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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
Q

What is senile hypofiltration?

A

decline in GFR

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26
Q

What is tubular dysfunction

A

reduced ability to absorb and secrete solutes (especially sodium)

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27
Q

What is medullary hypotonicity?

A

reduced ADH effect and reduction in water reabsorbed

-unable to maximally concentrate or dilute urine

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28
Q

What is tubular frality?

A

more susceptible to hypoxic or nephrotoxic injury

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29
Q

What decrease GFR cause?

A

decrease in drug clearance and decreased renal blood flow

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30
Q

Why can’t an aged kidney handle salt/water imbalances?

A

impairment of sodium conservation (tubular dysfunction)

decreased renin and aldosterone production

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31
Q

What does the renal system make the elderly more prone too?

A

decreased GFR causes inability to excrete free water =

fluid overload, pulmonary edema and hypoosmolar states (watch hypo-osmolar fluid administration)

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32
Q

What is the best indicator of drug clearance?

A

creatinine clearance

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33
Q

A patient with renal impairment is at an increased risk for?

A 
fluid overload
accumulation of metabolites and drugs
decrease drug elimination
prolonged effects of anesthetic drugs and adjuncts
electrolyte imbalances 
arrhythmias
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34
Q

Describe hepatic function in the geriatric population

A

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

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35
Q

Describe drug metabolism changes of liver in geriatrics

A

phase 1 drug metabolism is variable

phase 2 drug metabolism is not significantly effected

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36
Q

In the liver, what proteins increase and what proteins decreased?

A

albumin decreases

alpha-1 acid glycoprotein increases

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37
Q

What does albumin bind to??

A

acidic drugs (benzo, opioids)

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38
Q

What does AAG bind to?

A

basic drugs (lidocaine)

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39
Q

What do protein binding changes requrie?

A

no changes in dosing as the effects are counteracted by clearance

40
Q

Summarize the GI changes in geriatrics

A

decreased motility of oropharygneal/ upper esophageal area
decreased colonic function
decreased GI immunity
decreased GI drug metabolism

41
Q

Summarize Immune system changes in geriatrics

A

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
Q

Summarize endocrine system changes in geriatrics

A 
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
Q

WHat can be seen in geriatrics d/t endocrine changes

A

chronic electrolyte abnormalities

diabetes, hypothyroidism, impotence and osteoporosis

44
Q

Describe thermoregulation and its implications in geriatrics

A 
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
Q

How does body composition change in the elderly?

A

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
Q

Where is majority of TBW lost?

A

intracellular

10-15% decrease in intracellular fluid

47
Q

What decreases 20-30% by 75years?

A

blood volume
more vulnerable to hypotension
difficulty compensating for positional changes

48
Q

What happens to strength/muscle mass?

A

decrease in muscle mass
reduced strength
skeletal muscle mass decreases by 50% by age 80

49
Q

What does sacropenia cause?

A

functional decline

50
Q

What does a decrease metabolic rate cause?

A

decreased physical activity

decreases in serum testoterone/ growth hormone

51
Q

How does body fat increase in elderly?

A

percent of fat per TBW increases

52
Q

What are pancreatic changes in the eldery?

A

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
Q

What is a major risk factor for CV disease?

A

diabetes

54
Q

What is frality?

A

state of reduced physiologic reserve that is associated with increased susceptibility to disability
failure to response to increase stress (surgery or infection)

55
Q

What characterizes frality?

A

weight loss, fatigue, impaired grip strength, low physical activity, slow gait speed

56
Q

What are common geriatric syndromes?

A 
incontinence
delirium
falls
pressure ulcers
sleep disorders
eating/feeding problems
pain
depressed mood
dementia
physical disability
57
Q

What are geriatric syndromes characterized by?

A

alteration in body composition
gaps in energy supply/demand
signaling disequilibrium
neurogeneration

58
Q

What is a predictive disorder of an earlier death?

