Geriatric PPT and lecture notes Flashcards
I added a few %'s b/c heather stated she likes to test them??? I dunno if thats true and why they would be important but I added a few important ones
1
Q
the Age is years for geriatric/elderly patients is what?
A
65
2
Q
what % of population is over 65
A
12% (29.1 million)
3
Q
what percent of the population is baby boomers?
A
13%
4
Q
what % of those reaching 65 will require surgery sometime before death
A
50%
5
Q
At least 1 in 4 pt’s presenting for surgery are how old
A
65
6
Q
what are 6 chronic conditions seen with advanced age?
A
- Heart disease
- arthritis
- Impaired vision
- DM
- Cerebrovascular disease
- COPD
7
Q
what are the 5 most common proedures performed in the geriatric population
A
- cateract extraction
- TURP
- Herniorraphy
- Cholecystectomy
- Reduction of hip Fx
8
Q
the NIH predicts that after age 70 there is a ______% increase in mortality r/t surgery.
and ____% attributed to anesthesia alone.
A
300%
2% (in general population it is 0.001%) so its a pretty significant increase
9
Q
the NIH stated what 3 things were the most frequent causes of death in pt’s> 70 yo r/t surgical procedure
A
- MI
- Sepsis
- Thromboembolism
10
Q
*** what is the main CV change r/t aging ( 1 main concept to remember)
A
the general response is a decreasing response to stimulation of the ANS
11
Q
Can the old heart compensate for stress?
A
nope
12
Q
What happens to the cardiac reserve in the old fart?
A
reduced
13
Q
what happens to CO in the old foggie?
A
decreases
14
Q
CO decreases at what rate after the age of 30?
A
1% (its a linear relationship)
15
Q
CO of an 80yo is ______% of that of a 20 year old?
A
50%
16
Q
What decreases at a slower rate CO or CI?
A
CI
17
Q
what happens to the HR is old farts?
A
Decreases
18
Q
the Maximum HR decreases about ____% per decade after the age of 50?
A
5%
19
Q
what happens to conduction time in the older population?
A
Slowed
20
Q
the sympathetic response in HR decreases in the elderly b/c of what?
A
a decreased number of sympathetic receptors
21
Q
* decreased CO and HR lead to what?*
A
Increased circulation time
22
Q
** Sincce the decreasd CO and HR lead to increased circulation time, what does this mean to our pt’s? **
A
drugs take longer to circulate
23
Q
What happens to BP with age?
A
Increases
24
Q
The mean systolic BP reaches approximately what by age 70?
A
150
25
**** what is important to remember with the elderly pt while in the OR in relation to BP***
Keep within 20% of baseline
26
what can happen to diastolic BP with age?
may actually fall ( decrease)
27
what happens to Systolic BP in elderly
Increase
28
**what causes the increase in systolic BP in the oldies**
- decreased distensibility of great vessels
| - Arterio-atherosclerotic deterioration of vascular walls
29
What happens to the baroreceptor relfex in response to exercise and stress?
Decreasesd barorecptor reflex
30
What can develop due to a decreased barorecptor relfex in the elderly in response to stress and exercise?
postural hypotension
31
**** CO is maintained during stress and exercise by what? and what 3 things cause this to occur?
- -Increased diastolic filling & stroke volume.
1) not HR
2) Cardiac dilitation
3) compensatory response to decreased contractility and HR
32
**** what is the main concept to understand in r/t old people and the effects of stress and exercise??*****
it takes their bodies a long time to adjust to change.
33
Higher filling pressures are needed in the elderly to maintain SV b/c why
b/c of the prolonged contraction and relaxation times,
34
the elderly's decreased tolerance to rapid HR causes what 2 things?
- decreased filling time and resting time needed
| - increased risk of MI
35
**** main concept about HR and the elderly***
they cannot tolerate a high HR so keep it normal.
36
What are 6 anatomic changs of the heart
- Myocardial hypertrophy
- Endocardial thickening
- Valvular fibrocalcifications
- Decreased # of pacemaker cells
- sclerosis of conduction system
- Increase risk of HB
37
what are some examples of valvular fibrocalcifications in the elderly population
- murmurs
- endocarditis
- stenosis
- insufficiency
38
Is CAD involved in aging?
