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N931 Advanced Principles > Geriatrics- Modified Verison > Flashcards

Geriatrics- Modified Verison Flashcards

1
Q

What are CNS changes seen in the geriatric population?

A 
Decreased mylineation
Increased BBB permeability
Decreased cholinergic signaling
decreased alpha 2 agonist receptors
increased cognitive and post operative delirium
Increased sensitivity to metabolic stress
decreased cerebral blood flow
decreased cerebral rate
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2
Q

What are cardiovascular changes in the geriatric population

A

Decreased tissue elasticity/ less compliant heart
Increased afterload
Systolic HTN
LVH develops from ventricular vascular coupling, making myocardium prone to ischemia (increase in LVEDP)
Diastolic dysfunction

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3
Q

Summary of geriatric cardiovascular changes (structure of heart)

A

decrease in peak HR, CO, EF
dampening of autonomic and baroreceptor activity
slower resting heart rate
decreased ability to increase cardiac output by changes in heart rate
increase in CO d/t increase in EDV rather than HR (increase reliance on atrial contraction for CO)
decreased ability to withstand stress
increase in ventricular septal thickness, aortic and mitral valve leaflets
increase in LA size
increase in aortic stiffening and stenosis

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4
Q

Why does heart failure incidence increase with geriatrics?

A

ratio of beta 1 to beta 2 receptors change which causes impact on adrenergic agonist/ blockers impact ventricular function

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5
Q

Summary of geriatric cardiovascular changes (electrical conduction of heart)

A 
calcification of conduction system
prolongation of PR, QRS and QT intervals
more likely to have dysrhythmias
resting HR slows
decrease in maximum HR
decreased HR variability
increased likely to have pacemakers and AICD
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6
Q

Conclusion of geriatric cardiovascular changes (table)

A

myocardial hypertrophy, myocardial stiffening, reduced LV relaxation, reduced beta responsiveness, conduction system abnormalities, stiff arteries, stiff veins

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7
Q

Anesthetic implications of geriatric cardiovascular changes

A

decreased end-organ adrenergic responsiveness
prolonged circulation time
HTN peri-operative risk factor
decreased sensitivity to baroreceptors in aortic arch and carotid sinuses in response to BP changes
prolonged systolic phase of cardiac cycle
decreased sensitivity to beta- adrenergic modulation
decreased CO and SV

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8
Q

what is the most common complication and leading cause of death in Post-op period?

A

myocardial infarction

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9
Q

How does decreased end-organ adrenergic responsiveness manifest?

A

reduced capacity to increase heart rate in response to hypotension, hypovolemia, and hypoxia

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10
Q

What does increased circulation time mean for anesthesia anesthetics?

A

faster induction time with inhalation agents

delayed onset of IV drugs

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11
Q

How does decreased CO and SV manifest?

A

decreased conduction velocity and reduction in venous blood flow

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12
Q

What cell types in the brain undergo structural changes with aging?

A

ALL

neuronal death, glial cell reactivity, synaptic loss

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13
Q

What reduces in the CNS?

A

neuronal regenerative capacity
neural plasticity
decrease in nerve conduction velocity

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14
Q

What CNS function declines with age and what does not?

A

intellectual functioning, attention, memory and psychmotor function decline with age
language and executive function remain intact

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15
Q

What are mechanical respiratory changes seen in elderly?

A

decrease in elasticity changes respiratory mechanics and alveolar architecture
chest wall stiffer
lung tissue looses intrinsic elastic recoil
chest wall compliance and vital capacity decrease
lung compliance, work of breathing and residual volume increase
Total lung capacity stays the same
decrease in expiratory flows
decreased endurance of respiratory muscles

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16
Q

What are changes in gas exchange for geriatric patients?

A

decrease in functional alveolar surface area for gas exchange
reduction of arterial oxygen tension with age
PaO2 decreases at rate of 0.35mmHg per year
increase in V/Q mismatch
increase in intrapulmonary shunting
reduced elastic tissue in lung
emphysematous changes in lung
increased tendency for airways to close
Closing volume >FRC
residual volume increases

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17
Q

Overall, what defines gas exchanges changes in the elder lung?

