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AS - N935 Advanced Patho II > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

What age defines elderly?

A

> 65yo

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2
Q

What are the 5 key elements involved in aging biology?

A
  1. Genes
  2. Nutrition
  3. Lifestyle
  4. Environment
  5. Chance
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3
Q

What length is related to mortality?

A

Telomeres are typically long

Shortened telomere indicates shorter lifespan
Premature shortening associated w/ dementia

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4
Q

Oxidative Damage

A

Free radicals (reactive oxygen species) oxygen use/metabolism byproducts can damage chromosomal DNA → impair gene function, damage to mitochondrial DNA, & damage telomeres

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5
Q

Parkinson’s

A

Protein malfunction
Lewy bodies
α synuclein

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6
Q

Alzheimer’s

A

Protein dysfunction

β amyloid

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7
Q

CNS

A

Mood, memory, & motor function changes
Neuronal death, synaptic loss, glial cell reactivity
↓neuronal regenerative capacity
Brain mass ↓15% ↑CSF volume
↓nerve conduction velocity
Impaired cholinergic signaling & Dopamine signal transduction pathways
↓α2 agonist receptors
Peripheral nerve cell degeneration
↓myelinated fibers
↑risk postop delirium or cognitive dysfunction
↓neurotransmitter activity (glutamate receptors & GABAa binding sites)
↓CBF & cerebral metabolic rate
↑susceptibility to metabolic stress
Cognitive dysfunction r/t aging
Intellectual functioning, attention, memory, & psychomotor function decline w/ age

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8
Q

Glutamate

A

Excitatory

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9
Q

GABA

A

Gamma aminobutyric acid

Inhibitory

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10
Q

CNS

Anesthetic Considerations

A

↑drug sensitivity
Receptor down-regulation
Blood-brain barrier more permeable (drugs cross more readily)
Exaggerated response to CNS depressants (GA, hypnotics, opioids, benzodiazepines)
↓induction agents 25-50%

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11
Q

Neuraxial

Anesthetic Considerations

A

Neural damage risk d/t ↓myelinated nerve fibers
Difficult neuraxial placement d/t anatomic changes
Dura more permeable to LA
↓CSF volume
Enhance LA spread
Post-spinal sympathectomy → severe hypotension refractory to adrenergic stimulation
↓spinal/epidural block LA dose

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12
Q

Cardiovascular System

A

↓tissue elasticity (less compliant)
↑collagen cross-linked & fragmented elastin ↑tissue stiffness
↓end-organ adrenergic responsiveness
↑afterload
↑systolic BP 5mmHg per decade until 60yo then 10mmHg per decade
LV hypertrophy ↑L ventricular mass
Diastolic dysfunction
↓cardiomyocytes
↑heart failure incidence
Aortic sclerosis & stenosis
Electrical system declines - pacemaker cells (SA node) reduced, ↑dysrhythmias, bradycardia, less responsive to Atropine, ↑pacemakers or AICD incidence

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13
Q

What are 2 major structural changes in blood vessels?

A

STIFFENING & ATHEROSCLEROSIS

Atherosclerosis hallmark sign = inflammation → artery occlusion

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14
Q

Cardiac Supply & Demand

A

MISMATCH
Myocardium prone to ischemia
↑LVEDP + ↓ADBP → ↓O2 supply

Ventricular hypertrophy, LV end-systolic pressure, ↑aortic pressure, & ↑systole → ↑O2 demand

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15
Q

CV

Anesthetic Considerations

A

↓end-organ adrenergic responsiveness
Impaired ability to compensate in response to hypotension, hypovolemia, & hypoxia
Prolonged circulation time - faster inhalational induction & delayed IV onset
HTN → periop complications risk factor
↓venous compliance ↓VR
↓SV/CO
↓sensitivity to β adrenergic modulation

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16
Q

What is the most common complication & leading cause of death in the postop period?

A

Myocardial infarction

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17
Q

Respiratory System

A 
↓chest wall compliance 
↓Pel (lung elastic recoil) ↑compliance
↑VC/RV/CV/FRC
CV > FRC supine 45yo upright 65yo
TLC Ø difference or slight ↓
↓expiratory flows (FEV1 & FEF 75%)
Small airway diameters
Airway collapse w/ forced expiration
↓respiratory muscle endurance
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18
Q

FEV1

A

Forced expired volume in 1 second

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19
Q

FEF 75%

A

Forced expired flow at 75%

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20
Q

Gas Exchange

A 
↓alveolar surface area
↓PaO2
↑Va/Q mismatch
↑intrapulmonary shunting
↓Pel (emphysema presentation)
↑airway closure CV approached Vt
CV > FRC
Prone to atelectasis
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21
Q

What is impaired at the alveolar level?

