EXAM 3: Geriatric Patients

Question 1

Accepted Terms:

1) _____ refers to the study of the elderly
2) There is no consensus as the when a person becomes “elderly” - just a relative term
3) Aged/Elderly - many accept this as > ___ YO

Octogenarian: > 80 YO
Nonagenarian: >90 YO
Centenarian: >100 YO
Supercentenarian: >110 YO

Answer 1

Geriatrics

65

Question 2

We are getting older as a nation:

1) 2007: 37.9 million Americans > 65 years old
- 21.9 million are women, 16 million are men
- 12.6% of U.S. population
- 1 in 8 Americans
2) 2030: 72.1 million Americans > 65 years old
- 20% of U.S. population
3) 2007: 80,771 persons > age 100
4) 2006: Persons > 65 y.o. had a life expectancy of an additional 19 years

Answer 2

Do not have to know stats.

More elderly women than men
Life expectancy is increasing

Question 3

The 65+ age groups are growing which results in _____ healthcare dollar expenditure.

Answer 3

more

Question 4

Aging & Our Health:

Most frequent conditions in persons > 65:

• ____
• Diagnosed _____
• All types of ____ _____
• Any ______
• ______
• ______

2007: 25% of persons > 60 are obese
2019: 28.5% over age 65 are obese
2007: 93% of persons > 65 covered by Medicare

Answer 4

HTN
arthritis
heart disease
cancer
diabetes
sinusitis

Question 5

Top Health Conditions Over Age 65:

2020:

• HeartDisease
• Cancer
• Chronic Obstructive PulmonaryDisease(COPD)
• CerebrovascularDisease(Stroke)
• Alzheimer’sDisease
• Diabetes
• PneumoniaandInfluenza
• Accidents
• Life expectancy at age 65: Men 18.1 years, Women 20.6 years.

Question 6

Healthcare Resource Utilization:

2006: Although individuals ≥ 65 years of age represent 12% of the U.S. population:
- ___ of the 25 million surgical procedures annually
- Consume ___ of $140 billion U.S. healthcare budget

Half of population over 65 years of age will require surgery before they die

Half of all hospital days in the U.S. are utilized by the elderly population

Answer 6

1/3 of surgical procedures

1/2 of healthcare budget

Question 7

Review graphs on slides 10-16:

65+ require more physician office visits, have higher hospitalization rates, have more hip/knee replacements, and more coronary artery bypass grafting (declining d/t stenting).

Question 8

What causes us to age?

1) Control is unknown but progressive ______ changes affect both structure & function of organism
2) Cycle of aging within the ______ occurs
3) ___ _____ (ROS) stress cell mitochondria and its enzymatic machinery of oxidative phosphorylation
4) Defective mitochondrial DNA impairs ____ efficiency
5) Reduced cellular ability to scavenge by-products of _____ metabolism
6) Mitochondria modulates both bioenergetics and programmed ____ _____ – can be affected as well

Answer 8

1 - degenerative 
2 - mitochondria 
3 - free radical 
4 - bioenergetic 
5 - aerobic 
6 - cell death (apoptosis)

Question 9

Cycle of Aging (Slide 18)

Begins w/ _____ _____ which leads to increased intracellular ____ _____ (ROS) which then damages _____, ______, and _____ integrity. This can lead to decreased ______ and ______ capacity which leads to more oxidative stress. It can also decrease ______ capacity and lead to loss of tissue/organ functional _____, increased susceptibility to disease/infection/injury, and ultimately increased probability of death.

Answer 9

oxidative stress
free radicals 
membranes, proteins, genetic 
antioxidants and scavenging capacity 
bioenergetic 
reserve

Question 10

Frailty is a decrease in both ______ _______ and ______ to _______ and is predictive of post-op morbidity and mortality, emergence delirium, post-op SNF, and long hospitalization.

Answer 10

physiological reserve
resistance to stressors

• *more frail = more brain atrophy = emergence delirium
• *more frail than stated age - use LESS propofol

Question 11

There are more than 75 frailty tools used today. They can be used by specific diseases - cardiology, oncology, etc.

If a patient has ANY 4 of the following, they are considered FRAIL:

1) Self-reported _____ or lack of _____
2) Unplanned ____ _____ > 10 _____ in prior year
3) ______ (use grip strength)
4) Slow ____ _____
5) Lack of _____

Answer 11

1 - exhaustion, energy
2 - weight loss >10 lbs
3 - weakness
4 - walking speed
5 - activity

Question 12

Organ function varies from person to person even w/out the presence of disease.

