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Co-Exisiting Disease 2 > Geriatrics > Flashcards

Geriatrics Flashcards

1
Q

4 physiologic changes:

A
  1. Basal organ function unchanged
  2. Decreased functional reserve
  3. Decreased ability to compensate
  4. Hearing loss
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2
Q

Mechanism of aging for all organ systems:

A

Aging is associated with a loss of physiologic reserve that increases the vulnerability to disease
-decreases ability to compensate for stress

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3
Q

Risk of death double every what?

A

8.5 years

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4
Q

When one examines periop mortality, the risk of death also double with that?

A

Rough every additional decade of age

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5
Q

CV and autonomic aging makes BP inherently more unstable during anesthesia, primarily due to (3)

A
  1. Exaggerated responses to changes in ventricular filling
  2. Exaggerated responses to changes in sympathetic nervous system activity
  3. Impaired baroreflex control of BP owing to a decrease response to beta-receptor stimulation
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6
Q

Concomitant vascular disease may lead to what?

A

Organ hypoperfusion at BP that would be easily tolerate by a young, healthy adult

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7
Q

Baroreflex begins with high and low pressure baroreceptors that send info to where?

A

Medulla via vagus and glossopharyngeal nerves

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8
Q

The most prominent defect of the baroreflex in elderly subjects is the failure to mount as vigorous of what?

A

Cardiac response

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9
Q

Why is there a failure in cardiac response?

A

Decrease in beta-receptor responsiveness

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10
Q

The change in sympathetic nervous system activity that accompanies a change in BP is actually enhanced or declined with age?

A

Enhanced

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11
Q

Alpha receptor, vasoactive component of the baroreflex is effective or not effective?

A

Just as effective as in young adults, if not more so

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12
Q

Most prominent and consequential changes for CV are: (3)

A
  1. Decrease in response to beta-receptor stimulation
  2. Stiffening of the connective tissue in arteries, veins, and heart
  3. Increase in activity of the sympathetic nervous system
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13
Q

Less important changes of CV include: (2)

A
  1. Gradual myocyte death without replacement

2. Diminished response to atropine

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14
Q

Systolic HTN include: (3)

A
  1. Loss of elasticity in the arterial tree
  2. Ventricles that contract with good strength by more slowly than young hearts
  3. Poor tolerance of hypovolemia
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15
Q

What are the 3 diminished chronotropic and inotropic response to anything that involves beta-receptor stimulation?

A
  1. Exercise
  2. Exogenous catecholamine administration
  3. Baroreflex
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16
Q

L ventricular hypertrophy is due to?

A

Increased impedance to ejection of SV

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17
Q

Coronary artery disease with people > than what age have a what % chance of developing significant CAD?

A

70 years

50%

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18
Q

Decreased max HR attainable due to what 2 things?

A
  1. “Beta-blockade” that occurs with aging

2. Fibrosis/atrophy of the conducting system that occurs

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19
Q

Cardiac reserve is maintained by what?

A

Frank starling mechanism

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20
Q

CO increased by an enhance SV resulting from an increase of what?

A

End diastolic volume

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21
Q

Induction times of IV agents and inhaled agents?

A

IV agents: delayed

Inhaled agents: shorter onset

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22
Q

Frank starling mechanism is a dependence on a catecholamine mediated increase in what 2 things?

A

HR and inotrophy

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23
Q

Sarcomere stretch enhances the sensitivity of the contractile proteins to calcium, thereby increasing the strength of contraction

A

Frank starling mechanism

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24
Q

Ventricle response less effectively to what?

A

Beta receptor stimulation

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25
Q

Since ventricles response less effectively to beta receptor stimulation, then the ventricle must depend almost solely on what?

A

Frank starling mechanism

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26
Q

90% of 80 year old patients have what heart issue?

A

Regurgitation

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27
Q

Pacemaker cell reduced by 90% at what age?

A

70

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28
Q

What specific dysrhythmias increases with age?

A

Afib

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29
Q

Ability for old heart to withstand stress is significantly increased or decreased?

A

Decreased

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30
Q

Max body oxygen consumption is the product fo what 3 things?

A
  1. CO
  2. Oxygen carrying capacity of the blood
  3. Ability of the body to extract oxygen from the blood
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31
Q

With age, max oxygen consumption decreases at approximately how much per decade? And decline steepens after what age?

A

10%; 60

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32
Q

Decrease in max CO is the primary contributor to the decline owing to the decrease in what?