A

↓oxygen exchange

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22
Q

Closing capacity & FRC at 45yo

A

FRC supine = closing capacity
FRC upright > closing capacity

*FRC impacted w/ position changes ↓when patient supine

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23
Q

Closing capacity & FRC at 65yo

A

FRC supine < closing capacity
FRC upright = closing capacity\

*FRC impacted w/ position changes ↓when patient supine

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24
Q

Other Respiratory Changes

A 
↓ability to clear secretions
↑aspiration risk
↓respiratory drive in response to hypoxia, hypercarbia, & resistive load
Predisposed to ↑apnea episodes
↑airway reactivity
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25
Q

Renal System

A 
Kidney parenchymal tissue atrophy
↓RBF & renal mass
↓drug clearance
↓GFR 1mL/yr
Dilute urine (unable to maximally concentrate)
Tubular frailty - more susceptible to hypoxic or nephrotoxic injury
Impaired Na+ conservation
↓renin/aldosterone production
Prone to fluid overload or dehydration
Unable to accommodate hemodynamic changes - more susceptible to injury
↓sensitivity to volume/osmoreceptor
Diminished thirst response
Bladder dysfunction/incontinence
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26
Q

What is the best indicator of drug clearance?

A

Creatinine clearance

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27
Q

What are renal failure patients at ↑risk to experience?

A
  1. Fluid overload
  2. Metabolite & drug accumulation
  3. ↓drug elimination
  4. Prolonged anesthetic drugs & adjuncts effects
  5. Electrolyte imbalances
  6. Arrhythmias
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28
Q

Hepatic System

A

↓liver mass 20-40%
↓hepatic blood flow & functional hepatic reserve
Altered drug metabolism & protein binding
↓metabolism → prolonged half-life
↓↑↓↓↓↑↑↓↑ →

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29
Q

Phase 1

A

Variable
Oxidation, reduction, & hydrolysis
CYP450 enzyme

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30
Q

Phase 2

A

Not significantly altered

Conjugation, sulfonic acid, or acetylation

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31
Q

Serum albumin _____ & α1 acid glycoprotein _____

A

Decreases & increases

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32
Q

Gastrointestinal System

A

↓motility & colonic function
↓GI immunity & drug metabolism
Liver function impact on NPO status

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33
Q

Immune System

A 
Innate & adaptive changes
↓immune cells bactericidal activity
↑cytokine & chemokine levels
Low-grade chronic inflammatory process
↓T & B cell function
Impaired ability to fight infection & control cancers
34
Q

Endocrine System

A

Endocrine gland atrophy
↓hormone production
Impaired endocrine function & glucose homeostasis
Insulin, thyroxine, growth hormone, renin, aldosterone, & testosterone deficiencies
Chronic electrolyte abnormalities
Diabetes, hypothyroidism, impotence, & osteoporosis
↓lean body mass

35
Q

Resting Metabolic Rate

A

↓1% per year after 30yo

Total energy expenditure ↓
*↑energy expenditure w/ multiple comorbidities & chronic illness

Unable to tolerate ↓O2 demand

36
Q

Pancreas

A

↓pancreatic islet β cells number & function
↓insulin secretion & peripheral insulin resistance
↑hepatic glucose production
Impaired fat/protein production

37
Q

What is a major risk factor for CV disease?

A

Diabetes

  • Risk periop & postop complications
  • Impaired cognition/dementia
38
Q

Body Composition

A

↓intracellular fluid & blood volume → hypotension
↓muscle mass & reduced strength
↑fat % per total body weight
Atrophy → 1° impact fast-twitch muscle fibers
Loss body protein & motor neurons
↑waist circumference
Fat accumulation w/in muscles
↓collagen, elastin, SQ fat, dermal/epidermal skin thickness
Prone to skin tears & nerve injuries
↑↓↑↓↑↑↓↑ → ↑↓↑ → ↔ α ⋅ β Ø λ π η

39
Q

How to prevent skin tears & nerve injuries?