Yes
39
The elderly have an increased risk of dveloping what rhythm change?
HB
40
Elderly can have up to ___% decrease in pacemaker cells
80
41
******* main summary points of the CV changes in the elderly***
3 things that decrease????
- CO
- Maximum HR
- BP (diastolic)
42
******* main summary points of the CV changes in the elderly***
3 things that increase????
- LVEDP
- SV
- Heart size
43
the cardiac reserves are decreased to the margin of error that can be tolerated is what?
Decreased
44
Inhalation agents, induction agents as well as others that cause a decrease in CO must be used _________ or ________ to prevent an exaggerated response
Judiciously or Avoided
45
What are 3 reasons the preoperative ECG is essential in the lderly
- serves as a baseline
- serves as a diagnostic tool
- shows ischemic patterns (ST elevation MI, ST depression ischemia)
46
What do you want to rememebr about homemeds preop
- evaluate HTN meds
- assess fluid/electrolyte balance
- if on diuretics watch K+
- maintain meds unless contraindicated (hold insulin, use inhalers, always BB, hols ACEi's)
47
*** what is the best lead to monitor intraop and why?
V5, best one to use over lead II b/c has a better detection of ischemia (ST depression)
48
*** 3 things to remember during induction
-slower aproach
- Judicious use of drugs
- Slow circulation time
REMEMBER EVERYTHING SLOWS
49
in relation to respiratory changes there is usually a decrease in what 2 things
- elasticity
| - maximum lung function
50
Respiratory changes begin as early as what age?
30
51
respiratory changes that decrease with age?
- Forced Vital Capacity (FVC)
- Forced Expiratory Volume in 1 sec (FEV1)
- alveoli and pulmonary capillaries
- muscle strength
- flexibility of rib cage
52
the loss of paranchymal support of the small airways causes what
early collapse at increasingly higher lung volumes
53
FEV1 decreases from about 4.5L at age 20 to about _______L at age 80
2.5L
54
the loss of paranchymal support and decrease in FEV1 cause the lveoli to do what in the elderly
remain more distended and less distensible on inspiration
55
what causes a decreased MV
decreae in both rate and TV
56
what causes the decreased O2 consumption an dCO2 production
decreased metabolic rate
| decreased airway reflexes
57
what causes the decreased alveolar gas exchange
VQ mismatch
| uneven inspired gas distribution
58
what pulmonary factors increase with age
- dead space
- FRC
- Alveolar size
- closing volumes
- secretions
59
What causes increased dead space
- large airways increase in diameter
| - Small airways increase in diameter
60
What causes the increase in functional residual capacity (FRC)
the ratio of residual volume to total lung capacity decreases from 20% in early years ti 35-40% in elderly
61
what causes the increased alveolar size
septal membranes weaken and stretch
62
what causes increased closing volumes
loss of elastic recoil
63
what causes increased secretions
- Tracheobronchial production of secretion increase
| - decreased ability to eliminate secretions
64
what are 3 respiratory factors that remain unchanged in the pulmonary system
- PaCO2 (resting) (the hypoxic and hypercarbic drive is reduced by half
- Pulmonary circulating volume (pulmonary capillary beds decreases, less reserve)
- total lung capacity (TLC)
65
```
**** Main points from respiratory changes****
Total Lung Capacity (TLC)?
Residual Volume (RV)?
