Geriatrics (Mordecai) Exam II

Question 1

By what year is 20% of the U.S. population expected to be over the age of 65?

A) 2025
B) 2030
C) 2040
D) 2050

Answer 1

B) 2030

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Question 2

By 2050, how many people worldwide are expected to be over 60 years old?

A) 1 billion
B) 1.5 billion
C) 2 billion
D) 2.5 billion

Answer 2

C) 2 billion

*baby boomers are now advanced in their age. *

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Question 3

In 2003, older patients made up ___% of the U.S. population, accounted for ___% of hospitalizations, and ___% of hospital charges.

A) 10%, 25%, 35%
B) 12%, 33%, 44%
C) 15%, 40%, 50%
D) 20%, 50%, 60%

Answer 3

B) 12%, 33% (1/3rd), 44%

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Question 4

Older patients tend to require 2 to 3 times more _______ and experience _______ hospitalizations compared to younger patients.

A) surgeries, longer
B) medications, shorter
C) appointments, shorter
D) surgeries, shorter

Answer 4

A) surgeries, longer

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Question 5

True or False

Aging is a universal and progressive physiological process.

Answer 5

True
## Footnote

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Question 6

Aging results in _______ homeostatic imbalance.

A) Increased
B) Decreased
C) Stable
D) No change in

Answer 6

A) Increased

Mordecai - Their fluid and electrolyte shifts and things like that are going to become more and more compromised with time

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Question 7

Which of the following occur as part of the aging process? Select 2
A) Decreased functional capacity
B) Increased homeostatic balance
C) Decreased end-organ reserve
D) Increased ability to fight infections

Answer 7

A) Decreased functional capacity
C) Decreased end-organ reserve

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Question 8

Aging leads to an increased incidence of ___.

A) Enhanced homeostatic balance
B) Reduced disease processes
C) Pathophysiological processes
D) Physiological processes

Answer 8

C) Pathophysiological processes

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Question 9

What percentage of people over 60 years old experience memory decline?

A) 30%
B) 40%
C) 50%
D) 60%

Answer 9

B) 40%

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Question 10

Memory decline in older adults is _ and it can be slowed by physical engagement like completing ADL’s.

A) Inevitable
B) Rare
C) Not inevitable
D) Always reversible

Answer 10

C) Not inevitable

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Question 11

In the elderly population, cerebral atrophy is characterized by a reduction in _ matter and neuronal shrinkage.

A) Black
B) Grey
C) White
D) Yellow

Answer 11

B) Grey

(only a small neuron loss)

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Question 12

In the aging process, there is a decrease in ___ matter, leading to functional changes.

A) White
B) Eggshell
C) Grey
D) Brown

Answer 12

A) White

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Question 13

Decreases in white matter in the aging brain leads to an increase in ___ size.

A) Cortical
B) Cerebral
C) Ventricular
D) Hippocampal

Answer 13

C) Ventricular

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Question 14

As the brain ages, decreases in white matter cause a progressive loss in:
Select 3

A) Mobility
B) Memory
C) Reflexes
D) Appetite
E) Balance
F) Language

Answer 14

A) Mobility
B) Memory
E) Balance

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Question 15

The coupling of cerebral metabolic rate of oxygen (CMRO2) and cerebral blood flow (CBF) both decrease in a parallel fashion, and so the EEG values and waveforms remain ____.

A) Increased
B) Decreased
C) Unchanged
D) Irregular

Answer 15

C) Unchanged

M - cerebral metabolic rate and cerebral blood flow seem to both decrease in a parallel fashion, and so the EEG values and waveforms remain unchanged.

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Question 16

Which of the following neurotransmitters show a significant decrease in animal studies of aging? Select 4

A) Dopamine
B) Glycine
C) Acetylcholine
D) Norepinephrine
E) Serotonin
F) Glutamate

Answer 16

A) Dopamine
C) Acetylcholine (ACh)
D) Norepinephrine
E) Serotonin

Glutamate is unchanged.