A

Careful positioning

40
Q

Thermoregulation

A

Impaired
↓hypothalamus function
Hypothermia more pronounced & lasts longer
Less effective peripheral vasoconstriction
Prolonged recovery from anesthesia
Impaired coagulation & immune function
Blunted ventilatory response to CO2
↑shivering incidence → O2 consumption & basal metabolic rate → hypoxia, acidosis, & CV compromise

41
Q

Frailty

A

Reduced physiologic reserve - associated w/ ↑disability susceptibility
↑vulnerability to adverse outcomes d/t ↓resistance to stressors
1° or 2°
Weight loss, fatigue, impaired grip strength, low physical activity, & slow gait
Decompensate more quickly
Frailty index predicts outcomes in non-surgical elderly population (preop risk assessment)
Periop risk factor r/t postop complications ↑LOS & discharge to skilled/assisted living facility

42
Q

Dementia

A

Intellectual decline
Changes in cognitive, behavioral, or health status
Degenerative brain diseases often incurable
Supportive therapy/treatment

43
Q

Reversible Dementia

A 
Chronic drug intoxication
Vitamin deficiency
Subdural hematoma
Major depression
Hydrocephalus
Hypothyroidism
44
Q

Falls

A 
Unstable gait
Poor muscle strength
Neural damage in basal ganglia & cerebellum
Peripheral neuropathy
Fall history → evaluate gain & balance
45
Q

PK/PD

A 
Polypharmacy
Loss neuronal tissue & receptor changes
↑sensitivity ↓anesthesia requirements
Consider BIS monitor
Anesthetic toxicity & cognitive dysfunction
46
Q

Anesthesia Management

A 
↓Vd
↑plasma concentration
↑body fat ↓muscle mass
↓plasma albumin
Impaired renal function ↑serum concentration & prolonged drug effects (renal dependent elimination)
47
Q

Inhalational Anesthetics

A

↓MAC 6% per decade after 40yo

N2O ↓8% per decade

48
Q

Propofol

A

↓induction dose 50% ↓infusion 20%
↑effect on hemodynamics
↓clearance (women > men)

49
Q

Etomidate

A 
Ideal drug (CV stable)
Less hemodynamic instability
↓Vd ↓clearance
↑sensitivity
↓induction dose
NO analgesic properties
50
Q

Thiopental

A

↓total dose 50-80%
↓Vd
Delayed recovery d/t ↓central Vd

51
Q

Midazolam

A

↑sensitivity MOA unknown
↑DOA
Contributes to postop delirium
Hydroxymidazolam metabolite potential accumulation w/ ↓renal function

52
Q

Opioids

A

↑sensitivity
↓hepatic metabolism
↓renal excretion
Metabolites (pharmacologically active Codeine, Morphine, & Meperidine) → analgesia & side effects

53
Q

Fentanyl

A

↑potency 50% > 80yo
↑sensitivity
↓dose
PD > PK

54
Q

Remifentanil

A 
Not dependent on liver or renal function
↓50% by 85yo
↓bolus dose 1/2
Infusion rate 1/3
Slower on & off
↑PD sensitivity
55
Q

Meperidine

A 
NOT RECOMMENDED
Normeperidine = active metabolite
Renal excretion
Half-life 15-30 hours
Associated w/ postop delirium
Postop shivering ↓dose
56
Q

NMBDs

A

PD & ED95 not significantly altered
PK ↓onset maximal block ↓hepatic metabolism ↓renal excretion ↑recovery time 50%
Residual blockade effect on pharyngeal function
DOC = Cisatracurium
- Hoffman elimination & ester hydrolysis
- Not organ dependent

57
Q

What is important to determine when providing informed surgical consent?

A

Decision-making capacity

58
Q

What are the 4 legally relevant criterion for decision making?

A
  1. Understanding treatment options
  2. Appreciating & acknowledging medical conditions & outcomes
  3. Exhibiting reasoning/rational discussion of treatment options
  4. Clearly choosing a preferred treatment option
59
Q

Autonomy

A

Patient right to self-determination

60
Q

Beneficence

A

Obligation or responsibility to help the patient

Do Good

61
Q

Nonmaleficence

A

Not intentionally harm the patient

Do not harm

62
Q

Justice

A

Treat the patient fairly

63
Q

DNR Status

A

Suspension - full or partial

No suspension

64
Q

DNR Status

A

Suspension - full or partial

No suspension

65
Q

Nutritional Status

A

25% malnutrition
- Associated w/ adverse health outcomes
- Postop complications
ETOH check vitamin B12 & folate levels

↓intake d/t taste loss & ↓appetite
↓lean body mass
Slower protein turnover

Severe nutritional risk:
> 10-15% weight loss over 6mos
BMI < 18.5kg/m^2
Serum albumin < 3g/dL