Organ functional capacity determines if a person is considered _______ old or young. Young people w/ declining organ function can be considered _______ old & vice versa.

Answer 12

physiologically

Question 13

Alterations in a person’s functional capacity are influenced by:

• _____ and _____ activity levels
• ______ conditions
• ______ habits
• ____
• _____ background

Answer 13

physical and mental activity 
comorbid
social
diet
genetic (plays a huge role)

Question 14

Physiological age is NOT chronological age - it is representative of ____ _____.

Graph on Slide 22

Answer 14

organ function

*% organ function declines as we age

Question 15

Functional reserve is the difference between _____ and _____ _____ _______.

_____ is associated w/ reduced functional reserve.

Answer 15

basal and maximal organ capacity

aging

Question 16

Functional reserve “safety margin” allows the individual to meet increased organ demands brought on by ____, _____, increased CO/CO2 production/excretion needs, polypharmacy, and ______.

Anesthesia providers desire quantitative methods to asses an individual’s functional reserve.

Answer 16

stress, disease, surgery

*patient needs enough reserve to accommodate stress of surgery

Question 17

Metabolic Equivalent of Task (METs) is the body’s _____ _______ (related to endurance/stamina - not organ function).

1 MET = energy used when _____ or ______; oxygen consumption = ____ mL O2/kg/min

4 METs = 4x more ____ _____ than at rest

Answer 17

energy expenditure

resting or sitting still - 3.5 mL O2/kg/min (rest O2 consumption)

energy expenditure

**anesthesia demands on the body will NOT exceed greater than 4 METS - however a patient w/ only 1 MET may not be able to handle the stress of DL/surgery

**For cardiac surgery - give esomolol, fentanyl to reduce demand/work of heart during induction

Question 18

Metabolic Equivalent of Task Examples:

METs ____: eat, dress, use toilet, walk around, walk a block or more on level ground

METs ____: light housework, climb 1 flight of stairs

METs ____: walk@4mph, jog short distances, heavier housework, moderate recreational activities, climb more than 2 flights of stairs without having to stop

METs ____: participate in strenuous sports activities

Answer 18

<4
=4
>4
>10

Question 19

Review graph on slide 25:

We want a _____ window between basal and maximal organ function - a _____ functional reserve.

Answer 19

large

Question 20

Body composition as we age:

1) Atrophy of ___, ____, and ____
2) ____ specific
3) _____ lean tissue mass (LTM) – muscle
4) _____ body fat
5) Decreased ___ ____ in women
6) Decreased weight men _____ than women
7) Total body water (TBW) _____10-20% due to reduced LTM and skeletal muscle mass
8) _______ intracellular water

Answer 20

1 - brain, liver, kidneys
2 - gender
3 - decreased
4 - increased
5 - bone density
6 - greater in men 
7 - decreased 
8 - decreased

Question 21

Metabolism:

1) Decrease in ____ contributes to an age-related decline in _____.

2) Decrease ____ ______ due to reduced ______
- core temp reduced up to ___x more than in young adults
- ____ relationship between re-warming time required and chronological age
- decreased ____ activity and ______ response

Answer 21

1 - LTM - BMR

2 - heat production - LTM
2x
direct
SNS, thermoregulatory

Question 22

Carbohydrate metabolism is altered in the elderly:

• decreased ____ limits _____ of carbohydrates.
• reduced ______ of pancreatic islet cells to _____, increased _____ resistance

Answer 22

LTM - storage

sensitivity - glucose; insulin

Question 23

Cardiovascular Physiology w/ Aging:

1) Ventricles and atria are ____ and _____
2) Decreased ____ d/t decreased metabolic demands and decreased ____
3) Increased ____ ____
4) Decreased ___ _____ sensitivity (decreased response to ___ _____)
5) Dependent on ____ ____ for ventricular filling - CO is increased by ______ NOT by ____
6) Decreased ____ _____ w/ PPV; bleeding can decrease ______ (exaggerated in elderly)
7) ______ w/ widening ____ ____
- Aorta and larger vessels lose _____ and ability to store hydraulic energy
- Greater ______ which impedes stroke volume ejection
- LV wall tension _____, LV mass ______