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Question 17

Which of the following are true regarding neuraxial changes in aging? Select 2

A) Decreased epidural space
B) Increased volume of cerebrospinal fluid
C) Increased permeability of the dura
D) Increased diameter of myelinated nerve fibers

Answer 17

A) Decreased epidural space
C) Increased permeability of the dura

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Question 18

The volume of cerebrospinal fluid (CSF) in the neuraxial space ___ with age, leading to less dilution of the local anesthetic.

A) Increases
B) Decreases
C) Stays the same
D) Fluctuates

Answer 18

B) Decreases

M - There is a lower amount of CSF in the epidural space and so less dilution of the product so reducing the dose for that reason

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Question 19

Neuraxial changes in elderly patients result in the reduction in the diameter and number of ____________ fibers in the dorsal and ___ nerve roots.

A) Unmyelinated, rostral
B) Myelinated, lateral
C) Unmyelinated, ventral
D) Myelinated, ventral

Answer 19

D) Myelinated, ventral

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Question 20

In elderly patients, the distance between Inter-Schwann cells ___ in the peripheral nervous system.

A) Increased
B) Decreased
C) Unchanged
D) Variable

Answer 20

B) Decreased

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Question 21

In aging, the peripheral nevous system has reduced _________ due to the decreased mylelination across the nerve fibers.

A) Nerve fiber growth
B) Sensory input
C) Synaptic transmission
D) Conduction velocity

Answer 21

D) Conduction velocity

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Question 22

Elderly patients are more sensitive to both ___ and ___ nerve blocks.

A) Neuraxial, peripheral
B) Sympathetic, parasympathetic
C) Central, autonomic
D) Motor, sensory

Answer 22

A) Neuraxial, peripheral

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Question 23

In elderly patients, decreased contractility is primarily due to ___.

A) Increased stroke volume
B) Left ventricular hypertrophy
C) Enhanced ventricular compliance
D) Increased myocardial mass

Answer 23

B) Left ventricular hypertrophy

M - Over time there’s gonna be a decrease in the contractility due to that left ventricular hypertrophy that will develop

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Question 24

As the heart ages, the left ventricular wall thickens due to years of ___.

A) Decreased vascular compliance and afterload
B) Chronic hypertension and increased afterload
C) Decreased systemic vascular resistance and chronic hypertension
D) Increased vascular compliance and contractility

Answer 24

B) Chronic hypertension and increased afterload

M -pretty much every American is going to develop some degree of hypertension or increasing blood pressure, increased SVR and reduction in the vascular compliance as they get older.

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Question 25

In elderly patients, the number of myocytes in the heart ___.

A) Remains unchanged
B) Increases
C) Decreases
D) Doubles

Answer 25

C) Decreases

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Question 26

Aging leads to a decrease in ______ cells, making elderly patients more susceptible to arrhythmias.

A) AV node
B) SA node
C) Myocyte
D) Purkinje

Answer 26

B) SA node

M - these patients become more susceptible to arrhythmias, particularly tachy and Brady syndromes.

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Question 27

With aging, the aortic valve becomes ___.

A) Thickened and calcified
B) Thinner and more flexible
C) More elastic
D) Narrower but soft

Answer 27

A) Thickened and calcified

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Question 28

The increased ventricular stiffness in elderly patients leads to ___.

A) Higher ventricular filling pressures
B) Lower ventricular filling pressures
C) Increased contractility
D) Reduced afterload

Answer 28

A) Higher ventricular filling pressures

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Question 29

In elderly patients, the reduced beta-adrenergic sensitivity results in a reduced ability to increase ___.

A) Stroke volume at rest and ejection fraction
B) Peripheral vascular resistance and ejection fraction
C) Preload during stress and heart rate
D) Ejection fraction and maximal heart rate

Answer 29

D) Ejection fraction and maximal heart rate during stress

M-the sympathetic system is a little less responsive and our elderly patients cannot mount that flight or flight cardiac response and pick up their heart rate in times of need or in times where they may be dehydrated or have a drop in their SVR.

