Elderly - Exam 7 Flashcards
T/F Age-dependent changes result in reduced functional reserve capacity of each organ system
true
With age, _ stiffening causes _ afterload, _ myocardial O2 consumption and wall stress.
arterial
increased
increased
Changes in the elderly:
Respiratory System decreases
-VC
-Exp. Reserve Vol. (ERV)
-Insp, Reserve Vol. (IRV)
-Elasticity of lung (elastin)
-lung recoil
-chest wall compliance
-lung lass
-response to high CO2 or low O2
-protective airway reflexes
-upper airway muscle tone
-FEV and FEV1
-Alv. surface area
-ability to cough/clear secretions
Changes in the elderly:
Respiratory system increases
-lung (alveolar) compliance
-dead space
-closing capacity + closing volume
-MV
-Residual Vol (RV)
-FRC
-V/Q mismatch
-Barrel Chest
-WOB
-aspiration risk
T/F Total lung capacity is decreased in elderly patients
FALSE
unchanged!!!!
Changes in the elderly:
Neuro system decreases
-PNS tone (afferent responses)
-Myelinated peripheral neurons
-amount of dendrites and synapses
-Activity of GABA, ACh, NE, and Dopamine
-brain mass(0.1-1%/yr)
-Catecholamine sensitivity
-Adrenergic Sensitivity (Beta)
-Autonomic Function
-Thermoregulation
Changes in the elderly:
Neuro system(misc) increases
-SNS tone (plasma catecholamines)
-hypothermia
-shivering
-vasoconstriction
-wound infections
-Bleeding
T/F Number of neurons decreases with age
false, no change
Changes in the elderly:
Cardiovascular decreases
-Compliance (AVM)
-Conduction
-Chronotropic and Inotropic response
-Baroreceptor function
-Diastolic Function
-SV
-Blood Volume (~20-30%)
-HR (220-age=MAX)
-CO
Changes in the elderly:
Cardiovascular increases
-myocardial hypertrophy (LVH)
-SVR/ afterload
-HTN (cardiac workload)
-Valve calcifications (AS)
-Arrhythmias
-PP
-Circulation time
-Clotting
T/F Systolic function increasing is the reason for increased SVR in the elderly.
false, systolic function does NOT change with age.
-many other factors increasing SVR
Changes in the elderly:
Musculoskeletal decreases
-lean body mass
-total body water
-basal metabolic rate
Change in the elderly:
Musculoskeletal increases
-surface area to body mass ratio
-kyphosis/lordosis
-OA
-total body fat
Changes in the elderly:
Renal/Endocrine decreases
-renal blood flow
-renal mass (250->180g)
-Cr Clearance
-GFR (10% per decade past 40 or 1mL/min/m/yr)
-ability to concentrate urine
-ability to balance Na+ (HYPONATREMIA)
-elimination of hydrophilic drugs
-response to acid load (ammonium secretion)
-Aldosterone and ADH production
-ability to compensate for hyperglycemia
Changes in the elderly:
Renal/Endocrine increases
-insulin resistance
-urologic disease risk (prostate/bladder)
-hypothyroidism
How would you expect serum creatinine to change in elderly patients and why?
No change
-decreased skeletal muscle mass and decrease in GFR balance out
Changes in the elderly:
Hepatic decreases
-hepatic mass (2.5->1.5% of body mass)
-hepatic blood flow (40%)
-hepatic drug metabolism
-plasma protein binding
-albumin production (acidic drug binding)
-PChE production
-Phase 1 reactions
-1st pass metabolism
-recovery from IA
-incidence of PONV
Changes in the elderly:
Hepatic increases
-Alpha-1 Acid Glycoprotein production (basic drug binding)
-incidence of NAFLD
T/F Enzyme function and phase II reactions decrease in the elderly
false, unchanged
Changes in the elderly:
Spinal decreases
-response to test doses (EPI)
-volume of CSF
Changes in the elderly
Spinal increases
-sensitivity of dura to LA
-difficulty of block placement
-specific gravity of CSF
-spread of LA
-response to sympathectomy
VTE risk in elderly pts is increased due to increased incidence of Virchow’s triad:
-venous stasis
-hypercoagulable state
-aberrant blood flow
_ (systolic/diastolic) function is preserved while _ (systolic/diastolic) function is diminished in elderly pts.
systolic preserved
diastolic dysfunction
Causes of venous stasis seen in elderly pts:
-varicose veins
-postmenopausal estrogen replacement therapy
-smoking
-CHF
-immobility
To maintain CO, elderly pts rely on which 2 mechanisms?
