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ANE 8510 - Principles of Anesthesia II > Exam 2 - Geriatrics (Grayson's) > Flashcards

Exam 2 - Geriatrics (Grayson's) Flashcards

1
Q

Memory decline is:
A. inevitable
B. related to ability to complete ADLs
C. occuring to 50% of ppl > 70 yr old
D. due to decreased grey matter

A

B. r/t ability to complete ADLs

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2
Q

Structural changes in the nervous system associated with aging include: Select 3.
A. increased grey matter
B. decreased grey matter
C. decreased white matter
D. neuronal growth
E. decreases in ventricular size
F. cerebral atrophy

A

B. decreased grey matter
C. decreased white matter
F. cerebral atrophy

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3
Q

Fill in the blank:

A(n) ____ (increase or decrease) in white matter in the aging brain causes ventricle size to ____ (increase or decrease).

A

A decrease in white matter in the aging brain causes ventricle size to increase.

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4
Q

Which of the following neurotransmitters show a decrease associated with aging? Select all that apply.

A. Dopamine
B. ACh
C. NorEpi
E. Serotonin
F. Glutamate

A

Dopamine
ACh
Norepinephrine
Serotonin

Glutamate is unchanged!.

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5
Q

What neuraxial changes occur due to aging? select 2.
A. increased epidural space
B. increased permeability of dura
C. increased volume of CSF
D. decreased diameter/number of myelinated fibers in dorsal and ventral nerve roots

A

B. increased permeability of dura - which lowers required dose
D. decreased diameter/number of myelinated fibers in dorsal and ventral nerve roots

And:
DECREASED epidural space - which lowers required dose
DECREASED volume of CSF - which lowers required dose b/c less dilution of product

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6
Q

Are elderly patients more or less sensitive to neuraxial and peripheral nerve blocks?

A

more sensitive

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7
Q

Decreases in what two characteristics of the peripheral nervous system are noted secondary to aging? select 2.
A. axon terminals
B. inter-schwann cell distance
C. neuromuscular junction
D. conduction velocity

A

B. inter-Schwann cell distance
D. Conduction velocity

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8
Q

What cardiac changes occur within the heart due to aging? Select 3.
A. SA node cells increase and more beta-adrenergic sensitivity
B. myocyte number increase
C. conduction velocity decreased
D. lower filling pressure
E. thickened and calcified aortic valve
F. decreased contractility

A

C. conduction velocity decreased
E. thickened and calcified aortic valve
F. decreased contractility d/t LV thickening (which is caused from increased afterload)

Also:
* myocyte number decreases
* SA node cells decrease
* increased ventricular stiffness…causing higher filling pressure
* less beta-adrenergic sensitivity…causing a decrease in max HR and EF during stress

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9
Q

Why does vasculature stiffen as we age? Select 2
A. more collagen and elastin
B. more NO release
C. less collagen and elastin
D. less NO release

A

C. ↓ collagen & elastin
D. ↓ Nitric Oxide release = less vasodilation

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10
Q

As we age, our lungs have a loss of what 2 things?
A. elastic recoil
B. surfactant
C. compliance
D. closing capacity
E. anatomic dead space

A

A. loss of Elastic recoil
B. loss of Surfactant

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11
Q

With aging, our bronchioles and alveolar ducts become enlarged, causing early collapse of small airways during exhalation. This leads to: select 3.
A. increased anatomic DS
B. decreased anatomic DS
C. increased closing capacity
D. increased total lung capacity
E. decreased residual volume
F. increased V/Q mismatch from impaired gas exchange

A

A. increased anatomic DS
C. increased closing capacity
F. increased V/Q mismatch from impaired gas exchange

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12
Q

Loss of vertebral height and calcification of vertebrae leads what pulmonary changes? Select 3.
A. barrel chest
B. decreased closing volume
C. diaphragmatic flattening
D. increased chest wall compliance
E. increased work of breathing
F. decreased residual volume

A

A. barrel chest
C. diaphragmatic flattening
E. increased work of breathing from chest wall tightness!

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13
Q

Describe the changes in following volumes and capacities seen with normal aging.