Functional Residual Capacity (FRC)
Vital Capacity (VC)
```
TLC- Decreased
RV- increased
FRC- increased
VC- Decreased
66
Vital Capacity
the maximum amt of air a person can expel from lungs after maximum inhalation
67
FRC
the volume of air present in the lungs, specifically the parenchyma tissues, at the end of passive expiration
68
RV
the volume of air remaining in the lungs after a maximal exhalation
69
TLC
maximum volume to which the lungs can be expanded with the greatest possible inspiratory effort
70
Anesthetic concerns r/t pulmonary changes
- Onset and emergence of inhalation anesthetics may be delayed
- Higher Fi02 may be needed
- Increased secretions may cause need for pulmonary toilet during periopertive period
- increased closing volumes may require PEEP
71
pulmonary toilet
Pulmonary hygiene, (formerly referred to as pulmonary toilet) is a set of methods used to clear mucus and secretions from the airways
-Methods used for pulmonary hygiene include suctioning of the airways, chest physiotherapy, blow bottles,[3] and nasotracheal suction.[5] Bronchoscopy, in which a tube is inserted into the airways so that an examiner can view them, can be used therapeutically as part of pulmonary hygiene.[4] Incentive spirometry and use of analgesics (pain medications) that do not inhibit breathing are also parts of pulmonary toilet.[6] Coughing is also important for ridding the airways of secretions, so healthcare providers are careful not to oversedate patients, because that could inhibit coughing.[7] Tracheotomy facilitates pulmonary toilet.[8] Percussion, another method, loosens secretions and allows the cilia of the airways to remove material. Positioning is another method for promoting drainage of secretions; sometimes patients are placed in a prone position to aid in this purpose.
72
what can cause the onset and emergence of inhalational anesthetics to be delayed
- decreased vent pattern
| - increased shunting
73
what things decrease in the nervous system in response to aging
- brain weight
- opiate receptors
- Nerve conduction
- cerebral blood flow
- epidural space
- thermoregulation
74
Why does the brain weight decrease?
atrophic changes mainly frontal lobe
| decreased # of neurons (cerebral cortex)
75
what are things that occur do to the decrease in # of opiate receptors
* *decrease sensitivity to pain
- increased sensitivity to narcs/inhaled agents
- decreased MAC and Narc requirement
76
what is important to remember while positioning a pt due to decrease in opiate receptors
decreased sensations to pain, so extra protection
77
is autoregulation maintained dispite decreased blood flow in the elderly?
YES
78
************* age for aged?
> 80
79
************* age for elderly/ geriatric
>65
80
Why is thermoregulation decreased
- less fat
| - less shivering
81
what are anesthetic implications for CNS r/t need to maintain normal BP to sustain cerebral perfusion
- maintain bp within 20% baseline
| - HTN may cause CVA
82
what are anesthetic implications for CNS r/t preoperative period
```
-evaluate:
hearing
sight
organic brain syndrome
other changes
(know baselines)
```
83
what are anesthetic implications for CNS r/t positioning
be carefull less sensitive to pain
84
what are anesthetic implications for CNS r/t regional anesthestics
- CSF pressure lower (less incidence of spinal H/A
- CSF specific gravity higher
- greater dispertion of LA
- Les CV reserve so greater hypotension with sypathetic block
- smaller doses for epidurals may be needed
85
what are anesthetic implications for CNS r/t induction/emergence
- slower times
| - decreased circulation times
86
what are anesthetic implications for CNS r/t agents
more sensitive
87
what are anesthetic implications for CNS r/t temperature
monitor closely due to loss of regulation
88
what decreases with age in the renal system?
- renal mass
- GRF(46% by 90yo)
- Nephron number and size
- perfusion (1-2%/year after 25yo)
89
What happens to secretion of aldosterone with aging? what are the consequences?
- -- decreased secretion
- increased Na and H2O loss
- Increased K+ retention
90
what happens to drug elimination r/t renal system in he elderly
decreases
91
what happens to SQ fat
loss
92
what occurs to skin
becomes thinner
93
what happens to body hair?
loss
94
**************************************** what 3 things all contribute ti loss of body heat in the elderly?
loss of SQ fat
Thinner skin
Loss of body hair
95
what happens to the risk of adverse drug reactions in the elderly?
increases
3% in ages 30 or less
21.3% in people over 70
96
what 2 things cause alterations in drug absorption
```
delayed GI motility
Circulatory changes (slow)
```
97
what 3 things cause alterations in GI (all tend to slow absorption)
- delayed absorption
- GASTRIC SECRETIONS MORE ALKALINE
- passive diffusion of drugs across cell membrane more difficult
98
what 4 things effect absorption of drugs in relation to absorption
- circulatory times slowed
- delays in onset of IV/inhaled drugs
- periphreal circulation slowed
- slowed IM absorption
99
what changes in body composition cause alterations in volume of distribution?