-preload
-atrial kick
MAX HR equation:
MAX HR = 220- age in yrs
ex) 220 - 65 years = 155
Most common arrhythmia seen in elderly pts:
Afib
How does having A fib lower CO?
eliminates atrial kick, decreasing L vent filling `
What maintains perfusion when someone has aortic stenosis?
NSR
good diastolic volume
A _ BP and _ HR should be avoided in pts with aortic stenosis to prevent ischemia from reduced length of diastole and poor perfusion.
low BP
high HR
Decreased beta adrenergic sensitivity causes a lower _ heart rate, _ cardiac output, and limited responsiveness to beta agonists such as _
lower max HR
decreased CO
poor response to DOBUTAMINE
Poor response to baroreceptors in elderly can predispose them to having _ hypotension
orthostatic
T/F Restrictive, obstructive lung disease, and sleep apnea incidence increases with age?
true
What puts elderly pts at higher risk of atelectasis?
MECHANICAL CHANGES
-decreased vital capacity
-decreased pulmonary reserve
-increased WOB
-increased RV
-reduced FRC compared to closing capacity
Strategies to minimize atelectasis risk in elderly pts:
-early ambulation
-chest PT
-incentive spirometry
4 ways CRNA can prevent aspiration in elderly pts
-neuraxial or regional with minimal sedation instead of GA
-avoid intermediate/long-acting NMBA
-opioid sparing methods
-neutralize stomach with nonparticulate antacids (Bicitra)
Decrease in which two muscles’ tone predisposes old pts to having airway obstructions when they sleep?
-hypopharyngeal
-genioglossal
Age related decrease in kidney mass is from _ atrophy which is due to _
cortical atrophy
glomerulosclerosis
T/F A “normal” value of serum creatinine in an elderly pt may be masking a reduced GFR and obscuring ischemic and nephrotoxic injuries.
True
-serum creatinine isnt a great indicator of renal function
What increases UTI risk in elderly pts?
-urine retention from bladder/urologic diseases
-vaginal atrophy from decreased estrogen in women
-pelvic prolapse in women
Because of poor hepatic blood flow, older pts more slowly metabolize drugs cleared by phase 1 pathways which include:
-also give some drugs that are cleared this way-
-oxidation
-reduction
-hydrolysis via CYP450 system
-ketamine, morphine, fentanyl, sufentanil, lidocaine, flumazenil
Phase 2 metabolic pathways such as _ and _ are not affected by age.
acetylation and conjugation
Beers criteria recommend avoiding which PONV prophylaxis meds due to AMS risk? Which one is better to use instead?
-prochlorperazine
-promethazine
-metoclopramide (except in gastroparesis)
-corticosteroid
-ondansetron (watch QT)
Muscle function and _ decreases faster with age than muscle _ does.
quality
quantity
T/F Older pt’s total body fat increases because their subcutaneous fat reserves increase too.
false, they lose their subcutaneous fat reserves, causing temp dysregulation
Basal core temp in old pts about _ *C less than adults 25-64
0.4*C
Which areas of the brain do older adults experience less neuronal activity?
-hippocampus
-frontal/prefrontal cortex
-temporal lobe
Cortical gray matter thins at a rate of _ - _ % per year
0.5-1%
_ is the decline in memory and cognition from frank neuron loss that interferes with ADLs and has many subtypes
dementia
Causes of specific types of neuron destruction
-vascular dementia
-Alzheimer’s
-Lewy Body dementia
Vasc: hemodynamic abnormalities
Alz: abnormal tau and beta amyloid proteins (GLOBAL neuron death)
LB: abnormal alpha-synuclein deposits
Parkinson’s risks and related consequences in elderly pts:
immobility - DVT
dysphagia and resp depression - aspiration and pneumonia
urine rtn - UTI
psychiatric complications - delirium
Concerns with certain meds common with Parkinson’s disease
Antiemetics (metoclopramide and promethazine) - antagonize dopamine, worsen EPS
MAOI’s - increase risk of serotonin syndrome with certain opioids (tramadol)
Propofol - induces dyskinesia (manage with decadron)
Mood disorders such as _ are often underrecognized and predispose old pts to having POCD, cardiac events, increased postop opioid use, and poor postop outcomes.