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Question 30

True or False

Elderly are more prone to decompensation during neuroaxial anesthesia

Answer 30

True

M - anything that can cause them to systemically vasodilate, it’s gonna be harder for them to pick up their heart rate and maintain adequate cardiac output.

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Question 31

Vascular stiffness in the elderly is due to ___.

A) Breakdown of collagen and elastin
B) Increased nitric oxide production
C) Enhanced vascular compliance
D) Decreased afterload

Answer 31

A) Breakdown of collagen and elastin

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Question 32

What are some consequences of decreased nitric oxide in the cardiovascular system of elderly patients? Select 2

A) Reduced vasodilation
B) Increased coronary perfusion
C) Decreased ability to handle physical stress
D) Enhanced vascular elasticity

Answer 32

A) Reduced vasodilation
C) Decreased ability to handle physical stress

M - the coronaries can’t dilate necessarily optimally to perfuse the heart as effectively during times of stress

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Question 33

Early wave deflection in elderly patients’ blood vessels contributes to ___.

A) Increased afterload and diastolic dysfunction
B) Increased preload and stroke volume
C) Enhanced coronary dilation and diastolic dysfunction
D) Decreased vascular resistance and increased afterload

Answer 33

A) Increased afterload and diastolic dysfunction

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Question 34

The loss of surfactant and elastic recoil in elderly patients causes ___.

A) Decreased lung compliance
B) Increased lung compliance
C) Reduced airway collapse
D) Improved gas exchange

Answer 34

B) Increased lung compliance

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Question 35

The enlargement of bronchioles and alveolar ducts in elderly patients results in ___.

A) Increased airway patency during exhalation
B) Late airway collapse during exhalation
C) Enhanced inspiratory effort
D) Early airway collapse during exhalation

Answer 35

D) Early airway collapse of small airways during exhalation

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Question 36

The early collapse of small airways during exhalation in elderly patients leads to ___.
Select 3

A) Increased anatomic dead space
B) Decreased closing capacity
C) Impaired gas exchange
D) Reduced oxygenation needs
E) Increased closing capacity

Answer 36

A) Increased anatomic dead space
C) impaired gas exchange
E) Increased closing capacity

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Question 37

Aging leads to structural changes in the pulmonary system, resulting in _______ gas exchange and decrease in baseline oxygen saturation compared to younger individuals.

A) Increased
B) Improving
C) Unchanged
D) Impaired

Answer 37

D) Impaired

M - their arterial CO2 levels are going to creep up a little higher over time, and their oxygen saturations at baseline will be just a little lower than what a younger healthy patient would be…these patients may baseline SAT 95, 96…

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Question 38

The loss of vertebral height and calcification of the vertebrae in elderly patients results in ___.

A) Funnel chest
B) Barrel chest
C) Pigeon chest
D) Bottle chest

Answer 38

B) Barrel chest

M -the elderly will kind of lose a little bit of their height. And this is going to be due to osteoporosis, calcification of the vertebrae, and calcification of the intercostal cartilage.

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Question 39

Diaphragmatic flattening and chest wall stiffness in elderly patients contributes to ___.

A) Increased work of breathing
B) Reduced lung compliance
C) Improved chest wall flexibility
D) Enhanced lung recoil

Answer 39

A) Increased work of breathing

M - this can contribute to like the dyspnea on exertion that the elderly patients experience. They’re not able to climb a flight of stairs as easily or walk a long distance without getting short of breath oftentimes.

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Question 40

Which of the following lung volume changes are typical in elderly patients? Select 3

A) Decreased vital capacity
B) Increased closing capacity
C) Decreased residual volume
D) Increased residual volume
E) Increased total lung capacity
F) Increased vital capacity

Answer 40

A) Decreased vital capacity
B) Increased closing capacity
D) Increased residual volume

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Question 41

As elderly patients age, the total lung capacity ___.