  • Vital Capacity
  • Closing Capacity
  • Residual Volume
  • Total Lung Capacity
A
  • decreased VC
  • increased closing capacity (RV+CV)
  • increased RV
  • TLC stays about the same!
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14
Q

FEV₁ will decrease by 6-8% per decade. This is because of: select 2.
A. increased muscle mass
B. decreased muscle mass
C. increased closing capacity
D. decreased closing capacity

A

B. decreased muscle mass
C. increased closing capacity

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15
Q

Due to aging, we develop weaker pharyngeal muscles which can lead to:
A. profound atelectasis
B. dysphasia
C. inadvertent endobronchial intubations
D. increased aspiration risk

A

D. increased aspiration risk from the decreased clearance of secretions!

Also:
less efficient coughing, ↓ esophageal motility, less protective upper airway reflexes

suction them more aggressively

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16
Q

Whats the most important mechanism of action for the increased A-a gradient seen with aging? select 2.
A. physiological dead space increases
B. shunt increases
C. alveolar oxygenation declines
D. arterial oxygenation declines

A

B. shunt increases,
D. arterial oxygenation declines

so an increased V/Q mismatch and increased A-a gradient! since more small airways collapse as we age…

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17
Q

What renal changes occur due to aging? select 2.
A. decreased GFR
B. increased response to ADH
C. increased urinary retention
D. decreased renin release

A

A. ↓ GFR
C. ↑ Urinary retention = ↑ UTI’s

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18
Q

Renal system of elderly patients have trouble adjusting their fluid and electrolyte levels because of a blunted response to: select 3.
A. oxytocin
B. TSH
C. aldosterone
D. vasopressin
E. renin
F. norepinephrine

A

C. aldosterone
D. vasopressin
E. renin

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19
Q

Anything requiring metabolism through the liver using Phase I should be given with caution since liver function declines with age. Phase I includes which 2?
A. CYP450s
B. acetylation
C. conjugation
D. redox reactions

A

A. CYP450s
D. redox reactions

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20
Q

Your 80 yr old patient just woke up with PONV. What is the first antiemetic of choice for the elderly patient?
A. metoclopramine
B. promethazine
C. ondansetron
D. prochlorperazine
E. dexamethasone

A

C. ondansetron

AVOID: metoclopramine, promethazine, prochlorperazine - major sedative effects!!

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21
Q

Related to musculoskeletal system, what thins out causing potential for skin breakdown and impaired wound healing?
A. muscle
B. subq fat
C. bones
D. hair

A

B. subcutaneous fat

but yeah muscle mass decreases and strength declines

22
Q

What is important to consider regarding the vasoconstriction threshold of the aging population?
A. 0.5 degree C more for adults 60-80 y/o
B. 1 degree C more for adults 60-80 y/o
C. 1 degree C less for adults 60-80 y/o
D. 0.5 degree C less for adults 60-80 y/o

A

C. 1 degree C less for adults 60-80 y/o

so they will theoretically start shivering sooner than you and i

23
Q

List the six significant predictors of 6 mos-1yr mortality for the elderly.

A
  • Comorbidities
  • Hypoalbuminemia
  • Anemia
  • Impaired cognition
  • Recent fall
  • Functional dependence

CHAIR-F

24
Q

What are the neurotoxicity factors that are thought to be involved in the pathogenesis of dementia? select 3.
A. tau
B. magnesium
C. cholesterol
D. amyloid B plaques
E. calcium
F. kappa

A

A. tau
D. Amyloid plaques
E. Ca⁺⁺
and overall Neuroinflammation (TNF, interleukin)

25
Q

What are amyloid plaques thought to do in the CNS?
A. disrupt cell membranes over time
B. exaggerated release of calcium from ER
C. release inflammatory factors
D. destabilizes microtubules

A

A. may disrupt cell membranes over time

Function actually unknown, not as toxic as we originally thought b/c they aggregate then eliminated

26
Q

A neurofibrillary tangle (NFT) is phosphylated and aggregated tau proteins. Tau is destructive because it:
A. disrupt cell membranes over time
B. exaggerated release of calcium from ER
C. release inflammatory factors
D. destabilizes microtubules

A

D. destabolizes microtubules

27
Q

Tauopathy is described as:
A. increased amyloid plaques due to decreases in temp by 2-3 deg C
B. increased tau due to decreases in temp by 2-3 deg C
C. decreased tau due to repeated exposure to volatiles
D. increased amyloid plaques due to repeated exposure to volatiles

A

B. increased tau due to decreases in temp by 2-3 deg C

28
Q

What can cause increased phosphorylated tau?
A. increased cytokines
B. prolonged use of propofol
C. repeated exposure to volatiles
D. decreased calcium release

A

C. repeated exposure to volatiles (specifically halothane, isoflurane, & sevo)

29
Q

Flip card to see graph of Amyloid and Tau relations to symptoms.

