Geriatrics- Modified Verison Flashcards
What are CNS changes seen in the geriatric population?
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
What are cardiovascular changes in the geriatric population
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
Summary of geriatric cardiovascular changes (structure of heart)
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
Why does heart failure incidence increase with geriatrics?
ratio of beta 1 to beta 2 receptors change which causes impact on adrenergic agonist/ blockers impact ventricular function
Summary of geriatric cardiovascular changes (electrical conduction of heart)
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
Conclusion of geriatric cardiovascular changes (table)
myocardial hypertrophy, myocardial stiffening, reduced LV relaxation, reduced beta responsiveness, conduction system abnormalities, stiff arteries, stiff veins
Anesthetic implications of geriatric cardiovascular changes
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
what is the most common complication and leading cause of death in Post-op period?
myocardial infarction
How does decreased end-organ adrenergic responsiveness manifest?
reduced capacity to increase heart rate in response to hypotension, hypovolemia, and hypoxia
What does increased circulation time mean for anesthesia anesthetics?
faster induction time with inhalation agents
delayed onset of IV drugs
How does decreased CO and SV manifest?
decreased conduction velocity and reduction in venous blood flow
What cell types in the brain undergo structural changes with aging?
ALL
neuronal death, glial cell reactivity, synaptic loss
What reduces in the CNS?
neuronal regenerative capacity
neural plasticity
decrease in nerve conduction velocity
What CNS function declines with age and what does not?
intellectual functioning, attention, memory and psychmotor function decline with age
language and executive function remain intact
What are mechanical respiratory changes seen in elderly?
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
What are changes in gas exchange for geriatric patients?
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
Overall, what defines gas exchanges changes in the elder lung?
reduced oxygen exchange at alveolar level
more prone to respiratory failure
more prone to ateletasis
What are changes in the respiratory sensing of geriatrics?
attenuated protected cough mechanisms
reduced respiratory drive in response to hypoxia, hypercarbia and resistive load
increased airways reactivity
What does the changes in a geriatric coughing mechanism place them at risk for?
aspiration
In summary, structural changes of pulmonary system
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
IN summary, what are anesthetic implications of geriatric respiratory symptoms?
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
Renal changes in the elderly
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
What the five changes in the renal system in the eldery?
renal vascular dysautonomy senile hypofiltration tubular dysfunction medullary hypotonicity tubular frality
What is renal vascular dysautonomy?
attenuated autonomic renal vascular reflexes that protect from hypo/hypersensitive effects
What is senile hypofiltration?
decline in GFR
What is tubular dysfunction
reduced ability to absorb and secrete solutes (especially sodium)
What is medullary hypotonicity?
reduced ADH effect and reduction in water reabsorbed
-unable to maximally concentrate or dilute urine
What is tubular frality?
more susceptible to hypoxic or nephrotoxic injury
What decrease GFR cause?
decrease in drug clearance and decreased renal blood flow
Why can’t an aged kidney handle salt/water imbalances?
impairment of sodium conservation (tubular dysfunction)
decreased renin and aldosterone production
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)
What is the best indicator of drug clearance?
creatinine clearance
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
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
Describe drug metabolism changes of liver in geriatrics
phase 1 drug metabolism is variable
phase 2 drug metabolism is not significantly effected
In the liver, what proteins increase and what proteins decreased?
albumin decreases
alpha-1 acid glycoprotein increases
What does albumin bind to??
acidic drugs (benzo, opioids)
What does AAG bind to?
basic drugs (lidocaine)
What do protein binding changes requrie?
no changes in dosing as the effects are counteracted by clearance
Summarize the GI changes in geriatrics
decreased motility of oropharygneal/ upper esophageal area
decreased colonic function
decreased GI immunity
decreased GI drug metabolism
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
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
WHat can be seen in geriatrics d/t endocrine changes
chronic electrolyte abnormalities
diabetes, hypothyroidism, impotence and osteoporosis
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
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
Where is majority of TBW lost?
intracellular
10-15% decrease in intracellular fluid
What decreases 20-30% by 75years?
blood volume
more vulnerable to hypotension
difficulty compensating for positional changes
What happens to strength/muscle mass?
decrease in muscle mass
reduced strength
skeletal muscle mass decreases by 50% by age 80
What does sacropenia cause?
functional decline
What does a decrease metabolic rate cause?
decreased physical activity
decreases in serum testoterone/ growth hormone
How does body fat increase in elderly?
percent of fat per TBW increases
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
What is a major risk factor for CV disease?
diabetes
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)
What characterizes frality?
weight loss, fatigue, impaired grip strength, low physical activity, slow gait speed
What are common geriatric syndromes?
incontinence delirium falls pressure ulcers sleep disorders eating/feeding problems pain depressed mood dementia physical disability
What are geriatric syndromes characterized by?
alteration in body composition
gaps in energy supply/demand
signaling disequilibrium
neurogeneration
What is a predictive disorder of an earlier death?
diminishing cognitive performance over any time interval
What is reversible dementia?
chronic drug intoxication vitamin deficiency subdural hematoma major depression hydrocephalus hypothyroidism
Treatment for dementia
incurable vitamin E NSAIDs estrogen acetylcholinesterase inhibitors
What do falls indicate in elderly?
unstable gait
poor muscle strength
neural damage in basal ganglia and cerebellum
peripheral neuropathy
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
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
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
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
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
What are the elderly like to ?
decreased reserve
prone major adverse events
What is a frailty pre-op risk factor?
related to postoperative complications, increased LOS and discharged to skilled/assisted living facility
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
Frailty index
to predict outcomes in nonsurgical elderly population
may have role in perioperative risk assessment
What are the four legally relevant criterion for decision making
- understanding treatment options
- appreciating and acknowledging medical condition and outcomes
- exhibiting reasoning/ rational discussion of treatment options
- clearly choosing a preferred treatment option
Autonomy
patients right to self-determination
Beneficence
an obligation or responsibility to help the patient “to do good”
Nonmaleficence
to not intentionally harm the patient; do no harm
Justice
to treat patient fairly
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
What is a severe nutritional risk
unintentional weight loss >10-15% over 6months
BMI <18.5kg/m2
serum albumin <3g/dL
what is poor functional status an indicator of?
risk factor for SSI and postoperative complications
How can you evaluate cognitive status?
mini cog- 3 item recall and clock drawing
What does the increase # of medications geriatric patients place them at risk for?
increase risk of adverse events
Beer’s criteria
drugs that are potentially harmful to eldery
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
What can be emergent surgery for geriatric patient?
trauma, falls, hip fracture, intracranial bleeding, intra-abdominal/ vascular emergencies
What should you assess for in emergent surgeries?
acute heart failure, fat embolism, acute lung injury, dehydration
What can lead to increased O2 requirements/ low oxygen saturation?
worsening LV function
acute lung injury
aspiration or pneumonia
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
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
What is the strongest predisposing factor for Postop delirium and cog dysfunction
pre-existing dementia
what can treat Postop delirium and cog dysfunction
short term fix haloperidol
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
what affects perioperative outcomes
emergency surgery
number of comorbidites
type of surgical procedure
What are the two most important factors for perioperative outcomes
surgical risk of the procedure
number of defined clinical risk factors in patient
Increased number of clinical risk factors leads to increased
risk of surgical procedure and overall risk of poor outcomes
Pulmonary insufficiency or infection are the leading causes of
morbidity
What is the most common outcome after surgery?
delirium