Answer 23

1 - thicker, stiffer
2 - CO, HR
3 - vagal tone
4 - beta adrenergic, beta-blockers 
5 - atria kick; LVEDV (volume/contractility) NOT HR
6 - venous return; stroke volume
7 - HTN, pulse pressure
compliance
afterload
increase, increase

Question 24

Pulmonary Physiology w/ Aging:

1) Loss of elastic tissue _____ non-uniformly - increased ____ and ____ b/c lungs can’t ____ on expiration
2) Increased _____ ______ (volume small airways collapse): small airways cannot be kept open by _____ forces, closing volume is ____ than volume of lung at rest end-exhalation.
3) Costo-chondral and thoracic joint _____ further contributes to a reduction in lung compliance.
4) Reduced alveolar surface area ~___%
5) Pulmonary gas exchange _____ d/t to ventilation perfusion ______ and progressively worsening venous ______
6) PaO2 _____ as we age - less gas exchanging units available.
7) Decreased response to _____ and _______ - anesthetic-induced HPV depression further complicates.

Answer 24

1 - recoil; increased FRC, RV - recoil
2 - closing capacity - elastic - greater than
3 - stiffening
4 - 15% decrease
5 - inefficiency - mismatch - admixture
6 - decreases (same perfusion but decreased lung surface = shunting)
7 - hypoxia and hypercarbia

Question 25

Hepatic & Renal Function w/ Aging:

1) _____ hepatic blood flow & portal perfusion
2) **Organ function decreases by ___% per year after age ____.
3) Liver mass decreases by ~__% by age 80.
4) Reduced _____ handling abilities.
5) Reduced hepatic _______ and _____ ______ which results in decreased ____ ____ metabolism.
6) _____renal blood flow and renal mass.
7) Decreased ______ enzymatic process
8) Decreased ____ and _____ clearance - *serum creatinine is normal, but don’t assume renal function is normal (d/t decreased LTM)
9) Susceptible to ____ ____ if too much IVF or infused too rapidly
10) Unable to tolerate ____ or decreased CO effects on metabolism
11) Renal ___ handling is less efficient (d/t decreased ______ = decreased ___ conservation = ________)

Answer 25

1 - decreased
2 - 1%, 30 (he said this would be a question)
3 - 40%
4 - nitrogen
5 - biotransformation and protein synthesis - first pass
6 - decreased
7 - CP450
8 - GFR, CrCl
9 - fluid overload
10 - hypotension
11 - Na - aldosterone - Na - dehydration

Question 26

CNS Changes w/ Aging:

1) Diminished _____
2) Decreased ______ synthesis and loss of _____
3) Decreased _____ density
4) **___% brain mass can be lost by year 80
5) Diminished _______ conduction
6) ______ is depleted
7) Reduction in cerebral ____ ____
8) Reduced _____ _____ by neuronal tissue
9) Decreased ______ function
10) Increased incidence of post-op ______ (post-op cognitive dysfunction is increased w/ ______ use and advanced age)
11) Decreased _____ activity
12) Decreased ______ control mechanisms

Answer 26

1 - reflexes
2 - NT, neurons
3 - receptor 
4 - 30% (he said know this)
5 - neurotransmission
6 - dopamine
7 - blood flow
8 - O2 consumption 
9 - cholinergic 
10 - delirium - anticholinergic use
11 - SNS
12 - thermoregulatory

Question 27

Drug Use:

1) Increased incidence of drug interactions d/t ______
2) ____ of all people >75 YO are on at least 2 different meds
3) 30% of prescribed meds are consumed by elderly
4) 40% of all OTC meds are consumed by elderly

Answer 27

polypharmacy

half

Question 28

Drug Elimination:

1) Reduced _____ excretion and hepatic _______
2) Many are on ____ _____ and ___ ____ ______ which can POTENTIATE NMB agents.
3) ______ is slow to eliminate (can take over 6 hours - avoid)
4) Decreased protein binding (low albumin) means higher concentrations of the drug in the ____ form causing an _____ drug effect

Answer 28

1 - renal, biodegradation
2 - loop diuretics, Ca+ channel blockers
3 - midazolam
4 - free, increased

Question 29

Body Composition and Our Drugs:

1) Decreased Vd for ____ soluble drugs & decreased _____ ______ equal increased ___ drug concentrations & ____ BUT slower ______.
2) Decreased blood volume equals increase in plasma drug _______ so….. _____ dose!
3) Increased body fat and increased Vd for ____ soluble drugs along w/ decreased muscle mass - will need _____ dose initially, but remember, ____soluble drugs have delayed elimination time.

