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Pathophys II > Geriatric considerations part 2 > Flashcards

Geriatric considerations part 2 Flashcards

1
Q

Describe body composition.

A

decrease in intracellular fluid
blood volume decreases by 20-30% by 75 years
loss of muscle mass/reduced strength

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2
Q

There is a reduction in _____ body mass.

A

lean body mass

weight declines

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3
Q

Describe what happens to the basal metabolic rate

A

decrease in basal metabolic rate- decreased physical activity
decreases in serum testosterone/growth hormone

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4
Q

The percentage of fat per TBW

A

increases (body fat increases)

waist circumference increases

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5
Q

Describe what happens to the skin of the elderly.

A

decrease in dermal & epidermal thickness of skin
loss of collagen & elastin
decrease in subcutaneous fat
prone to skin tears & nerve injuries
careful positioning in this population**

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6
Q

Describe thermoregulation in the elderly.

A

impaired thermoregulation

  • decreased function of hypothalamus
  • increased incidence of shivering
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7
Q

_______ is more pronounced and lasts longer in the elderl.y

A

Hypothermia

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8
Q

Describe frailty.

A

a state of reduced physiologic reserve that is associated with increased susceptibility to disability
independent predictor of in hospital mortality*****

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9
Q

Frailty is characterized by

A

weight loss, fatigue, impaired grip strength, low physical activity & slow gait speed.

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10
Q

Geriatric syndromes include:

A

incontinence, delirium, falls, pressure ulcers, sleep disorders, eating/feeding problems, pain, depressed mood, dementia, & physical disability

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11
Q

Reversible dementia can be due to

A

chronic drug intoxication, vitamin deficiency, subdural hematoma, major depression, hydrocephalus, & hypothyroidism

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12
Q

_________ over any time interval is predictive of an earlier death.

A

Diminishing cognitive performance*****

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13
Q

Treatment for dementia includes

A

vitamin E, NSAIDs, estrogen, acetylcholinesterase inhibitors

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14
Q

_____ is the norm in the elderly.

A

polypharmacy

  • increased effects of drug interactions
  • increased sensitivity to anesthetics
  • loss of neuronal tissue & changes in receptors
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15
Q

Drug dosages should be adjusted for

A

smaller lean body mass**

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16
Q

Total body water

A

decreases 10-15%
-decreased central compartment volume
decreased blood volume= decreased in initial Vd
-increase in initial plasma concentration following IV drugs

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17
Q

Body Fat _____ and muscle mass ______

A

increases; decreases

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18
Q

Decreased plasma albumin & increased alpha 1 acid glycoprotein has

A

no significant impact on clinical pharmacology

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19
Q

______ in renal function leads to increased serum concentrations and prolonged effects of drugs dependent on renal elimination

A

Decrease

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20
Q

Describe inhalational agents in the elderly.

A

minimum alveolar concentration decreases** with age

-decreases 6% per decade after age 40

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21
Q

The ideal induction agent for the elderly is

A

etomidate

-reduce induction doses in elderly

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22
Q

Describe propofol use in the elderly.

A

may require a 50% decrease in dosing
require less propofol for steady-state maintenance of a defined stage of hypnosis
hemodynamic effects are greater*
propofol infusion rates should be decreased by 20%

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23
Q

Describe the use of thiopental for the elderly.

A

reduce total dose of drug in elderly

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24
Q

Describe the use of midazolam in elderly.

A

elderly patients are more sensitive
increased duration of action
contributes to postoperative delirium
metabolite, may accumulate if decreased renal function

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25
Q

Describe opioid use in the elderly.

A

-increased sensitivity to opioids
-decreased metabolism by liver
reduced excretion by kidney

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26
Q

The primary risk of opioids is

A

respiratory depression****

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27
Q

Describe the use of fentanyl in the elderly.

A

decrease dose in elderly patients

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28
Q

Describe the use of remifentanil in the elderly.

A

decrease bolus dose by half
infusion rate at 1/3rd that of younger patients
not dependent on liver & renal function for clearance

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29
Q

Describe the use of meperidine in the elderly.

A

NOT RECOMMENDED IN ELDERLY**

related to active metabolite- normeperidine & associated with postoperative delirium

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30
Q

Describe the use of NMBDs in the elderly.

A

Pharmacokinetics are significantly altered
delayed onset to maximal block
decreased metabolism by liver possible
delayed excretion by kidneys possible
impact of residual blockade on pharyngeal function can be signficant

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31
Q

_____ may be NMBD of choice in elderly.

A

Cisatricurium

-hoffman elimination so not organ dependent

32
Q

Frailty is a perioperative risk factor for

A

complications & mortality

33
Q

The preoperative assessment of the elderly individual should include

A

decreased reserve

prone to major events

34
Q

Frailty is related to

A

postoperative complications, increased LOS & discharge to skilled/assisted living facility

35
Q

A frailty index is used to

A

predict outcomes in the nonsurgical elderly population

36
Q

_____ is important to provide informed surgical consent.

A

Determining decision making capacity

37
Q

Four legally relevant criterion for decision making include:

A

understanding treatment options
appreciating and acknowledging medical condition & outcomes
exhibiting reasoning/rational discussion of treatment options
clearly choosing a preferred treatment option

38
Q

The four ethical principles include

A

autonomy
beneficence
non-maleficence
justice

39
Q

Perioperative DNR status can be

A

full suspension
partial suspension
no suspension

40
Q

Describe the nutritional status of the elderly.

