Geriatric Pt- Lecture 1

Question 1

What produces higher than anticipated plasma concentration of IV agents?

Answer 1

decrease in blood volume

Question 2

What happens to Vd of H20 soluble meds in geriatric patients?

Answer 2

Vd decreases so plasma concentrations are higher than normal

Question 3

What happens to the Vd of fat sol meds in geriatric population?

Answer 3

longer 1/2 life because of increase in body fat and may cause extension of pharmacologic properties and slower excretion from the body

Question 4

Three theories of aging process?

Answer 4

1- programmed aging (killer gene), 2- telomere shortening, 3- gradual, cumulative process of damage and deterioration

Question 5

What is “safety margin for function above basal needs?”

Answer 5

functional reserve

Question 6

When does functional reserve peak? Then what happens?

Answer 6

30 years. Gradually declines over next few decades and experiences steeper decline after age 80

Question 7

What simple test can you measure functional reserve w?

Answer 7

4 METs

Question 8

What causes the decline in basal metabolism in geriatric pts?

Answer 8

change in body composition- less skeletal muscle, more fat

Question 9

What happens to the total body water and how much does blood volume decrease in elderly?

Answer 9

decreases; 20-30%

Question 10

Why are elderly patients more susceptible to hypotension with shifts in position?

Answer 10

decreased blood volume and decreased total body water

Question 11

What is one thing that stays intact in the elderly CNS system?

Answer 11

autoregulation

Question 12

What 5 things decrease in the elderly CNS?

Answer 12

brain mass (primarily frontal lobe of cerebral cortex), # of neurons, synthesis of NTs, synthesis of functional receptors, CBF

Question 13

What structure that affects thermoregulation in CNS does not function well in elderly?

Answer 13

hypothalamus

Question 14

Why does hypothermia last longer in elderly? What does hypothermia d/t anesthetic elimination?

Answer 14

less effective peripheral vasoconstriction, decreased basal metabolic rate, high ratio of surface to body ratio mass; slows it, prolongs recovery, impairs coagulation, increases chance that pt will shiver (increases O2 consumption 400%)

Question 15

How much should Propofol doses be lowered in elderly?

Answer 15

15%

Question 16

MAC decreases how much per decade?

Answer 16

6%

Question 17

Is the elderly heart more or less compliant?

Answer 17

less

Question 18

Why is atrial contraction more important in maintaining adequate ventricular filling in the elderly patients?

Answer 18

because the combination of ventricular hypertrophy and lower myocardial relaxation result in late diastolic filling and diastolic dysfunction

Question 19

Why is HTN common in elderly and what type of HTN is it (concentric or eccentric)?

Answer 19

common d/t loss of ventricular elasticity; concentric

Question 20

Do elderly have a decreased, same, or increased amt of catecholamines?

Answer 20

increased

Question 21

3 reasons why elderly have difficulty increasing CO

Answer 21

diminished baroreceptor responses, endogenous physiological beta blocked, reduced efficacy of beta agonists

Question 22

What do the cardiovascular changes in the elderly do to drug circulating time?

Answer 22

prolong it

Question 23

What type of onset do IA versus IV drugs have in elderly?

Answer 23

faster with IA, slow onset of IV drugs

Question 24

What leads to loss of vascular elasticity in elderly?

Answer 24

decrease in elastin production and increase in collagen damage

Question 25

What does decrease in elasticity and compliance do to PVR, afterload, and vascular system?

Answer 25

stiffens

Question 26

What does the pulse pressure do in the elderly?

Answer 26

widen

Question 27

What causes the overall stiffening of atria and ventricles?

Answer 27

loss of collagen

Question 28

What is something that predisposes the elderly to arrhythmias?

Answer 28

calcification of conducting system, including loss of SA node

Question 29

Patients with diastolic dysfunction, which is very common in the elderly, are dependent upon what for filling?

Answer 29

atrial kick

Question 30

This corresponds to the amount of O2 consumed by a 70 kg male at rest (around 3 mL of O2/kg/min)?

Answer 30

MET

Question 31

3 causes of higher BP in elderly?

Answer 31

increased PVR, decreased arterial elasticity, cardiac workload

Question 32

What causes a decreased TV in elderly?

Answer 32

VC

Question 33

Why is there an increased work of breathing?

Answer 33

inelastic chest and closure of small airways

Question 34

At what age does the PaO2 decrease? And why?

Answer 34

75+ (PaO2 83); attributed to premature closing of small airways and decreased surface area for gas exchange so therefore, a VQ mismatch and less efficient gas exchange

Question 35

What type of vent settings should you avoid in the elderly pt with increased wob?

Answer 35

avoid high pressure, high TV, consider PEEP, and lower FiO2

Question 36

What causes the VQ mismatch?

Answer 36

increase in compliance

Question 37

What type of response do the elderly have to hypercapnea and hypoxia?

Answer 37

diminished response

Question 38

What is necessary for maintaining small airway diameter?

Answer 38

elastic recoil

Question 39

Increased compliance does what to the airway diameter?

Answer 39

decreases/narrows and increases closing volume

Question 40

Closing volumes exceed FRC at what age in erect position and what age in supine position?

Answer 40

65; 45

Question 41

What can prevent small airway collapse?

Answer 41

greater lung inflation

Question 42

Why are elderly patients at an increased risk for aspiration?

Answer 42

diminished protective airway reflexes

Question 43

What type of change is seen in hepatic enzyme function in elderly?

Answer 43

little change

Question 44

What happens to the liver size and blood flow in elderly?

Answer 44

decrease

Question 45

Hepatic blood flow decreases what percentage per decade?

