1st generation antihistamines * anticholingers (atropine, scopolamine) * skeletal muscle relaxants (cyclobenzaprine)

Co-existing Test 1 (4 decks)

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