A) Increases dramatically
B) Remains about the same
C) Decreases significantly
D) Fluctuates unpredictably

Answer 41

B) Remains about the same

M - the total lung capacity doesn’t necessarily change as much due to the compensation that they experience over time.

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Question 42

The decrease in muscle mass and increase in closing capacity in elderly patients leads to a decreased FEV1 by ____ per decade.

A) 2-3%
B) 3-6%
C) 6-8%
D) 7-9%

Answer 42

C) 6-8%

M - The closing capacity is a combination of the residual volume and closing volume. Both those two volumes will increase causing that increase in closing capacity.

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Question 43

Weaker pharyngeal muscles in elderly patients result in ___. Select 2

A) Increased clearance of secretions
B) Decreased clearance of secretions
C) Enhanced swallowing reflexes
D) Increased esophageal motility
E) Less efficient coughing

Answer 43

B) Decreased clearance of secretions
E) Less efficient coughing

M - at the end of our cases, you’re really going to have to suction them a little bit more aggressively because they’re not going to be able to give you a good strong cough.

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Question 44

What are the functional respiratory changes observed in elderly patients? Select 2

A) Increased FEV1
B) Decreased closing capacity
C) Improved clearance of secretions
D) Less protective upper airway reflexes
E) Decreased esophageal motility

Answer 44

D) Less protective upper airway reflexes
E) Decreased esophageal motility

M - that puts them at a little bit of an aspiration risk.

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Question 45

The widening gap between FRC and closing capacity over time contributes to increasing ___.

A) Decreased shunting
B) Increased VQ mismatch
C) Increased oxygenation
D) Unchanged oxygenation

Answer 45

B) Increased VQ mismatch

M - The VQ mismatch relationship between the FRC and closing capacity is that gap is gonna widen. We see an increase of their FRC slightly but a much greater increase in their closing capacity…as this mismatch increases with age, eventually that closing capacity will exceed the FRC.

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Question 46

As closing capacity exceeds FRC in elderly patients and VQ mismatch gets worse it results in ________. Select 2

A) Increased shunting
B) Decreased closing capacity
C) Decreased arterial oxygenation
D) Decreased shunting
E) Increased arterial oxygenation

Answer 46

A) Increased shunting
C) Decreased arterial oxygenation

Most important mechanism of action for alveolar-arterial oxygen gradient

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Question 47

The glomerular filtration rate (GFR) decreases by how much after the age of 30?

A) 2 mL/min/m2 per decade
B) 20 mL/min/m2 per decade
C) 1 ml/min/m2 per year
D) 10 mL/min/m2 per year

Answer 47

C) 1 mL/min/m2 per year

M - the GFR is going to decrease with age. It decreases at about 1 mL/min/m2 per year after the age of 30…its down about 10 per decade after age 30…by the time the patients are in their 70s, 80s, and 90s, they have significantly compromised kidneys

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Question 48

Elderly patients often experience a decreased _____ in their kidneys, which can be exacerbated by comorbidities

A) Creatinine
B) A1C
C) BUN
D) GFR

Answer 48

D) GFR (Glomerular Filtration Rate)

M - Things like diabetes and h ypertensionhave pretty significant effects on the kidneys, but also things like the drugs that they’re taking… IVP dye for CTs, angiograms, dehydration over time, all these things are going to affect their kidney function

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Question 49

Which of the following hormones have a blunted response in elderly patients affecting their fluid and electrolyte balance? Select 3

A) Dopamine
B) Aldosterone
C) Norepinephrine
D) Vasopressin
E) Glucagon
F) Renin
G) Serotonin

Answer 49

B) Aldosterone
D) Vasopressin
F) Renin

M - this is gonna affect some of our drugs, especially the ones that are cleared through the kidneys.

