Geriatric considerations part 2 Flashcards
Describe body composition.
decrease in intracellular fluid
blood volume decreases by 20-30% by 75 years
loss of muscle mass/reduced strength
There is a reduction in _____ body mass.
lean body mass
weight declines
Describe what happens to the basal metabolic rate
decrease in basal metabolic rate- decreased physical activity
decreases in serum testosterone/growth hormone
The percentage of fat per TBW
increases (body fat increases)
waist circumference increases
Describe what happens to the skin of the elderly.
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**
Describe thermoregulation in the elderly.
impaired thermoregulation
- decreased function of hypothalamus
- increased incidence of shivering
_______ is more pronounced and lasts longer in the elderl.y
Hypothermia
Describe frailty.
a state of reduced physiologic reserve that is associated with increased susceptibility to disability
independent predictor of in hospital mortality*****
Frailty is characterized by
weight loss, fatigue, impaired grip strength, low physical activity & slow gait speed.
Geriatric syndromes include:
incontinence, delirium, falls, pressure ulcers, sleep disorders, eating/feeding problems, pain, depressed mood, dementia, & physical disability
Reversible dementia can be due to
chronic drug intoxication, vitamin deficiency, subdural hematoma, major depression, hydrocephalus, & hypothyroidism
_________ over any time interval is predictive of an earlier death.
Diminishing cognitive performance*****
Treatment for dementia includes
vitamin E, NSAIDs, estrogen, acetylcholinesterase inhibitors
_____ is the norm in the elderly.
polypharmacy
- increased effects of drug interactions
- increased sensitivity to anesthetics
- loss of neuronal tissue & changes in receptors
Drug dosages should be adjusted for
smaller lean body mass**
Total body water
decreases 10-15%
-decreased central compartment volume
decreased blood volume= decreased in initial Vd
-increase in initial plasma concentration following IV drugs
Body Fat _____ and muscle mass ______
increases; decreases
Decreased plasma albumin & increased alpha 1 acid glycoprotein has
no significant impact on clinical pharmacology
______ in renal function leads to increased serum concentrations and prolonged effects of drugs dependent on renal elimination
Decrease
Describe inhalational agents in the elderly.
minimum alveolar concentration decreases** with age
-decreases 6% per decade after age 40
The ideal induction agent for the elderly is
etomidate
-reduce induction doses in elderly
Describe propofol use in the elderly.
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%
Describe the use of thiopental for the elderly.
reduce total dose of drug in elderly
Describe the use of midazolam in elderly.
elderly patients are more sensitive
increased duration of action
contributes to postoperative delirium
metabolite, may accumulate if decreased renal function
Describe opioid use in the elderly.
-increased sensitivity to opioids
-decreased metabolism by liver
reduced excretion by kidney
The primary risk of opioids is
respiratory depression****
Describe the use of fentanyl in the elderly.
decrease dose in elderly patients
Describe the use of remifentanil in the elderly.
decrease bolus dose by half
infusion rate at 1/3rd that of younger patients
not dependent on liver & renal function for clearance
Describe the use of meperidine in the elderly.
NOT RECOMMENDED IN ELDERLY**
related to active metabolite- normeperidine & associated with postoperative delirium
Describe the use of NMBDs in the elderly.
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
_____ may be NMBD of choice in elderly.
Cisatricurium
-hoffman elimination so not organ dependent
Frailty is a perioperative risk factor for
complications & mortality
The preoperative assessment of the elderly individual should include
decreased reserve
prone to major events
Frailty is related to
postoperative complications, increased LOS & discharge to skilled/assisted living facility
A frailty index is used to
predict outcomes in the nonsurgical elderly population
_____ is important to provide informed surgical consent.
Determining decision making capacity
Four legally relevant criterion for decision making include:
understanding treatment options
appreciating and acknowledging medical condition & outcomes
exhibiting reasoning/rational discussion of treatment options
clearly choosing a preferred treatment option
The four ethical principles include
autonomy
beneficence
non-maleficence
justice
Perioperative DNR status can be
full suspension
partial suspension
no suspension
Describe the nutritional status of the elderly.