A

diminishing cognitive performance over any time interval

59
Q

What is reversible dementia?

A 
chronic drug intoxication
vitamin deficiency
subdural hematoma
major depression
hydrocephalus
hypothyroidism
60
Q

Treatment for dementia

A 
incurable
vitamin E
NSAIDs
estrogen
acetylcholinesterase inhibitors
61
Q

What do falls indicate in elderly?

A

unstable gait
poor muscle strength
neural damage in basal ganglia and cerebellum
peripheral neuropathy

62
Q

What are pharmacokinetic and pharmacodynamic changes in the elderly

A

poly-pharmacy
increase sensitivity to anesthesia
loss of neuronal tissue and changes in receptors
increased effects of drug interactions

63
Q

Explain the management of anesthesia with elderly

A

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
Q

Describe the implications of decrease in TBW

A

decreased central compartment volume
decreased blood volume = decrease in initial Vd
increase in initial plasma concentration following IV drugs

65
Q

Describe the implications of increased body fat/decreased muscle mass

A

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
Q

Describe anesthesia implications for decreased plasma albumin, increased AAG

A

theoretical affect on circulating free drug and concentration of drug at effect site
no significant impact on clinical pharmacology

67
Q

What are the elderly like to ?

A

decreased reserve

prone major adverse events

68
Q

What is a frailty pre-op risk factor?

A

related to postoperative complications, increased LOS and discharged to skilled/assisted living facility

69
Q

Frailty definition:

A

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
Q

Frailty index

A

to predict outcomes in nonsurgical elderly population

may have role in perioperative risk assessment

71
Q

What are the four legally relevant criterion for decision making

A
  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
Q

Autonomy

A

patients right to self-determination

73
Q

Beneficence

A

an obligation or responsibility to help the patient “to do good”

74
Q

Nonmaleficence

A

to not intentionally harm the patient; do no harm

75
Q

Justice

A

to treat patient fairly

76
Q

Malnutrition in elderly

A

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
Q

What is a severe nutritional risk

A

unintentional weight loss >10-15% over 6months
BMI <18.5kg/m2
serum albumin <3g/dL

78
Q

what is poor functional status an indicator of?

A

risk factor for SSI and postoperative complications

79
Q

How can you evaluate cognitive status?

A

mini cog- 3 item recall and clock drawing

80
Q

What does the increase # of medications geriatric patients place them at risk for?

A

increase risk of adverse events

81
Q

Beer’s criteria

A

drugs that are potentially harmful to eldery

82
Q

What drugs are included in beers criteria

A

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
Q

What can be emergent surgery for geriatric patient?

A

trauma, falls, hip fracture, intracranial bleeding, intra-abdominal/ vascular emergencies

84
Q

What should you assess for in emergent surgeries?

A

acute heart failure, fat embolism, acute lung injury, dehydration

85
Q

What can lead to increased O2 requirements/ low oxygen saturation?

A

worsening LV function
acute lung injury
aspiration or pneumonia

86
Q

What are implications of intraoperative management?

A 
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
Q

Post-operative delirium and cognitive dysfunction

A 
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
Q

What is the strongest predisposing factor for Postop delirium and cog dysfunction

A

pre-existing dementia

89
Q

what can treat Postop delirium and cog dysfunction

A

short term fix haloperidol

90
Q

Risk factors for postoperative cognitive dysfunction are

A 
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
Q

what affects perioperative outcomes

A

emergency surgery
number of comorbidites
type of surgical procedure

92
Q

What are the two most important factors for perioperative outcomes

A

surgical risk of the procedure

number of defined clinical risk factors in patient

93
Q

Increased number of clinical risk factors leads to increased

A

risk of surgical procedure and overall risk of poor outcomes

94
Q

Pulmonary insufficiency or infection are the leading causes of

A

morbidity

95
Q

What is the most common outcome after surgery?

A

delirium

N931 Advanced Principles (14 decks)

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