Answer 45

10%

Question 46

At what age does liver volume begin to increase?

Answer 46

50%

Question 47

What happens to the rate of hepatic plasma clearance?

Answer 47

reduced rate

Question 48

How does elderly hepatic function affect drug reactions?

Answer 48

there is an increase in drug reactions w hepatic problems

Question 49

What does the reduced rate of plasma clearance d/t hepatic ftn in elderly do to the clinical effects of most IV anesthetics?

Answer 49

prolongs the effects

Question 50

What do you have to be mindful about with elderly and their livers and narcotics?

Answer 50

risk of respiratory depression

Question 51

What are 4 exceptions to hepatic function in elderly prolonged effects of most IV anesthetics?

Answer 51

Cisatracurium, Atracurium, Suxxs, Esmolol

Question 52

Vd of hydrophillic versus lipophillic drugs in elderly patients because of liver function

Answer 52

decreased Vd in hydrophillic, which is caused by increase in plasma concentration; increased Vd of lipophillic drugs caused by decrease in plasma concentration

Question 53

What happens to the renal blood flow, renal mass, GFR, and labs in elderly?

Answer 53

decrease, decrease, decrease, remain unchanged

Question 54

Decreased renal drug clearance particularly of hydrophillic or lipophillic drugs?

Answer 54

hydrophillic

Question 55

Best indicator of renal drug clearance?

Answer 55

creatinine clearance

Question 56

What type of response to renal changes in the elderly cause to aldosterone and ADH?

Answer 56

decreased response

Question 57

Drugs with renal elimination have shorter or longer duration in elderly?

Answer 57

longer

Question 58

Older patients have tendency to lose what electrolyte?

Answer 58

Na

Question 59

What happens to PNS vs SNS tone/activity in elderly?

Answer 59

decreased PNS, increased SNS

Question 60

What happens to SVR, SBP, SV, CO in elderly?

Answer 60

increase, increase, decrease, decrease

Question 61

What happens to the size of central airway versus small airway in elderly?

Answer 61

increases, decreases

Question 62

Decrease/increase in lung compliance and decrease/increase in chest wall compliance?

Answer 62

increase, decrease

Question 63

Most everything in elderly decreases except for these 5 things:

Answer 63

storage size for lipid sol drugs, sympathetic neural activity, lung compliance, reserve vol and FRC, closing vol, and closing capacity

Question 64

Midazolam has what 1/2 life in elderly?

Answer 64

6 hours versus 2 in younger person

Question 65

Greater Vd does what to reservoir? Lesser Vd does what to plasma concentration?

Answer 65

increases; increases

Question 66

Increased body fat means what endocrine wise?

Answer 66

insulin resistance

Question 67

Elderly lose heat how much faster than younger adults?

Answer 67

twice

Question 68

Skeletal muscle mass decreases around what percentage?

Answer 68

10%

Question 69

What does decreased muscle mass do to resting O2 consumption and CO?

Answer 69

decrease, decrease

Question 70

Why must you be careful with titration of muscle relaxants, especially Vec and Roc in elderly?

Answer 70

decreased liver mass and decreased skeletal muscle mass

Question 71

Which compartment loses water more in the elderly-ICF or ECF?

Answer 71

ICF

Question 72

Up to a __% decrease in plasma volume in elderly?

Answer 72

30

Question 73

What does a decrease in plasma volume do to drug concentrations?

Answer 73

increases

Question 74

Decreased plasma protein binding means what for those drugs highly protein bound?

Answer 74

increase in free plasma concentration

Question 75

Risk to benefit ratio on those patients> 65 depend on what 4 factors?

Answer 75

age, physiological status and coexisting diseases according to ASA, whether surgery is elective or urgent, type of procedure and home care

Question 76

What do you need to do to the dose of General, MAC, and local anesthesia in elderly?

Answer 76

DECREASE

Question 77

Decrease dose of induction agents how much in older patient?

Answer 77

30-40%

Question 78

What happens to the levels and duration of action with SAB in elderly?

Answer 78

get higher faster and last longer

Question 79

Positives about regional anesthesia in elderly?

Answer 79

lower PDPH, lower incidence of hypoxemia if heavy sedation avoided, decreased DVT and blood loss

Question 80

Negative about regional anesthesia in elderly?

Answer 80

post op residual paresthesias are more common

Question 81

What is the most frequent type of anesthetic complication in elderly?

Answer 81

neurological

Question 82

How long is cognitive decline after surgery reversible?

Answer 82

3 months

Question 83

Post operative cognitive dysfunction is different from delirium how?

Answer 83

It's a progressive development of symptoms and is subtle

Question 84

Predictors of post operative cognitive decline?

Answer 84

age, low education level, preop cognitive impairment, depression, surgical procedure, low albumin, prior stroke or TIA

Question 85

Most accurate indicator of kidney function in elderly?

Answer 85

GFR

Question 86

Ratio of GFR to creatinine clearance decreases/increases in elderly?

Answer 86

decreases

Question 87

4 preop lab tests reasonable for all geriatric pts?

Answer 87

BUN, Cr, Hg, albumin

Question 88

What is the MET score for walking around house, take care of yourself, walk a block on level ground?

Answer 88

MET 1

Question 89

MET score for doing light work around the house like dusting or walking dishes; climb a flight of stairs or walk up a hill?

Answer 89

MET 4

Question 90

participating in strenuous sports is how many METs?

Answer 90

>10

Question 91

5 criteria for frailty scale?

Answer 91

weight loss, decreased grip strength, exhaustion, low physical activity, slowed walking speed

Question 92

patients with severe nutrition risk should have nutrition support how many days prior to surgery?

Answer 92

10-14