Answer 29

1 - water - protein binding - free - response - elimination
2 - concentrations - DECREASE dose
3 - lipid - larger - lipid

**Fort said he would not increase dose of propofol!

Question 30

Review graph on slide 41:

Elderly have increased use of antidepressants (SSRIs) - these can impact anesthetic drugs.

Question 31

Implications for CRNAs:

1) Declining PaO2 - may need increased _____
2) ______ w/ reduced BMR
3) Airway management concerns are increased since _____ are diminished - may not want to extubate as quickly.
4) Maintain ____ _____ & ____ ____ to optimize preload.
5) Duration of epidural anesthesia is ______.
6) Duration of subarachnoid block is ______.

Answer 31

1 - FiO2
2 - hypothermia - keep them warm
3 - reflexes 
4 - sinus rhythm/atrial kick
5 - shorter
6 - longer

Question 32

Implications for Paralytic Use:

1) NMB _____ remains unchanged in elderly - reduced lean muscle mass is offset by increased _________.
2) Duration of blockade is ______ due to declines in hepatic and renal clearance.
3) ______ NMB cautiously because less LTM, increased elimination times, & potentiation due to Ca+ blockers and loop diuretics.
4) NMB that are organ independent in their metabolism/elimination may be more effectively predictable in elimination (ex: _____ & ______)

Answer 32

1 - dosing - increased cholinoreceptors (anticholinergic state but more cholinergic receptors)
2 - prolonged
3 - re-dose
4 - cisat, atracurium (Hoffman elimination)

Question 33

Additional Drug Implications:

1) Exaggerated responses to drugs warrant ______ in the dosages of anesthetic drugs.
2) Base anesthetic plan on assessment of ____ ____.
3) Expect ______ as fluid volume and SNS activity is reduced (even if HTN pre-op).
4) Expect ______ induction as circulation time is increased -don’t be inpatient & push more Propofol. Inhalation agent uptake time is _____.
5) Latest research indicates there is no difference between GA and RA on POCD - may be d/t administering versed before regional?

Answer 33

1 - decrease
2 - organ function
3 - hypotension
4 - SLOWER (IV induction); FASTER (inhalation)

Question 34

Implications for Anesthetic Drugs & Adjuncts:

1) Careful w/ pre-op _______ (renal elimination)
2) Consider ___ ______ pre-op as _____ risks are greater in the elderly (decreased reflexes, etc.)
3) Limit ____-containing IV fluids (no storage).
4) _____ depend on renal elimination.

Answer 34

1 - anxiolytics
2 - H2 antagonist - aspiration
3 - glucose
4 - opioids

Question 35

Anesthesia Drug Implications:

1) ______ (opioid) is considered best with renal insufficiency.
2) Run less ______ agent as anesthetic requirements fall linearly with age, ____ is reduced around __% per decade after age ___.
3) Very sensitive to _______ drugs causing increased side effects – may go crazy if you give Robinol; give ephedrine if HR is low.
4) Avoid Versed as it contributes to post op cognitive dysfunction!

Answer 35

1 - fentanyl
2 - voltaile - MAC decreases 4% per decade after 40
3 - anticholinergic

Question 36

Cardiac & Pulmonary Implications:

1) Watch for an increase in dysrhythmias as ____ cells and ______ tissue are reduced.
2) Dramatic drop in blood pressure with anesthetic drugs as _______ sensitivity is decreased.
3) Compensatory CV responses to hypovolemia, hypoxia and hypotension are _______.
4) Much greater risk for intraoperative myocardial ischemia and infarct as CAD is more advanced, workload is ______.

Answer 36

1 - nodal, conduction
2 - baroreceptor
3 - diminished
4 - greater

Question 37

Pulmonary Implications:

1) Ensure adequate tidal volumes as patients are at greater risk of _______ formation.
2) _______ risks are higher as protective airway reflexes are diminished.
3) Delayed gastric emptying = ___ _____
4) Mask seal and ventilation is more challenging as patients are more ______.
5) Harder to re-establish spontaneous respiration as response to ______ is diminished.
6) **reduce PEEP in elderly d/t effect on ______ ____

Answer 37

1 - atelectasis 
2 - aspiration 
3 - full stomach
4 - edentulous 
5 - hypercarbia 

**reduce PEEP in elderly d/t effect on venous return