A

reduced oxygen exchange at alveolar level
more prone to respiratory failure
more prone to ateletasis

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18
Q

What are changes in the respiratory sensing of geriatrics?

A

attenuated protected cough mechanisms
reduced respiratory drive in response to hypoxia, hypercarbia and resistive load
increased airways reactivity

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19
Q

What does the changes in a geriatric coughing mechanism place them at risk for?

A

aspiration

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20
Q

In summary, structural changes of pulmonary system

A 
chest wall
stiff/decreased compliance
flattened diaphragm
lung parenchyma
increased lung compliance
increased small airway closure
muscle stretch
control of breathing
decreased central/peripheral chemoreceptor sensitivity
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21
Q

IN summary, what are anesthetic implications of geriatric respiratory symptoms?

A

risk for respiratory failure
careful use of NMDRs, opioids, benzos
avoid high pressure/ large TV
consider alveolar recruitment manuevers (PEEP)
limit high inspired O2
maintain PaCo2 near normal preoperative value
consider regional/ local with sedation
risk for aspiration
adequate hydration
RSI with GA
ensure fully reversed prior to extubation
consider post-operative CPAP/Bipap
vigilant monitoring
encourage cough/deep breathing/postoperatively
supplemental oxygen post-operatively

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22
Q

Renal changes in the elderly

A

decreased renal function
atrophy of kidney parenchymal tissue
deterioration of renal vascular structures
decreased renal BF
decreased renal mass
reduced clearance of hypdrophilic agents and hydrophilic metabolites

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23
Q

What the five changes in the renal system in the eldery?

A 
renal vascular dysautonomy
senile hypofiltration
tubular dysfunction
medullary hypotonicity
tubular frality
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24
Q

What is renal vascular dysautonomy?

A

attenuated autonomic renal vascular reflexes that protect from hypo/hypersensitive effects