A

Max HR

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33
Q

Rule of thumb for max HR?

A

220 - age

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34
Q

There is a moderate decrease in resting what with age?

A

SV

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35
Q

Do hemoglobin levels decrease with age?

A

No

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36
Q

Ventricles must overcome what in order to eject blood?

A

Aortic pressure

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37
Q

The strength of a given contraction is largely determine when during a contraction?

A

Beginning

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38
Q

If most of the effort of the contraction is used up just to overcome aortic pressure, what does the SV look like?

A

Very little

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39
Q

The ventricle must increase its contractile effort and will do so by what 2 things?

A
  1. Increasing contractility
  2. Increasing end-diastolic volume to increase the sarcomere stretch (Frank-Starling curve or length-tension relationship)
    OR BOTH
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40
Q

The inability to increase contractility as easily as in a young heart makes the elderly heart more dependent on what?

A

Ventricular filling

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41
Q

One can expect the elderly heart to be less tolerant to what?

A

Hypovolemia

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42
Q

Elderly patients have decline in what 2 things at peak exercise?

A

SV and HR

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43
Q

Inability of these individuals to augment stroke volume is caused by: (4)

A
  1. Decrease in the ability of the heart to increase diastolic filling
  2. Decrease in systolic pump function caused by an increased afterload
  3. Intrinsic myocardial contractile defects
  4. Greater diminution of the cardiovascular response to beta-adrenergic stimuli
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44
Q

During exercise, mixed venous oxygen levels increase or decrease and why?

A

decrease dramatically, mostly because exercising muscle is capable of extracting as much as 90% of the delivered oxygen

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45
Q

Training improves maximal body oxygen consumption to the same or less degree in young and old and what does it improve?

A

Same; increase in LVED volume

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46
Q

Elderly women improve their oxygen consumption primarily by what?

A

increasing oxygen extraction

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47
Q

Two mechanisms cause this increase in systolic blood pressure (systolic HTN):

A
  1. Stiffening of the arteries typically leading to systolic hypertension
  2. The speed of transmission of the pressure wave
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48
Q

Approximately half of the stroke volume still remains where?

A

thoracic aorta at the end of ejection

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49
Q

a stiffened thoracic aorta will develop a higher or lower pressure with the increase in volume in comparison to a softer, more balloon-like aorta?

A

Higher

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50
Q

In the elderly, the pressure wave travels faster or slower through a stiff artery than a pliable artery

A

Faster

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51
Q

The wave pressure wave returns to the heart when?

A

Latter part of the ejection rather than diastole

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52
Q

The increased pressure in late ejection places a strain where?

A

LV

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53
Q

strength of the contraction does what during ejection progresses?

A

Decreases

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54
Q

In the elderly, the returning wave increases pressure when and what does that cause the heart to do?

A

Late in ejection so the heart must work harder to eject

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55
Q

Heart strain stimulates what?

A

Muscle growth

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56
Q

The systolic hypertension, particularly the late systolic hypertension, causes what?

A

Ventricular hypertrophy

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57
Q

The veins contain at least what % of the body’s blood?

A

75%

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58
Q

responsible for maintaining a relatively constant central blood volume (lungs and heart) despite changes in posture or changes in blood volume

A

Veins

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59
Q

If there is inadequate blood volume in the veins, venous pressure does what?

A

drops significantly in stiff veins and there is inadequate venous pressure to support atrial filling

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60
Q

elderly heart become more dependent on what?

A

Atrial filling

61
Q

Is the CV system Abel to maintain atrial filling?

A

Less able to

62
Q

plasma epi/norepi levels?

A

2-4 times higher

63
Q

Increased plasma epi/norepi levels reflects a what?

A

Decrease in autonomic end-organ responsiveness

  • loss of receptor sites and/or a reduced receptor sensitivity.
  • “Endogenous beta-blockade of aging“**
64
Q

chrono/inotropic response

65
Q

Baroreceptor responsiveness?

A

reduced

-less tachycardia in response to hypotension or acute hemodilution.

66
Q

Anesthetics increase or decrease sympathetic tone

67
Q

Response to Atropine?

68
Q

Does age compromise the response to acetylcholine at the muscarinic receptors?

69
Q

Why is there a decrease in response to atropine?

A

Appears that vagal outflow decreases with age, providing less vagal stimulation to be removed by the atropine
-supported by the decrease in heart rate variability with respiration in the elderly

70
Q

Changes in vagal activity are solely responsible for the effects of?