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Question 50

Which of the following are more common in elderly patients due to decreased kidney function? Select 2

A) Heart disease
B) UTIs
C) Increased bowel motility
D) Urinary retention

Answer 50

B) UTIs
D) Urinary retention

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Question 51

As the liver function declines with age, which metabolic pathway is most affected and is “not ok”?

A) Phase I
B) Phase II
C) Conjugation
D) Acetylation

Answer 51

A) Phase I - (oxidation, reduction, hydrolysis via CYP450)

Phase II - (acetylation and conjugation)

M - lots of our narcotics and anesthetics are going to have a prolonged effect because of this taking longer to metabolize

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Question 52

In elderly patients, the response to post-operative nausea and vomiting (PONV) is generally:

A) More severe
B) The same as younger patients
C) Less severe
D) Does not occur

Answer 52

C) Less severe

M - generally Zofran is gonna be totally adequate for them. You don’t need to go too heavy on the antiemetics for them.

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Question 53

Which of the following medications should be avoided in elderly patients to prevent complications of excessive antiemetic use? (Select 3)

A) Promethazine
B) Prochlorperazine
C) Zofran
D) Metoclopramide

Answer 53

A) Promethazine
B) Prochlorperazine
D) Metoclopramide

Select 19

Question 54

Age-related changes in the musculoskeletal system include: Select 3

A) Decrease in muscle mass
B) Subcutaneous fat thickens
C) Impaired wound healing
D) Osteoarthritis development
E) Increased joint flexibility
F) Increased ability to thermoregulate

Answer 54

A) Decrease in muscle mass
C) Impaired wound healing
D) Osteoarthritis development

Subcutaneous fat thins

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Question 55

Age-related changes in thermoregulation include:

A) Comparable vasoconstriction threshold in elderly and young adults
B) Elderly patients have a lower vasoconstriction threshold by about 1°C
C) Elderly patients are more efficient in thermoregulation
D) Elderly patients have a higher vasoconstriction threshold by about 1°C

Answer 55

B) Elderly patients have a lower vasoconstriction threshold by about 1°C

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Question 56

In regards to operating risk, according to the Denny and Denson study, high mortality was observed in patients:

A) 50 years old
B) 60 years old
C) 70 years old
D) 90 years old

Answer 56

D) Over 90 years old

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Question 57

Regarding operative risk, the Djokovi and Hedley-Whyte study found that which factor predicted mortality?

A) Age
B) ECG
C) ASA
D) Weight

Answer 57

C) ASA status

Select 23

Question 58

The Del Guercio and Cohn study demonstrated that patients with _________ in the SICU had a 100% mortality rate.

A) Correctable comorbidities
B) Uncorrectable comorbidities
C) Minor comorbidities
D) Comorbidities outside of the SICU

Answer 58

B) Uncorrectable comorbidities

Select 23

Question 59

The Finlayson et al. study found that high mortality rates were associated with ____________.

A) Hospital patients
B) Nursing home residents
C) ICU patients
D) Patients under 50 years old

Answer 59

B) Nursing home residents

Select 23

Question 60

Which of the following is considered a significant predictor of 6-month to 1-year mortality?

A) Recent fall
B) Functional independence
C) High albumin levels
D) Increased muscle mass

Answer 60

A) Recent fall

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Question 61

What is a significant factor for predicting mortality 6mo-1yr is in elderly patients?

A) High red blood cells
B) Increased physical activity
C) Increased oxygen saturation
D) Impaired cognition

Answer 61

D) Impaired cognition

M - ..patients develop Alzheimer’s and dementia, especially end -stage, they’re just not able to take care of the care of themselves.