depression
Do we automatically suspend DNR orders for surgery?
nah, but it still happens…
Legal definition of capacity:
-ability to communicate treatment choice
-comprehension of info given by physicians
-voice understanding of their medical condition, options for treatment, and outcomes
-can conduct rational discussion about treatment options
Most successful method to reduce delirium risk in elderly?
multidisciplinary nonpharm programs
-“HELP” program
-reorientation, early mobilization, promotion of wake/sleep cycles
T/F It’s ok to use antipsychotics as a prophylaxis for delirium
false, only if they’re a danger to self/others
Reduce MAC by _ % per decade after age _
6% after age 30
-8% for N2O
Delirium prevention strategies:
-educate staff
-multi disciplinary nonpharm methods
-daily activity
-reorientation
-family/friend at bedside
-sleep hygiene
-early mobility
-visual/hearing impairment adaptations
-nutrition + fluid intake
-pain mgmt
-appropriate med use
-O2 PRN
-prevent constipation
-minimize pt tethers (foley, EKG leads, SCD,etc)
BEERs list meds to avoid in delirious pt:
-antipsychotics (only give if agitated and harmful to self/others)
-BENZOS (worsen delirium)
Factors associated with high risk of functional decline:
-cognitive impairment
-need for surrogate consent
-use of mobility aids
-hx of falls
Aging may cause lower sensitivity to for low intensity pain, specifically to _
heat
Beers List Multimodal pain mgmt drugs to avoid in old pts:
-gabapentin
-long-acting opioids
T/F Regional has been shown to decrease incidence of postop cognitive disorders in the elderly
false, no technique has
Meds that have potential neuro S/E that are commonly used in periop period also on Beer’s list:
-Diphenhydramine (highly anticholinergic, confusion)
-Hydroxyzine (highly anticholinergic, confusion)
-Scopolamine (highly anticholinergic)
-Amitriptyline (highly anticholinergic, sedating)
-Antipsychotics (inc risk CVA and death in dementia pt)
-Benzos (high sensitivity, poor metabolism, fall risk, delirium risk)
-Metoclopramide (EPS s/e in old pts)
-Pethidine (bad analgesic, neurotoxic)
-Pentazocine (cns changes ,confusion, hallucination)
-NMBD (poorly tolerate, anticholinergic s/e)
-Meperidine (Demerol)
T/F Cognition and capacity are the same thing
false, may overlap but capacity is more complex
Classic tool used to assess alcohol use in pts:
CAGE questionnaire
-yes to any of the Q trigger possible detox protocols, thiamine and folic acid supps
Depression assessment tool for elderkly:
Patient Health Questionnaire-2
-“yes” to any Q = positive screen, need for further investigation
Frailty assessment tools:
-Frailty phenotype (wt loss, grip strength, exhaustion, low phys activity, 15ft walk speed)
-Frailty index/deficit accumulation (tons of measures of comorbidity, ADL, etc)
-Modified Frailty index (Hx DM, COPD or PNA, MI, PCI/angina, HTN on meds, PVD, dementia, TIA or CVA, CVA with deficit, ADLs)
-Gait speed (5m gait 6+ sec)
-Timed up and go (10+s, 11-14, or 15 s)
-Falls(6 mo hx of falls)
-Robinson ( Katz score, Mini Cog, Charlson index, anemia <35%, albumin <3.4, hx falls)
Prehabilitation for frail older pts includes:
-nutrition support
-exercise
T/F Frailty is a risk factor for delirium
true
Brief Cognitive screening tools:
-Minicog ~ 2-4 min
-Montreal Cognitive Assessment (MoCA)~10-15 min
-Mini Mental State Exam (MMSE) ~7-10min
-Clock Drawing Test ~<2 min
-Verbal Fluency test ~ 2-4min
-Cognitive Disorder Exam (CODEX) ~3 min
Total body water decreases by 10-15%; lean muscle mass decreases; body fat (NOT subQ fat) increases which causes _ - soluble medications with a larger volume of distribution to last longer
lipid-soluble
With age, neuronal tissue _, receptor number _, and receptor sensitivity _