A

Respiration on HR

71
Q

Lung volumes reduce (3)

A

VC
TLC
Max breathing capacity

72
Q

Lung volumes increase (2)

73
Q

Parenchymal changes of the lung mimic?

74
Q

Loss of functional alveoli with age reduces?

A

Elastic recoil

75
Q

Closing volume increases (2)

A
  1. small airway collapse at greater lung volumes

2. air trapping and V/Q mismatch.

76
Q

PaO2 incline or decline with age?

77
Q

PaO2 equation?

A

102 - (.5 x age)

78
Q

Decreased ventilatory response to (2)?

A

Hypoxia and hypercarbia

79
Q

Brain mass incline or decline with age?

80
Q

Gray or white matter is greater?

81
Q

Brain mass decline causes what compensatory response? (2)

A
  1. increase in CSF volume, (a form of low-pressure hydrocephalus)
  2. reduction in cerebral blood flow
82
Q

Brain atrophy causes how many loss of neurons per day?

83
Q

What remains intact with central nervous system? (2)

A

CBF and CMRO2

84
Q

Autoregulation of CBF (the response of cerebral vasculature to changes in BP) and the cerebral vasoconstrictive response to hyperventilation change?

A

No, stay intact

85
Q

Body composition:

Skeletal muscle, body fat, intracellular hydration, plasma volume, protein binding?

A 
Loss of skeletal muscle (lean body mass)
Increase in % of body fat
Intracellular dehydration
Reduced plasma volume 
Reduced protein binding
86
Q

Increase in % of body fat specifics (3)

A
  1. greater reservoir for lipid-soluble drugs
  2. slower elimination time
  3. prolonged anesthetic effects
87
Q

Since there is a decrease in albumin, more or less available to cross BBB and produce effect due to reduced binding effectiveness of available proteins?

88
Q

Aging has little effect on circulating what? (3)

A

RCM, WBC count, number/function of platelets

89
Q

Renal tissue atrophy due to?

A

Loss of glomeruli (50% by age 80) and replaced with fibrosis and fatty tissue

90
Q

GFR and RBF?

A

GFR: decrease 1ml/min/yr or 1-1.5%/year
RBF: decrease 1%/year after age 30 (cortex>medulla)

91
Q

Creatinine clearance and serum Cr levels?

A

Creatinine clearance: decline

Serum Cr: remain normal

92
Q

Absorption for glucose?

93
Q

Urine output during and after major surgery?

94
Q

What does alpha agonists do to BF to kidneys and urine output?

95
Q

What does vasopressin do to BF to kidneys and urine output?

96
Q

What is responsible for a very high percentage of periop mortality in elderly surgical pts?

97
Q

It’s important to maintain UO of what?

98
Q

Hepatic size and BF?

A

Size decreases and proportionally decreases with BF (40-50% by age 80)

99
Q

Enzyme concentration and function of liver?

A

Maintained

100
Q

Hepatic clearance of drugs and duration of effect?

A

Decreased clearance and longer duration

101
Q

DMR decreases at what rate?

A

1% per ear after 30

102
Q

What is more common intraop?

A

Hypothermia

103
Q

Post op shiver?

A

Increase; O2 consumption up to 400-500% and may precipitate hypoxemia or myocardial ischemia

104
Q

What can hypothermia do with anesthetic elimination and awakening?

A

Reduce elimination and prolong awakening

105
Q

Airway reflexes are less effective and can cause what more likely?

A

Aspiration

106
Q

Glucose and insulin effects?

A

Glucose: intolerance
Insulin: resistance

107
Q

Is there a difference with NDMR dosing?

108
Q

What can you see with NDMR dosing?

A

Longer duration and slower onset

109
Q

Arthritic changes with airway (4)

A
  1. Decrease cervical spine and neck mobility
  2. Smaller mouth opening
  3. Smaller glottic opening (smaller ETT)
  4. Fragile teeth
110
Q

Are they prone to airway collapse?

111
Q

Blood oxygen levels?

112
Q

After leaving PACU, hypoxia more likely and what is the equation?

A

PaO2=102 - (0.5 x age)

113
Q

Less or greater need for supplemental oxygen?

114
Q

Poor tethering of airways permits what?

A

Atelectasis; increasing risk of hypoxia and pneumonia

115
Q

Chest wall does what with age?