- fat content of TBW increases 20-40%
| - lean body mass decreases by 10-20%
100
what causes alteration in drug binding in the elderly?
serum albumin concentration decreases 20%
* * most drugs used bind to albumin
* * lower albumin levels allows more unbound active drug to circulate
101
what slows rate of elimination of inhaled agents
decreased ventilation
102
what happens to MAC values of the elderly
-decrease 20-30%
103
Post operative problems in elderly
- atelectasis/PNE
-MI/CHF/ conduction problems
Thromboembolism
104
***** is a question on the test ask about organs the answer is generally what??****
DECREASED
105
** why can't elderly retain heat***
Can't shiver
106
7 common age related A&P changes??
- DECREASED organ function
- INCREASED body fat
- DECREASED blood volume
- DECREASED ability to retain heat
- DECREASED in lean body mass
- DECREASED skin elasticity
- collagen loss
- DECREASED intracellular water
107
11 Common age related CV A&P changes
- impaired pump fxn
- prolonged circulation time
- myocardial fiber atrophy
- HTN
- Impaired cardiac adrenergic receptor quality
- Increased PVR
- DECREASED CO
- DECREASED organ fxn
- DECREASED organ perfusion
- left ventricular hypertrophy
- CAD
108
8 common pulmonary age related A&P changes
- INCREASED lung compliance
- DECREASED forced expiratory volume
- INCREASED closing volumes
- DECREASED resting arterial O2 tension
- INCREASED alveolar-arterial differences
- V/Q mismatch
- DECREASING FRC
- DECREASING TLC
109
6 common age related CNS A&P changes
-DECREASED activity
- DECREASED O2 consumption
-REDUCED # of functioning receptors
- REDUCED production of NT
- Neuron loss
- DECREASED CBF
All decreased
110
7 common Age related renal/hepatic changes
- DECREASED renal blood flow
- DECREASED urine concentrating ability
- DECREASED ability to conserve H2O
- DECREASED elimination of drugs
- DECREASED hepatic blood flow
- DECREASED plasma drug clearance
***** all DECREASED***
111
surgical pt's at risk for post operative delerium
```
70 or older
Hx of delerium
ETOH abuse
preop narc use
preop depression
```
112
```
***************************************************she said to focus on this
age related changes to pharmacokinetics
name the effect of the change!!
Contracted vascular volume
Decreased protein binding
Increased total body lipid storage sites
decreased renal and hepatic blood flow
```
- high inital plasma concentrations
- Increased availability of free drug
- prolonged action of lipid-soluable drugs
- prolonged action of drugs dependent on kidney and liver elimination
113
Contracted vascular volume causes what r/t PK
- high inital plasma concentrations
114
Decreased protein binding causes what r/t PK
Increased availability of free drug
115
Increased total body lipid storage sites causes what r/t PK
prolonged action of lipid-soluable drugs
116
decreased renal and hepatic blood flow causes what r/t PK
prolonged action of drugs dependent on kidney and liver elimination
117
What are some common coexisting diseases in elderly pts
- systemic HTN
- CAD
- CHF
- PV disease
- COPD
- Anemia
- renal disease
- liver disease
- DM
- Arthritis
- Dementia
118
how to calculate CO
HR x SV
119
Average SV of a pt
60-80 mls
120
Normal CO of a person (not elderly)
4.8-6.4 L/min
| average hr 80x70ml=5,600ml=5.6 L/min
121
what is Cardiac index
is a vasodynamic parameter that relates the cardiac output (CO) to body surface area (BSA),[1] thus relating heart performance to the size of the individual. The unit of measurement is litres per minute per square metre (l/min/m2).
122
Normal CI
2.6 - 4.2 L/min per square meter
123
How to calculate CI
CO/BSA=CI
124
how to calculate BSA
0.007184 x Wkg^0.425 x Hcm^0.725
125
so calculate the CO and CI for a 162cm 88kg pt with a HR of 76 (assume SV 65)
```
CO= hr x SV
CO= 76 x 65=4940=4.94L/min
```
BSA=0.007184 x Wkg^0.425 x Hcm^0.725
BSA = 0.007184 x 88^0.425 x 162^0.725
BSA= 1.926m^2
CI=4.94/1.926=2.56490135