A
30
Q

Anesthesia causes an exaggerated release of what ion?
A. magnesium
B. sodium
C. calcium
D. potassium

A

C. calcium - release from ER through ryanodine and IP₃ receptors.

thought to be neurotoxic in elderly

31
Q

Neuroinflammation contributes to cognitive decline through the release of which three inflammatory factors?
A. histamine
B. cytokines
C. prostaglandin
D. C-reactive protein
E. IL-6
F. TNFα

A

B. Cytokines
E. IL-6
F. TNFα

32
Q

What 3 anesthetic drugs are capable of modulating inflammation?
A. toradol
B. lidocaine
C. propofol
D. dexamethasone
E. isoflurane
F. bupivacaine

A

A. toradol
B. lidocaine
D. dexamethasone

33
Q

According to Mordecai, what is the DOC for maintenance anesthesia to decrease incidence of POCD in elderly patients?
A. sevoflurane
B. isoflurane
C. desflurane
D. propofol

A

D. propofol

so TIVA and avoid gas = maintanence anesthesia of choice!

34
Q

What are some anesthesia implications for the elderly patient? select 3.
A. opioid sparing strategies
B. neuraxial and regional should be avoided b/c of osteoporosis
C. avoid long acting NMBD and reverse adequately
D. pad skin and nerves
E. use only volatile anesthetics as maintanence
F. get a PET scan before surgery to have baseline function data

A

A. opioid sparing strategies
C. avoid long acting NMBD and reverse adequately
D. pad skin and nerves - b/c of reduction in subq fat and thin skin!
Also:
- use neuraxial/regional when possible
- neutralize stomach acid
- consider EEG-based titration (BIS monitors)
- avoid HoTN (keep 20% of baseline)

35
Q

What occurs to drugs due to decreased cardiac output secondary to aging?
A. slower onset and slower clearance
B. slower onset and faster clearance
C. faster onset and faster clearance
D. faster onset and slower clearance

A

A. slower onset and slower clearance
due to:
- Slower distribution to initial site of action
- Slower redistribution
- Slower distribution to metabolic organs

36
Q

Drug challenges r/t neuromuscular junction changes that occur with aging include: select 2.
A. increased ACH release upon neuronal impulse
B. decreased concentration of ACh receptors
C. decreased ACh in presynaptic vesicle
D. decreased distance between axon and motor end plate

A

B. decreased concentration of ACh receptors
C. decreased ACh in presynaptic vesicle

And:
- increased distance between axon and motor end plate
- decreased ACh release

all of these mean LESS NMBD required for elderly patient

37
Q

Regarding drugs dependent on kidney/liver metabolism, what should be considered for elderly patient? select 2.
A. prolonged drug effect
B. there is no delay in recovery phase
C. avoid cisatricurium as it is dependent on kidney/liver metabolism
D. decreased need during maintanence phase

A

A. prolonged drug effect
D. decreased need during maintanence phase

38
Q

What is the algorithm for preoperative assessment of Thoracic surgery patients?

A
39
Q

How is predicted post-operative FEV₁ (ppo FEV₁) calculated?

A

(Preop FEV₁ %) x (1 - % of lung tissue removed/100)

40
Q

How many total lung segments are there?

A

42

41
Q

How many lung segments are in the LUL?

A

10

42
Q

How many lung segments are in the RLL?

A

12

43
Q

How many lung segments are in the RUL?

A

6

44
Q

How many lung segments are in the RML?

A

4

45
Q

The right middle lobe and right lower lobe are resected in a critically ill patient. How much lung tissue was removed in this surgery?

A

16/42 = 38%

46
Q

Predict the post-operative FEV₁ for a patient who had their right lower lobe removed. The patients preoperative FEV₁ is 70%.

A

(Preop FEV₁ %) x (1 - % of lung tissue removed/100)

PPO FEV₁ =70 x ( 1 - 29/100) = 49.7 … 50%

47
Q

What is the “triad” of preoperative thoracotomy assessment?

A
48
Q

What do we want the PPO FEV1 to be in order to extubate a post-thoracotomy patient in the OR?

A

greater than 40%!
- extubate in OR if pt is awake, warm, & comfortable (AWaC)

49
Q

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is 30 - 40% ?

A

Consider extubation based on:

  • Exercise tolerance
  • Diffusing capacity of CO
  • V/Q scan
  • Comorbidities
50
Q

How would the CRNA manage extubation on a post-thoracotomy patient if the PPO FEV₁ is <30% ?

A
  • Staged weaning from ventilator!!! Send them to ICU
  • Consider extubation if >20% plus thoracic epidural anesthesia in place.

ANE 8510 - Principles of Anesthesia II (17 decks)

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