A

Stiffens; more effort to expand chest, increase work of breathing

116
Q

Increased V/Q mismatch of aging is usually overcome by what?

A

Supplemental oxygen

117
Q

Risk of what is higher?

118
Q

MAC decreases what with age?

A

4% for each decade over age 40

119
Q

Lipid soluble anesthetic drugs (barbiturates, benzos, opioids, etomidate) has what 4 effects?

A
  1. Increase plasmas concentration
  2. Induction dose less
  3. Longer duration of effect
  4. Delayed onset of action
120
Q

Diazepam’s beta elimination half life in hours is equal to what?

A

Pts age in years

121
Q

Midazolam’s half life is what?

122
Q

What causes increase sensitivity to LA?

A

Decreased neuronal population, neural conduction velocity, interschwann cell distance

123
Q

CO effect with SAB/epidural?

A

Decrease, but only by 10%

124
Q

What is the decrease in SV way less than the decrease in EDV with SAB/epidural?

A

Because EF increased

125
Q

The decrease in BP from SAB/epidural is most likely because?

A

Hypovolemia

126
Q

With respect to BP lability, what may confer some degree of stability by eliminating the surgical stimulation as a source of variation in sympathetic tone?

A

Spinal or epidural over GA

127
Q

Healthy elderly demonstrated how much decrease in vascular resistance during approximate T6 spinal anesthesia?

128
Q

4 facts about midazolam

A
  1. Increased potency
  2. Reduced clearance
  3. Half life twice as long (1.8-6.4; about 3 hrs)
  4. Decrease dose up to 75%
129
Q

6 facts about propofol? (Clearance, Vd, blood concentration, sensitivity, hemodynamic, dosage)

A
  1. Clearance decreased
  2. Volume of distribution unchanged
  3. Blood concentration increase and decrease more rapidly
  4. Increased sensitivity
  5. More dramatic effect on hemodynamic
  6. Only fraction of usual dose
130
Q

> 55 yrs dosage of propofol:

A

Reduce by 20-30%
Sedation: .3-.6mg/kg
Continuous: .9-2.7mg/kg

131
Q

Blood concentration of propofol is associated with what SBP?

132
Q

3 facts about ketamine?

A
  1. Decrease in clearance
  2. Duration of action extended
  3. Variable psychotic side effects
133
Q

Epidural ketamine or epidural morphine?

A

Less sedation and smaller risk of PONV, but need more analgesia

134
Q

Increased mortality percentage with ASA 2, 3, 4?

A

2: <10%
3: 10-15%
4: >20%

135
Q

What before surgery may help prevent preop dehydration in outpatients?

A

Clear liquids 2 hrs prior

136
Q

Why is it more difficult to keep up with fluid overload?

A

Kidneys eliminate both excess salt and water less rapidly

137
Q

What is used more frequently and are almost risk free if used short term?

138
Q

What provide less accurate information about volume status than either systolic pressure variation or trans esophageal echocardiography?

139
Q

Unless volume deficits is truly profound, the most likely cause of hypotension is probably why?

A

Decrease in SVR brought by decreased sympathetic outflow

140
Q

If problem is low SVR, then what should be given?

A

Alpha agonists (phenylephrine)

141
Q

Repetitive bonuses of what may become tiresome and ineffective to treat hypotension?

142
Q

State of vulnerability to internal and external stressors that increases the risk for negative outcomes…due to decline and deterioration of cellular, tissue, and organ properties

143
Q

Frailty is an indicator of what 2 things?

A
  1. Biological aging

2. Predictor of poor outcomes in aging

144
Q

What age do pts get the FRAIL questionnaire and the scores are associated with what?

A

> 65 years

2 years

145
Q

What does FRAIL stand for?

A

F: fatigue
R: resistance; unable to walk 1 flight of stairs
A: ambulation; unable to walk 1 block
I: illnesses; more than 5 illnesses
L: loss of wt; lost more then 5% in 6mths

146
Q

What is the underlying mechanism to postop cognitive decline?

A

Inflammation

147
Q

How to decrease inflammation? (2)

A

Steroids

NSAID (ofirmev)

148
Q

Ofirmev: dose every 4 hrs, 6hrs, max single, max daily

A

4 hrs: 650mg
6hrs: 1000mg
Single: 1000mg
Daily: 4000mg

149
Q

Ofirmev should be administered only as a how long infusion?

Co-Exisiting Disease 2 (11 decks)

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