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25
What is senile hypofiltration?
decline in GFR
26
What is tubular dysfunction
reduced ability to absorb and secrete solutes (especially sodium)
27
What is medullary hypotonicity?
reduced ADH effect and reduction in water reabsorbed | -unable to maximally concentrate or dilute urine
28
What is tubular frality?
more susceptible to hypoxic or nephrotoxic injury
29
What decrease GFR cause?
decrease in drug clearance and decreased renal blood flow
30
Why can't an aged kidney handle salt/water imbalances?
impairment of sodium conservation (tubular dysfunction) | decreased renin and aldosterone production
31
What does the renal system make the elderly more prone too?
decreased GFR causes inability to excrete free water = | fluid overload, pulmonary edema and hypoosmolar states (watch hypo-osmolar fluid administration)
32
What is the best indicator of drug clearance?
creatinine clearance
33
A patient with renal impairment is at an increased risk for?
``` fluid overload accumulation of metabolites and drugs decrease drug elimination prolonged effects of anesthetic drugs and adjuncts electrolyte imbalances arrhythmias ```
34
Describe hepatic function in the geriatric population
liver mass decreases 20-40% decreased blood flow decrease functional hepatic reserve in elderly decrease drug metabolism prolonged half-life increased/decreased distribution of medications
35
Describe drug metabolism changes of liver in geriatrics
phase 1 drug metabolism is variable | phase 2 drug metabolism is not significantly effected
36
In the liver, what proteins increase and what proteins decreased?
albumin decreases | alpha-1 acid glycoprotein increases
37
What does albumin bind to??
acidic drugs (benzo, opioids)
38
What does AAG bind to?
basic drugs (lidocaine)
39
What do protein binding changes requrie?
no changes in dosing as the effects are counteracted by clearance
40
Summarize the GI changes in geriatrics
decreased motility of oropharygneal/ upper esophageal area decreased colonic function decreased GI immunity decreased GI drug metabolism
41
Summarize Immune system changes in geriatrics
reduced bacterial activity of immune cells increased levels of cytokines and chemokines decreased T cell and B cell function reduced ability to fight infection and control cancers
42
Summarize endocrine system changes in geriatrics
``` endocrine glands atrophy reduced hormone production impaired endocrine function impaired glucose homeostasis deficiencies of insulin, thyroxine, GH, renin, aldosterone and testosterone resting metabolic rate decrease 1%/year after 30 total energy expenditure decreases decreased lean body mass ```
43
WHat can be seen in geriatrics d/t endocrine changes
chronic electrolyte abnormalities | diabetes, hypothyroidism, impotence and osteoporosis
44
Describe thermoregulation and its implications in geriatrics
``` decreased function of hypothalamus impaired thermoregulation lower basal metabolic rate hypothermia is more pronounced and lasts longer less effective peripheral vasoconstriction impaired coagulation impaired immune function blunted ventilatory response to CO2 increased shivering ```
45
How does body composition change in the elderly?
waist circumference increases fat accumulation inside muscle decrease in dermal and epidermal thickness of skin loss of collagen and elastin decrease in SQ fat easily skin tears weight declines (reduction in lean body mass) muscle atrophy greater in fast-twitch muscle fibers loss of motor neurons loss of body protein
46
Where is majority of TBW lost?
intracellular | 10-15% decrease in intracellular fluid
47
What decreases 20-30% by 75years?
blood volume more vulnerable to hypotension difficulty compensating for positional changes
48
What happens to strength/muscle mass?
decrease in muscle mass reduced strength skeletal muscle mass decreases by 50% by age 80
49
What does sacropenia cause?
functional decline
50
What does a decrease metabolic rate cause?
decreased physical activity | decreases in serum testoterone/ growth hormone
51
How does body fat increase in elderly?
percent of fat per TBW increases
52
What are pancreatic changes in the eldery?
decline in # and function of pancreatic islet beta cells decrease insulin secretion insulin resistance peripherally increased hepatic production of glucose and impaired production of fats/proteins glucose intolerance
53
What is a major risk factor for CV disease?
diabetes
54
What is frality?
state of reduced physiologic reserve that is associated with increased susceptibility to disability failure to response to increase stress (surgery or infection)
55
What characterizes frality?
weight loss, fatigue, impaired grip strength, low physical activity, slow gait speed
56
What are common geriatric syndromes?
``` incontinence delirium falls pressure ulcers sleep disorders eating/feeding problems pain depressed mood dementia physical disability ```
57
What are geriatric syndromes characterized by?
alteration in body composition gaps in energy supply/demand signaling disequilibrium neurogeneration
58
What is a predictive disorder of an earlier death?
diminishing cognitive performance over any time interval
59
What is reversible dementia?
``` chronic drug intoxication vitamin deficiency subdural hematoma major depression hydrocephalus hypothyroidism ```
60
Treatment for dementia
``` incurable vitamin E NSAIDs estrogen acetylcholinesterase inhibitors ```
61
What do falls indicate in elderly?
unstable gait poor muscle strength neural damage in basal ganglia and cerebellum peripheral neuropathy
