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Anesthesia Principles 1 > Geriatrics and Anesthesia > Flashcards

Geriatrics and Anesthesia Flashcards

1
Q

____ is less important as a stand-alone risk factor than actual comordities

A

Chronological age

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2
Q

Factors that influence perioperative outcomes in older adults include:

A

-Emergency surgery
-Number of baseline comorbidities
-Type of surgical procedure

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3
Q

Preoperative assessment of geriatric patients should include:

A

-Cognitive ability
-Decision making ability (Understand, appreciate, reason, make a choice)
-History of depression
-Postop delirium risk?
-Alcohol or substance abuse?
-Follow AHA algorithm for cardiopulmonary guidelines
-Frailty
-Nutritional / functional status
-Meds
-Support + advance directives

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4
Q

Chronological age definition

A

Age in years since birth

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5
Q

Biological age definition

A

Functional status

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6
Q

T/F: Chronological age alone is a reliable indicator of M&M

A

FALSE. It is actually more functional status dependent than actual age number

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7
Q

Geriatrics are at higher risk of issues maintaining homeostasis under what conditions?

A

Stressful situations
-Includes surgery, trauma, disease states

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8
Q

____ ____ is especially important in geriatrics for maintaining appropriate ventricular filling due to CV changes.

A

Atrial kick/contraction
-Geriatrics have increased afterload and SBP leading to thickening of ventricle and prolonged ejection time
-Ventricular hypertrophy + slower myocardial relaxation makes atrial contraction important in ventricular filling

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9
Q

Geriatric pts have a(n) ____ capacity to increase HR in response to HoTN, hypovolemia, and hypoxia.

A

Reduced capacity
-Decreased end-organ adrenergic receptors

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10
Q

Geriatric pts will have a ____ inhalation induction, and a ____ IV induction.

A

Faster inhalation
Slower IV
-Due to prolonged circulation time

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11
Q

Calcification of cardiac conduction system leads to:

A

-Increased risk of arrhythmias and heart blocks
-Increased risk of need for pacemaker
-Increased risk of valvular stenosis or regurgitation

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12
Q

CV changes we may see in geriatric patients include:

A

-Decreased venous return and arterial compliance
-Decreased CO and SV
-Increased PVR and cardiac work
-Decreased sensitivity of baroreceptors

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13
Q

____ ____ is the most common cardiac complication and leading cause of death in the postoperative period.

A

Myocardial infarction

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14
Q

Look at chart on slide 10 - good CV summary

A

YEEEEEEE HAWWWWWW YAAAAAWWWW

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15
Q

Some respiratory changes we should be aware of:

A

-Loss of elastic recoil causing V/Q mismatching
-Decreased ventilatory response to hypoxemia and hypercarbia which increases apnea episodes
-Decrease in laryngeal/pharyngeal support and protective reflexes ASPIRATION

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16
Q

T/F: Geriatric patients are at a higher risk of postoperative pulmonary complications.

A

TRUE. This is due to age + prevalence of co-existing disease.
-Atelactasis, bronchospasm, pneumonia, prolonged need for vent

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17
Q

Closing volume exceeds functional residual capacity at __ years old in the erect position and __ years old in the supine position.

A

65 in erect
45 in supine
-TLC maintains unchanged
-Decreased VC, IV, ERV, FVC and FVC1
-Increased RV, FRC

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18
Q

Look at chart on slide 14 - good pulm summary

A

Having fun so much fun

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19
Q

Geriatrics experience a ____ in GFR by 25-50%

A

Decrease
-Due to decreased renal mass (atrophy) and decreased renal blood flow

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20
Q

Renal blood flow drops ~___% per decade after 40.

A

~10%
-Older pts high risk fluid overload, drug build up if kidney clearance dependent, dehydration, electrolyte issues

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21
Q

T/F: Serum creatinine is unchanged in the geriatric patient without renal disease.

A

TRUE. Cr maintains due to decreased Cr production from overall declining skeletal muscle
-Cr clearance is the best indicator of drug clearance*

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22
Q

The aging adult liver decreases in mass by ~__-__%

A

~20-40% due to decreased blood flow
-Effects drug metabolism

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23
Q

Albumin concentration is ____ in elderly patients and is responsible for binding ____ drugs.

A

-Concentration decreases
-Binds acidic drugs (benzos, opioids)

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24
Q

Alpha1 acid glycoprotein concentration is ____ in elderly patients and is responsible for binding ____ drugs.

A

-Concentration increases
-Binds basic drugs (local anesthetics)

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25
Q

A ____ in the # and function of pancreatic islet beta cells seen in geriatrics causes a ____ insulin secretion.

A

-A decreased #/function
-Causes decreased insulin secretion

Also observe a peripheral insulin resistance often times

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26
Q

Geriatrics experience a ___ in overall basal metabolic rate.

A

Decrease
-Due to decreased physical activity and/or decreased testosterone and GH

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27
Q

___% of skeletal muscle mass is lost by the age of 80.

A

50%
-We also see a loss of body protein and alterations in carrier proteins

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28
Q

What change in the geriatric population causes a high risk of positioning injury?

A

Decrease in dermal and epidermal thickness of skin
-High risk of tears and nerve injury

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29
Q

Due to decreases in total body water, geriatrics are more vulnerable to ____ when undergoing position changes.

A

HoTN
-Total body water decreases 20-30% (mostly intracellular loss, but some ECF)

30
Q

Geriatrics experience a prolonged ____ due to lower functioning of the hypothalamus.

A

Hypothermia
-Have a lower metabolic rate, high surface to body area mass, and less effective peripheral vasoconstriction in cold

31
Q

Hypothermia causes what in the elderly patient in terms of anesthesia?

