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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
Q

What are some endocrine changes in the elderly?

A
  • 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
Q

How does TBW change with age?

Weight?

Lean body mass?

Total fat?

% fat per TBW?

A

decrease 10-15%

  • weight declines
    • lean body mass decreases
    • total fat decreases but % of fat per total body weight increases
27
Q

What is osteoarthritis?

Most susceptible?

RIsk factors?

A
  • 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
Q

Anesthesia significance of patient with OA?

A

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
Q

What is the classic triad of parkinson’s? What leads to the classic triad? What is cause of parkinsons?

A
  • 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
Q

What are drugs to treat parkinsons?

Drugs that exacerbate parkinson’s?

EPS txmt?

A
  • Mainstay= dopamine agonists
  • Drugs that preceipitate/exacertabe parkinsons
    • phenothiazines
    • butyrphenones (droperidol)
    • metoclopramide
  • Drugs that might treat EPS?
    • benadryl
31
Q

Does choice of MR matter in parkinson’s patient?

A

No

32
Q

What is the theory behind postop delirium and cognitive dysfunction?

A
  • 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
Q

What are distinguising features of dementia? Symptoms? course?

A
  • Distinguishing factors- memory impairment
  • symptoms- disorientaiton, agitation
  • course- slow onset, progressive, chronic
  • no cut/dry treatment
34
Q

What is distinguishing factor/symptoms/course of delirium?

A
  • 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
Q

Distinguishing features/symptoms/course of postoperative cognitive disorder?

A
  • 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
Q

Distinguishing features, symptoms, course of depression?

A
  • 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
Q

What is the confusion assessment method diagnostic algorithm?

A
  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
Q

What is an early hallmark of dementia?

A

intellectual decline

39
Q

What is the mini-cog?

A
  • 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
Q

What causes increase sensitivity to anesthesia in elderly?

A

loss of neuronal tissue

changes in receptor function

41
Q

What is the affect on TBW in elderly? Drug implication?

BOdy fat? Drug implications?

A
  • 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
Q

What are some changes in serum proteins in elderly?

A
  • Plasma albuin decrease
  • alpha acid glycoprotein increase

However, weight and lean body mass has more impact on drugs

43
Q

Metabolism of ehich drugs may be affected?

A

Those dependent on CYP 450

may see reduced clearane up to 30-40%

44
Q

Affect of MAC on aging?

A

decrease 6% per decade after 40 for VA

45
Q

ALteration in propfol with age?

A
  • Need 20% reduction in induction dose
  • Age related changes
    • deeper levels of anesthesia
    • increased timeto reach deeper stages of anesthesia
    • prolonged recovery time
46
Q

Changes in etomidate with age?

A
  • Ideal drug for elderly d/t hemodynamic stability
  • lower dose recommended
    *
47
Q

Changes for midazolam with elderly?

A
  • 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
Q

Changes for opioid for elderly?

A
  • 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
Q

What should we do to fentanyl for aging?

A
  • 50% increase in potency
  • increased sensitivity
  • decrease dose
50
Q

Remifentanil changes in elderly?

A
  • 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
Q

Demerol in elderrly?

A
  • very long half life
  • metabolized to normeperidine (active metabolite) excreted by kidneys
  • associated with postop delirium
  • NOT RECOMMENDED IN ELDERLY
52
Q

NMB agents in elderly?

A
  • 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
Q

What NMB agent would be agent of choice in elderly?

A

Cisatracurium or atracurium (less atra. d/t histamine release)

short acting and don’t need liver/renal metabolism

54
Q

Preop assessment of elderly?

A
  • 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
Q

What should determine need for additional intraop monitoring?

A

based in potential risk/benefits

potential massive blood loss

patient ASA

comorbidities

planned sx

56
Q

Summary of anesthetic plan changes for elderly?

A
  • 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
Q

Which drugs should we avoid in elderly?

A
  • 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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