62
What are pharmacokinetic and pharmacodynamic changes in the elderly
poly-pharmacy increase sensitivity to anesthesia loss of neuronal tissue and changes in receptors increased effects of drug interactions
63
Explain the management of anesthesia with elderly
Total body water decreases 10-15% body fat increases/ muscle mass decreases decreased plasma albumin/increased AAG decrease in renal function leads to increased serum concentrations and prolonged effects of drugs dependent on renal elimination
64
Describe the implications of decrease in TBW
decreased central compartment volume decreased blood volume = decrease in initial Vd increase in initial plasma concentration following IV drugs
65
Describe the implications of increased body fat/decreased muscle mass
increase in steady state volumes of distribution for lipophilic drugs and decrease foy hydrophilic drugs lipid soluble IV drugs have large Vd and prolonged clinical effects adjust drug dosages fro smaller lean body mass
66
Describe anesthesia implications for decreased plasma albumin, increased AAG
theoretical affect on circulating free drug and concentration of drug at effect site no significant impact on clinical pharmacology
67
What are the elderly like to ?
decreased reserve | prone major adverse events
68
What is a frailty pre-op risk factor?
related to postoperative complications, increased LOS and discharged to skilled/assisted living facility
69
Frailty definition:
biologic state associated with increased vulnerability to adverse outcomes that result from decreased resistance to stressors as a result of deterioration in multiple physiologic systems; may be primary or secondary
70
Frailty index
to predict outcomes in nonsurgical elderly population | may have role in perioperative risk assessment
71
What are the four legally relevant criterion for decision making
1. understanding treatment options 2. appreciating and acknowledging medical condition and outcomes 3. exhibiting reasoning/ rational discussion of treatment options 4. clearly choosing a preferred treatment option
72
Autonomy
patients right to self-determination
73
Beneficence
an obligation or responsibility to help the patient "to do good"
74
Nonmaleficence
to not intentionally harm the patient; do no harm
75
Justice
to treat patient fairly
76
Malnutrition in elderly
associated with adverse health outcomes impaired muscle function, decreased bone mass, immune dysfunction, anemia, reduced cognitive function, poor wound health, delayed recovery and risk of falling postoperative complications, increased costs, death
77
What is a severe nutritional risk
unintentional weight loss >10-15% over 6months BMI <18.5kg/m2 serum albumin <3g/dL
78
what is poor functional status an indicator of?
risk factor for SSI and postoperative complications
79
How can you evaluate cognitive status?
mini cog- 3 item recall and clock drawing
80
What does the increase # of medications geriatric patients place them at risk for?
increase risk of adverse events
81
Beer's criteria
drugs that are potentially harmful to eldery
82
What drugs are included in beers criteria
metoclopramide meperidine NSAIDs (gi bleed) ketorlac transdermal fentanyl (delirium, respiratory depression) agonist-antagonist opioids (side effects pronounced) methadone (long half life and risk of oversedation/ respiratory depression
83
What can be emergent surgery for geriatric patient?
trauma, falls, hip fracture, intracranial bleeding, intra-abdominal/ vascular emergencies
84
What should you assess for in emergent surgeries?
acute heart failure, fat embolism, acute lung injury, dehydration
85
What can lead to increased O2 requirements/ low oxygen saturation?
worsening LV function acute lung injury aspiration or pneumonia
86
What are implications of intraoperative management?
``` reduced incidence of DVT with regional reduced anesthetic requirement reduction drug doses by 25% avoid benzo peripheral IV placement risk of breakdown/ulcerations positioning considerations prone to hypotension with hypovolemia/ HTN with hypervolemia risk of hypothermia ```
87
Post-operative delirium and cognitive dysfunction
``` rapid decline in level of consicousness (difficulty focusing, shifting or sustaining attention) cognitive change (incoherent speech) memory gaps, disorientation, hallucination, not explained by pre-existing dementia/ impairment ```
88
What is the strongest predisposing factor for Postop delirium and cog dysfunction
pre-existing dementia
89
what can treat Postop delirium and cog dysfunction
short term fix haloperidol
90
Risk factors for postoperative cognitive dysfunction are
``` genetic disposition lower education level high alcohol intake or alcohol abuse increasing age high ASA status pre-existing mild cognitive impairment history of cerebrovascular accidet cardiac surgery longer duration intraoperative cerebral desaturation post-operative delirium postoperative infection ```
91
what affects perioperative outcomes
emergency surgery number of comorbidites type of surgical procedure
92
What are the two most important factors for perioperative outcomes
surgical risk of the procedure | number of defined clinical risk factors in patient
93
Increased number of clinical risk factors leads to increased
risk of surgical procedure and overall risk of poor outcomes
94
Pulmonary insufficiency or infection are the leading causes of
morbidity
95
What is the most common outcome after surgery?
delirium

N931 Advanced Principles (14 decks)

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