Geriatrics and Anesthesia Flashcards
____ is less important as a stand-alone risk factor than actual comordities
Chronological age
Factors that influence perioperative outcomes in older adults include:
-Emergency surgery
-Number of baseline comorbidities
-Type of surgical procedure
Preoperative assessment of geriatric patients should include:
-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
Chronological age definition
Age in years since birth
Biological age definition
Functional status
T/F: Chronological age alone is a reliable indicator of M&M
FALSE. It is actually more functional status dependent than actual age number
Geriatrics are at higher risk of issues maintaining homeostasis under what conditions?
Stressful situations
-Includes surgery, trauma, disease states
____ ____ is especially important in geriatrics for maintaining appropriate ventricular filling due to CV changes.
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
Geriatric pts have a(n) ____ capacity to increase HR in response to HoTN, hypovolemia, and hypoxia.
Reduced capacity
-Decreased end-organ adrenergic receptors
Geriatric pts will have a ____ inhalation induction, and a ____ IV induction.
Faster inhalation
Slower IV
-Due to prolonged circulation time
Calcification of cardiac conduction system leads to:
-Increased risk of arrhythmias and heart blocks
-Increased risk of need for pacemaker
-Increased risk of valvular stenosis or regurgitation
CV changes we may see in geriatric patients include:
-Decreased venous return and arterial compliance
-Decreased CO and SV
-Increased PVR and cardiac work
-Decreased sensitivity of baroreceptors
____ ____ is the most common cardiac complication and leading cause of death in the postoperative period.
Myocardial infarction
Look at chart on slide 10 - good CV summary
YEEEEEEE HAWWWWWW YAAAAAWWWW
Some respiratory changes we should be aware of:
-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
T/F: Geriatric patients are at a higher risk of postoperative pulmonary complications.
TRUE. This is due to age + prevalence of co-existing disease.
-Atelactasis, bronchospasm, pneumonia, prolonged need for vent
Closing volume exceeds functional residual capacity at __ years old in the erect position and __ years old in the supine position.
65 in erect
45 in supine
-TLC maintains unchanged
-Decreased VC, IV, ERV, FVC and FVC1
-Increased RV, FRC
Look at chart on slide 14 - good pulm summary
Having fun so much fun
Geriatrics experience a ____ in GFR by 25-50%
Decrease
-Due to decreased renal mass (atrophy) and decreased renal blood flow
Renal blood flow drops ~___% per decade after 40.
~10%
-Older pts high risk fluid overload, drug build up if kidney clearance dependent, dehydration, electrolyte issues
T/F: Serum creatinine is unchanged in the geriatric patient without renal disease.
TRUE. Cr maintains due to decreased Cr production from overall declining skeletal muscle
-Cr clearance is the best indicator of drug clearance*
The aging adult liver decreases in mass by ~__-__%
~20-40% due to decreased blood flow
-Effects drug metabolism
Albumin concentration is ____ in elderly patients and is responsible for binding ____ drugs.
-Concentration decreases
-Binds acidic drugs (benzos, opioids)
Alpha1 acid glycoprotein concentration is ____ in elderly patients and is responsible for binding ____ drugs.
-Concentration increases
-Binds basic drugs (local anesthetics)
A ____ in the # and function of pancreatic islet beta cells seen in geriatrics causes a ____ insulin secretion.
-A decreased #/function
-Causes decreased insulin secretion
Also observe a peripheral insulin resistance often times
Geriatrics experience a ___ in overall basal metabolic rate.
Decrease
-Due to decreased physical activity and/or decreased testosterone and GH
___% of skeletal muscle mass is lost by the age of 80.
50%
-We also see a loss of body protein and alterations in carrier proteins
What change in the geriatric population causes a high risk of positioning injury?
Decrease in dermal and epidermal thickness of skin
-High risk of tears and nerve injury
Due to decreases in total body water, geriatrics are more vulnerable to ____ when undergoing position changes.
HoTN
-Total body water decreases 20-30% (mostly intracellular loss, but some ECF)
Geriatrics experience a prolonged ____ due to lower functioning of the hypothalamus.
Hypothermia
-Have a lower metabolic rate, high surface to body area mass, and less effective peripheral vasoconstriction in cold
Hypothermia causes what in the elderly patient in terms of anesthesia?
Slowed elimination, prolonged recovery, impaired coagulation, impaired immune function, increased shivering
-Shivering = increased O2 comsumption
Shivering in the elderly patient causes:
Increased O2 consumption –> hypoxia, acidosis, cardiac compromise
The production of less heat per kg causes:
-Inability to maintain temp in cool OR
-Difficulty restoring normal temp
What are some ways of maintaining normothermia for elderly pts?