decreased food intake (M>W) due to decreased activity, decreased lean body mass, slower protein turnover
25% of elderly patients meet criteria for
malnutrition****
this increases postoperative complications & death
Severe nutritional risk includes
BMI <18.5 kg/m2
serum albumin < 3 g/dL
unintentional weight loss >10-15% over 6 months
Poor functional status is a
risk factor for SSI & postoperative complications
When assessing cognitive status it is important to assess
cognitive capacity, decision-making capacity, risk for postoperative delirium
_____ is the norm for elderly patients.
Polypharmacy**
Risk of adverse events increases with
number of medications**
If a patient is on anticholinergic medications,
discontinue if possible
associated with delirium & gait instability
Drugs that are on the Beer’s criteria list include:
metoclopramide (extrapyramidal effects) meperidine NSAIDs (GI bleed)- ketorolac transdermal fentanyl agonist-antagonist opioids methadone (long half-life & risk of over sedation/respiratory depression)
Goals of care for the elderly include
preoperative assessment should allow for discussion of goals of care patient & family make decisions formalize decisions legal paperwork
Emergent surgery has
worse outcomes than elective surgery
Emergent surgery can include
trauma, falls, hip fracture, intracranial bleeding, intraabdominal/vascular emergences
optimization versus emergency surgery
With emergency surgery it is important to assess for
acute heart failure, fat embolism, acute lung injury & dehydration
Describe choice of invasive monitoring in the elderly.
risk/benefit potential for blood loss/large fluid shifts ASA status concurrent illness planned surgery
Anesthetic management of the elderly patient includes.
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
Describe fluid/blood therapy in the elderly patient.
elderly patients do not tolerate hypovolemia (hypotension) or hypervolemia (CHF)
judicious administration of blood product
Describe postoperative management of the elderly patient.
postoperative delirium & cognitive dysfunction is a concern
defined as rapid decline in level of consciousness & cognitive changes not explained by preexisting dementia/impairment
Postoperative cognitive dysfunction is
a possible inflammatory response due to surgical stress leading to
Risk factors for postoperative cognitive dysfunction includes
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
Postoperative complications are mostly
cardiac, pulmonary or neurologic complications
Factors that affect perioperative outcomes include
emergency surgery
number of comorbidities
type of surgical procedure
Postoperative pain control in the elderly
must be differentiate from acute procedural pain & chronic pain
sources of pain can be distended bladder, incision, infection, inflammation, fracture, positioning, UTI, constipation
The two most important factors for perioperative outcomes include
surgical risk of the procedure
number of defined clinical risk factors in patient**
Increased number of clinical risk factors leads to
increased risk of surgical procedure & overall risk of poor outcomes***
There is an increased risk of complications for elderly patients undergoing
CV surgery**
The leading cause of morbidity in periop outcomes include
pulmonary insufficiency or infection*****
______ is common after major surgery*****
delirium
functional recovery is
not the norm in the elderly
Aging is the progressive
accumulation of random molecular defects (key point)
all major cell types in the brain undergo
structural changes (neuronal cell death, dendritic changes, synaptic loss)- decreased brain mass/increased CSF (key point)
Blood vessels become
stiff & thickened + atherosclerosis (key point)
Diastolic dysfunction
increases with age (systolic dysfunction is abnormal as well) (key point)
Closing volume approaches
tidal volume (atelectasis) (Key point)
The aging kidney is susceptible to
damage, cannot handle hemodynamic change & not able to handle salt/water imbalance (key point)
Frailty, due to reduced physiological reserve,
increases susceptibility to disability (key point)
Two most important risks for perioperative outcomes are
the surgical risk of procedure & the number of clinical risk factors (key point)
____ is common after major surgery
delirium (key point)
______ are reduced in the elderly.
Anesthetic requirements (key point)