A

Slowed elimination, prolonged recovery, impaired coagulation, impaired immune function, increased shivering
-Shivering = increased O2 comsumption

32
Q

Shivering in the elderly patient causes:

A

Increased O2 consumption –> hypoxia, acidosis, cardiac compromise

33
Q

The production of less heat per kg causes:

A

-Inability to maintain temp in cool OR
-Difficulty restoring normal temp

34
Q

What are some ways of maintaining normothermia for elderly pts?

A

-Warm IVF/blood
-Forced air warmer
-HME (environmental humidity >50%)

35
Q

Progressive loss of neurons, decreased NT activity, decreased # of myelinated nerves, and decreased brain volume leads to changes where?

A

Most prominent in cerebral cortex and frontal lobe
-Changes mood, memory, motor function

36
Q

The blood brain barrier of the geriatric patient is ____ permeable than in younger pts.

A

More permeable
-Increased sensitivity to drugs (lower dosing)
-Higher risk Alzheimer’s or delirium

37
Q

The dose of induction agents should be ____ by as much as ____% in older patients.

A

Decreased by as much as 50%

38
Q

___ monitoring may be beneficial in guiding titration of anesthesia in geriatrics.

A

BIS
-Decreased incidence of postop delirium and cognitive dysfunction

39
Q

Anatomic changes can contribute to difficulty with ___ and ___ in these patients.

A

Sub arachnoid blocks and epidurals

40
Q

Geriatrics can have a ____ spread of local anesthetic so we should ____ the dose.

A

Increased/enhanced spread so we should decrease dose

41
Q

T/F: Regional anesthesia is contraindicated in the geriatric population.

A

FALSE

42
Q

Four legally-relevant criteria to prove adequate decision making:

A
  1. Understanding treatment options
  2. Appreciates and acknowledges medical condition and likely outcomes
  3. Exhibits reasoning and engaging in a rational discussion of surgical treatment options
  4. Clearly choosing a preferred treatment option
43
Q

Frailty increases risk of:

A

-Postoperative complications, longer hospital stays, discharge to skilled facility

Primary: intrinsic aging
Secondary: end-stage of chronic illness

44
Q

Frailty can be assessed by:

A

Grip weakness, weight loss, walking speed, energy, decreases in activity

45
Q

Severe nutritional risk described by:

A
  1. BMI <18.5
  2. Serum albumin <3g/dL
  3. Unintentional weight loss of >10-15% in last 6 months

-These are associated with higher postop complications

46
Q

The current level of function is a predictor of ___-___ outcomes.

A

Long-term
-Need 4 METS to tolerate most surgeries

47
Q

The most important surgical outcome in this pt population

A

Avoid functional decline and maintain independence (return to baseline w/o changes!)

48
Q

MAC of inhalation agents ____ by ~6.7% per decade after 40yo.

A

Decrease
-All meds administered at lower dose!

49
Q

_____ is the NMB of choice for older adults.

A

Cisatracurium
-Undergoes Hoffman elimination and ester hydrolysis - not organ dependent!

50
Q

Propofol dosing

A

Decrease both bolus and infusion rates by 50%
(1-1.5 mg/kg for induction)

51
Q

Etomidate dosing

A

Decrease bolus by 50%

52
Q

Opioids dosing

A

Decrease bolus by 50%
Midazolam should be avoided, but if used decrease by 75%

53
Q

NDMB dosing

A

-No changes on intubation dose
-Maintenance based on twitch response

54
Q

DNMB dosing

A

No adjustment

55
Q

Patient’s right to self-determination
(informed consent, advance directives)

A

Autonomy

56
Q

Obligation to help the patient - “do good”

A

Beneficence

57
Q

To not intentionally harm the patient - “do no harm”

A

Nonmaleficence

58
Q

Treat the patient fairly

A

Justice

59
Q

A major neurocognitive disorder characterized by memory change or decline in language, memory, other cognitive skills effecting every day activites.

A

Dementia

60
Q

Subtypes of dementia

A

-Alzheimer’s (60-80%)
-Vascular dementia (10-20%)
-Parkinson’s w dementia (5%)
-Reversible dementia

61
Q

Alzheimer’s disease

A

Most common dementia subtype
-Slowly progressive brain disease with beta-amyloid protein deposits, intracellular neurofibrillary tangles, loss of neurons

62
Q

Vascular dementia

A

Risk: HTN and DM
-Commonly alongsisde Alzheimer’s
-Location, #, size of infarcts directly correlate to degree of functional decline

63
Q

Parkinson’s disease

A

Progressive degenerative disorder of basal ganglia with deficiency in dopamine

64
Q

Reversible dementia

A

Caused by meds, alcohol, metabolic disorders, depression, neoplasms

65
Q

The use of ____, ____, and ____ are associated with delirium and should be avoided.

A

Benzos, anticholinergics, and antihistamines

66
Q

T/F: Regional anesthesia is contraindicated in these pts.

A

FALSE. There is debate on whether it causes delirium, but it is useful in high postop pain pts

67
Q

____ ____ and ____ ____ ____ are the most frequent neurologic phenomena in older adults.

A

Postoperative delirium and postoperative cognitive dysfunction

68
Q

The biggest risk factor of postoperative delirium is:

A

Age >65

69
Q

Depression associated with:

A
  1. Postoperative delirium
  2. Increased risk of cardiac event and death
    -Continue antidepressants perioperatively
70
Q

What is different about the presentation of POCD versus POD?

A

POCD will have a more subtle onset with symptoms not seen for weeks to months

71
Q

Prevention of POCD:

A

-Prevent with good cerebral perfusion
-Short, minimally invasive procedures
-Multimodal pain management

Anesthesia Principles 1 (7 decks)

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