A

decreased food intake (M>W) due to decreased activity, decreased lean body mass, slower protein turnover

41
Q

25% of elderly patients meet criteria for

A

malnutrition****

this increases postoperative complications & death

42
Q

Severe nutritional risk includes

A

BMI <18.5 kg/m2
serum albumin < 3 g/dL
unintentional weight loss >10-15% over 6 months

43
Q

Poor functional status is a

A

risk factor for SSI & postoperative complications

44
Q

When assessing cognitive status it is important to assess

A

cognitive capacity, decision-making capacity, risk for postoperative delirium

45
Q

_____ is the norm for elderly patients.

A

Polypharmacy**

46
Q

Risk of adverse events increases with

A

number of medications**

47
Q

If a patient is on anticholinergic medications,

A

discontinue if possible

associated with delirium & gait instability

48
Q

Drugs that are on the Beer’s criteria list include:

A 
metoclopramide (extrapyramidal effects)
meperidine
NSAIDs (GI bleed)- ketorolac 
transdermal fentanyl 
agonist-antagonist opioids
methadone (long half-life & risk of over sedation/respiratory depression)
49
Q

Goals of care for the elderly include

A 
preoperative assessment should allow for discussion of goals of care
patient & family
make decisions 
formalize decisions
legal paperwork
50
Q

Emergent surgery has

A

worse outcomes than elective surgery

51
Q

Emergent surgery can include

A

trauma, falls, hip fracture, intracranial bleeding, intraabdominal/vascular emergences
optimization versus emergency surgery

52
Q

With emergency surgery it is important to assess for

A

acute heart failure, fat embolism, acute lung injury & dehydration

53
Q

Describe choice of invasive monitoring in the elderly.

A 
risk/benefit
potential for blood loss/large fluid shifts
ASA status
concurrent illness
planned surgery
54
Q

Anesthetic management of the elderly patient includes.

A 
reduced incidence of DVT with regional
reduced anesthetic requirement
reduce induction drug doses by 25%
avoid benzos
peripheral IV placement
risk of skin breakdown/ulcerations
positioning considerations
risk of hypothermia
prone to hypotension with hypovolemia/hypertension with hypervolemia
55
Q

Describe fluid/blood therapy in the elderly patient.

A

elderly patients do not tolerate hypovolemia (hypotension) or hypervolemia (CHF)
judicious administration of blood product

56
Q

Describe postoperative management of the elderly patient.

A

postoperative delirium & cognitive dysfunction is a concern

defined as rapid decline in level of consciousness & cognitive changes not explained by preexisting dementia/impairment

57
Q

Postoperative cognitive dysfunction is

A

a possible inflammatory response due to surgical stress leading to

58
Q

Risk factors for postoperative cognitive dysfunction includes

A 
genetic disposition
lower educational level
high alcohol intake or alcohol abuse
increasing age
high ASA status
preexisting mild cognitive impairment 
history of CVA
cardiac surgery 
postoperative delirium
postoperative infection
59
Q

Postoperative complications are mostly

A

cardiac, pulmonary or neurologic complications

60
Q

Factors that affect perioperative outcomes include

A

emergency surgery
number of comorbidities
type of surgical procedure

61
Q

Postoperative pain control in the elderly

A

must be differentiate from acute procedural pain & chronic pain
sources of pain can be distended bladder, incision, infection, inflammation, fracture, positioning, UTI, constipation

62
Q

The two most important factors for perioperative outcomes include

A

surgical risk of the procedure

number of defined clinical risk factors in patient**

63
Q

Increased number of clinical risk factors leads to

A

increased risk of surgical procedure & overall risk of poor outcomes***

64
Q

There is an increased risk of complications for elderly patients undergoing

A

CV surgery**

65
Q

The leading cause of morbidity in periop outcomes include

A

pulmonary insufficiency or infection*****

66
Q

______ is common after major surgery*****

A

delirium

67
Q

functional recovery is

A

not the norm in the elderly

68
Q

Aging is the progressive

A

accumulation of random molecular defects (key point)

69
Q

all major cell types in the brain undergo

A

structural changes (neuronal cell death, dendritic changes, synaptic loss)- decreased brain mass/increased CSF (key point)

70
Q

Blood vessels become

A

stiff & thickened + atherosclerosis (key point)

71
Q

Diastolic dysfunction

A

increases with age (systolic dysfunction is abnormal as well) (key point)

72
Q

Closing volume approaches

A 
tidal volume (atelectasis)
(Key point)
73
Q

The aging kidney is susceptible to

A

damage, cannot handle hemodynamic change & not able to handle salt/water imbalance (key point)

74
Q

Frailty, due to reduced physiological reserve,

A

increases susceptibility to disability (key point)

75
Q

Two most important risks for perioperative outcomes are

A

the surgical risk of procedure & the number of clinical risk factors (key point)

76
Q

____ is common after major surgery

A

delirium (key point)

77
Q

______ are reduced in the elderly.

A

Anesthetic requirements (key point)

Pathophys II (43 decks)

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