-Warm IVF/blood
-Forced air warmer
-HME (environmental humidity >50%)
Progressive loss of neurons, decreased NT activity, decreased # of myelinated nerves, and decreased brain volume leads to changes where?
Most prominent in cerebral cortex and frontal lobe
-Changes mood, memory, motor function
The blood brain barrier of the geriatric patient is ____ permeable than in younger pts.
More permeable
-Increased sensitivity to drugs (lower dosing)
-Higher risk Alzheimer’s or delirium
The dose of induction agents should be ____ by as much as ____% in older patients.
Decreased by as much as 50%
___ monitoring may be beneficial in guiding titration of anesthesia in geriatrics.
BIS
-Decreased incidence of postop delirium and cognitive dysfunction
Anatomic changes can contribute to difficulty with ___ and ___ in these patients.
Sub arachnoid blocks and epidurals
Geriatrics can have a ____ spread of local anesthetic so we should ____ the dose.
Increased/enhanced spread so we should decrease dose
T/F: Regional anesthesia is contraindicated in the geriatric population.
FALSE
Four legally-relevant criteria to prove adequate decision making:
- Understanding treatment options
- Appreciates and acknowledges medical condition and likely outcomes
- Exhibits reasoning and engaging in a rational discussion of surgical treatment options
- Clearly choosing a preferred treatment option
Frailty increases risk of:
-Postoperative complications, longer hospital stays, discharge to skilled facility
Primary: intrinsic aging
Secondary: end-stage of chronic illness
Frailty can be assessed by:
Grip weakness, weight loss, walking speed, energy, decreases in activity
Severe nutritional risk described by:
- BMI <18.5
- Serum albumin <3g/dL
- Unintentional weight loss of >10-15% in last 6 months
-These are associated with higher postop complications
The current level of function is a predictor of ___-___ outcomes.
Long-term
-Need 4 METS to tolerate most surgeries
The most important surgical outcome in this pt population
Avoid functional decline and maintain independence (return to baseline w/o changes!)
MAC of inhalation agents ____ by ~6.7% per decade after 40yo.
Decrease
-All meds administered at lower dose!
_____ is the NMB of choice for older adults.
Cisatracurium
-Undergoes Hoffman elimination and ester hydrolysis - not organ dependent!
Propofol dosing
Decrease both bolus and infusion rates by 50%
(1-1.5 mg/kg for induction)
Etomidate dosing
Decrease bolus by 50%
Opioids dosing
Decrease bolus by 50%
Midazolam should be avoided, but if used decrease by 75%
NDMB dosing
-No changes on intubation dose
-Maintenance based on twitch response
DNMB dosing
No adjustment
Patient’s right to self-determination
(informed consent, advance directives)
Autonomy
Obligation to help the patient - “do good”
Beneficence
To not intentionally harm the patient - “do no harm”
Nonmaleficence
Treat the patient fairly
Justice
A major neurocognitive disorder characterized by memory change or decline in language, memory, other cognitive skills effecting every day activites.
Dementia
Subtypes of dementia
-Alzheimer’s (60-80%)
-Vascular dementia (10-20%)
-Parkinson’s w dementia (5%)
-Reversible dementia
Alzheimer’s disease
Most common dementia subtype
-Slowly progressive brain disease with beta-amyloid protein deposits, intracellular neurofibrillary tangles, loss of neurons
Vascular dementia
Risk: HTN and DM
-Commonly alongsisde Alzheimer’s
-Location, #, size of infarcts directly correlate to degree of functional decline
Parkinson’s disease
Progressive degenerative disorder of basal ganglia with deficiency in dopamine
Reversible dementia
Caused by meds, alcohol, metabolic disorders, depression, neoplasms
The use of ____, ____, and ____ are associated with delirium and should be avoided.
Benzos, anticholinergics, and antihistamines
T/F: Regional anesthesia is contraindicated in these pts.
FALSE. There is debate on whether it causes delirium, but it is useful in high postop pain pts
____ ____ and ____ ____ ____ are the most frequent neurologic phenomena in older adults.
Postoperative delirium and postoperative cognitive dysfunction
The biggest risk factor of postoperative delirium is:
Age >65
Depression associated with:
- Postoperative delirium
- Increased risk of cardiac event and death
-Continue antidepressants perioperatively
What is different about the presentation of POCD versus POD?
POCD will have a more subtle onset with symptoms not seen for weeks to months
Prevention of POCD:
-Prevent with good cerebral perfusion
-Short, minimally invasive procedures
-Multimodal pain management