66
Q

Functional Status

A 
Poor functional status = surgical site infection & postop complications risk factor
25% > 65yo have impaired ADLs
Up & go mobility test
Review ADLs
Assess hearing & vision
67
Q

Cognitive Status

A

Assess cognitive ability, decision-making capacity, & postop delirium risk
Dementia history
- Mini cog = 3 item recall & draw a clock
- Advanced directives or surrogate decision maker

68
Q

Beer’s Criteria

A

Drugs potentially harmful
AVOID:
- Metoclopramide (extrapyramidal effects)
- Meperidine
- NSAIDs (GI bleed)
- Transdermal Fentanyl → delirium & respiratory depression
- Agonist-antagonist opioids
- Methadone (long half-life → over-sedation or respiratory depression)

69
Q

What increases w/ number of medications?

A

Risk of adverse events

  • Assess current medications
  • Chronic benzodiazepine
  • OTC or herbal supplements

Anticholinergics associated w/ delirium & gait instability
Discontinue when possible

70
Q

Emergency Surgery

A

Trauma, falls, hip fracture, intracranial bleeding, intra-abdominal, or vascular
Assess acute heart failure, acute lung injury, dehydration
↑O2 requirements
Worse outcomes than elective surgery - unable to optimize or perform full preop work-up

71
Q

Intraop Management

A 
Regional anesthesia ↓DVT incidence
↓Anesthetic requirements
↓induction doses 25%
Avoid benzodiazepines
Skin breakdown & ulcerations risk - positioning considerations
Hypothermia risk
72
Q

Fluid & Blood Therapy

A

Do not tolerate hypovolemia or hypervolemia
Hypovolemia → hypotension & organ hypoperfusion
Hypervolemia → HTN & CHF
↑Hgb/Hct goals

73
Q

Postop Management

A

Postop delirium & POCD common after cardiac & non-cardiac surgery
15-55% hospitalized elderly patients

74
Q

Postop Delirium & POCD

A

Rapid decline in LOC - difficulty focusing, shifting, or sustaining attention
Incoherent speech, memory gaps, disorientation, hallucination not explained by pre-existing dementia or impairment
Possible inflammatory response d/t surgical stress
Haloperidol short-term to control symptoms

75
Q

POCD Risk Factors

A 
Genetic disposition
Lower education
↑ETOH intake or abuse
Elderly
ASA status
Pre-existing mild cognitive impairment
CVA history
Cardiac surgery
Surgery & anesthesia duration
Intraop cerebral desaturation
Postop infection
76
Q

Postop Complications

A

Cardiac, pulmonary, or neurologic

  • Emergency surgery
  • # comorbidities
  • Surgical procedure type
77
Q

Postop Pain Control

A

Acute procedural pain vs. chronic pain
Identify source or cause - distended bladder, incision, infection, inflammation, fracture, positioning, UTI, or constipation

78
Q

Periop Outcomes

A
  1. Surgical procedure risk
  2. Patient clinical risk factors
    ↑clinical risk factors ↑surgical procedure risk → overall poor outcomes risk
    ↑hospitalization
    $$$
    Elderly = worse outcomes
    ↑complication risk w/ CV surgery
    2-5x mortality cardiac & non-cardiac surgery
    Postop complication 60%
    Prolonged mechanical ventilation
    Atrial fibrillation more common
    Surgical wound infection
    Stroke 2x
    Neurocognitive dysfunction
    DELIRIUM COMMON AFTER MAJOR SURGERY
    Functional recovery Ø norm
    Patients commonly discharged to long-term rehab or nursing home
79
Q

What is the leading cause of morbidity?

A

Pulmonary insufficiency or infection

80
Q

KEY POINTS

A

Aging = progressive accumulation of random molecular defects
ALL major cells types in brain undergo structural changes (neuronal cell death, dendritic changes, synaptic loss) ↓brain mass ↑CSF
Blood vessels - stiff & thick + atherosclerosis
↑diastolic dysfunction w/ age (systolic dysfunction abnormal)
Closing volume approach Vt → atelectasis
Kidney susceptible to damage - unable to accommodate hemodynamic change or Na+/H2O imbalance
Frailty ↑susceptibility to disability
1. Procedures surgical risk
2. Number clinical risk factors
Delirium common after major surgery
↓anesthetic requirements

AS - N935 Advanced Patho II (20 decks)

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