decreases
decreases
increases
ASA recommends old pts DC herbal supps - _ weeks preop
1-2 wks
Differences between Delirium and POCD
-definition
Delirium: ACUTE, fluctuating confusion with altered attention/awareness that can’t be explained by preexisiting or developing dementia
POCD: worsening preformance on neuropsych tests postop compared to preop baseline
Differences between delirium and POCD
-domain measured
Delirium: inattention, disorganized thinking, altered LOC
POCD: memory and exec function
Differences between delirium and POCD
-population
Delirium: not unique to surgical pts, affects ALL ages
POCD: pts after anesthesia/surgery, assoc with age
Differences between delirium and POCD
-assessment tools
Delirium: CAM/ CAM-ICU, 3D CAM
POCD: Detailed neurological testing
Differences between delirium and POCD
-time assessed
Delirium: after surgery (usually 1-3 days peak)
POCD: 1-3 mo after surgery resolves within 6-12 mo but can be lifelong
Differences between delirium and POCD
-epidemiology
Delirium: increased MORBIDITY
POCD: increases MORTALITY
Hepatic drug metabolism is slow due to decreased mass, blood _ & perfusion from fewer _
flow
hepatocytes
GFR decreases by _mL/min/m2 per year after 40
1ml/min/m2
Risk factors for postop cognitive dysfunction
Cardiac Surg(18%=0pts>43%>60%>87% per pt)
-previous CVA
-depression
-abnormal albumin
-MMSE score 24+
General/Ortho/Gyn surgery (0pt=<1%,>8%>19%>45% per pt)
-70+yo
-alcohol abuse
-poor cognitive status
-poor functional status
-abnormal lytes and/or BG
-noncardiac thoracic surgery
-aortic aneurism surgery
Postop delirium risk factors:
-old age
-male
-dementia
-ETOH
-depression
-longer case
-poor function status
-Parkinson
-CV disease
-metabolic disease
-AntiCh drugs
-ICU admit
POCD risk factors:
-low education level
-longer case
-depression
-preop cognitive decline
-postop infection
T/F POCD has specific diagnostic criteria
false,
diagnosed by exclusion, requires previous preop cognitive test
-no cure, preventative strategies
Are NMBA affected by age?
Generally no, roc and vec may have longer duration from less hepatic/renal function tho
RA vs GA benefits
-less thromboembolisms of all kinds
-less blood loss
-less hypoxic risk
-less opiate use usually
Why give less Thiopental in elderly?
Vd decreased, serum level increases
Why give less etomidate in elderly?
delayed metabolism/excretion
Why give less propfol in elderly?
increased brain sensitivity, decreased clearance
Why give less benzo in elderly?
increased brain sensitivity, less clearance
Opiates are all _ times more potent in elderly because:
2x
increased sensitivity
Why give less morphine in elderly?
less clearance
What is the main plasma protein of acid and base drugs?
Acid: albumin
Base: A1 glycoprotein
Which plasma binding increases and decreases with age?
Increases: A1 glycoprotein
Decreases: Albumin
T/F Blood loss is associated with delirium
true
Only opioid consistently assoc with delirium:
Meperidine (Demerol)
Most common postop system failures:
-neuro
-pulm
-cardiac
How does the potency of opioids (alfentanil, sufentanil, remifentanil, and fentanyl) compare to older adults versus younger adults?
A. half as potent in older adults
B. 10x more potent in older adults
C. same potency
D. 2x more potent in older adults
E. can’t be compared
D. 2x more potent
How much is the MAC for IA decreased per decade past 40 yo?
A. 1%
B. 9%
C. 4%
D. 2%
E. 6%
E. 6%
What affect does age have on closing capacity in the lungs?
A. closing capacity decreases with age
B. closing capacity stays the same
C. closing capacity increases with age
D. closing capacity = ERV over age 65
E. closing capacity < FRC over age 65
C. closing capacity increases with age