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Question 62

Which of the following conditions increases 6 months to 1 year mortality due to poor healing capacity?

a) Impaired cognition
b) Hypoalbuminemia
c) Comorbidities
d) Anemia

Answer 62

b) Hypoalbuminemia

M- hypoalbuminemia is compromes their healing so as they do have these falls, they’re not going to be able to bounce back quickly

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Question 63

Things that significantly increase the risk of mortality within 6 months to 1 year include:
Select 3

a) Anemia
b) Comorbidities
c) Functional independance
c) Increased clarity
d) Hyperalbuminemia
e) Functional dependance

Answer 63

a) Anemia
b) Comorbidities
e) Functional dependance

M - functional dependence is having to depend on somebody else for get the elderly fed, adequate nutrition, ADLs, getting dressed, getting around, and the more and more you depend on somebody else, just the less able you are to depend on yourself.

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Question 64

What is the primary factor causing neuroinflammation in the brain due to surgery and anesthesia?

a) Central inflammatory response
b) Peripheral inflammatory response
c) Dysfunctional anti-inflammatory response
d) Transiet neuroinflammation

Answer 64

b) Peripheral inflammatory response

M - with this peripheral inflammatory response, there’s going to be the release of inflammatory mediators. So some of these inflammatory mediators are going to be able to cross the blood -brain barrier and lead to neuroinflammation

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Question 65

Which of the following are effects seen in the vulnerable brain post-surgery and anesthesia?
(Select 2)

a) Dysfunctional anti-inflammatory response
b) Exaggerated neuroinflammation
c) Short-term cognitive decline
d) Anti-inflammatory response

Answer 65

a) Dysfunctional anti-inflammatory response
b) Exaggerated neuroinflammation - and exaggerated acceleration of Alzheimers Disease (AD) pathology

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Question 66

What is ultimately the end condition to happen in a vulnerable brain following surgery and anesthesia?

a) Transient cognitive decline
b) Long-term cognitive decline
c) No cognitive decline
d) Complete recovery with no complications

Answer 66

b) Long-term cognitive decline

M - they’re going to experience more of a long term cognitive decline, postoperative cognitive dysfunction, POCD, which can last months to years or be indefinite.

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Question 67

The normal brain responds to neuroinflammation by activating an __________
response

a) Dysfunctional anti-inflammatory response
b) Exaggerated neuroinflammation
c) Exaggerated acceleration of AD pathology
d) Anti-inflammatory response

Answer 67

d) Anti-inflammatory response

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Question 68

What happens in the normal brain in response to neuroinflammation caused by surgery and anesthesia? Select 2

a) Exaggerated neuroinflammation
b) Long-term cognitive decline
c) Transient neuroinflammation
d) Short-term cognitive decline

Answer 68

c) Transient neuroinflammation
d) Short-term cognitive decline

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Question 69

Which of the following factors are implicated in the pathogenesis of dementia in vulnerable brains?
(Select 4)

a) Amyloid β
b) Tau
c) Sodium
d) Calcium
e) Neuroinflammation
f) Dopamine
g) Serotonin

Answer 69

a) Amyloid β,
b) Tau,
d) Calcium,
e) Neuroinflammation - neuroinflammatory factors, things like tissue necrosis factor, interleukin

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Question 70

What is the primary origin of Amyloid-β?

a) Fragment of synaptic origin
b) Fragment of dendritic origin
c) Fragment of myelin sheath
d) Fragment of neuronal body

Answer 70

a) Fragment of synaptic origin

M - it develops when the synapses break down and it’s not real clear (unknown what the function of amyloid B is

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Question 71

Amyloid-β is most likely to form plaques in which part of the body?

a) The synaptic cleft
b) Inside the neuron nucleus
c) Extracellular space
d) The myelin sheath

Answer 71

c) Extracellular space.

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Question 72

True or False

Amyloid-β is known to be toxic

Answer 72

False

M - originally it was thought that these amyloid plaques would be cumulative and toxic over time. However, more research shows that it’s kind of a labile process. They can aggregate, but then it can also be eliminated.

Question 73

Amyloid-β accumulation can lead to:

a) Enhanced neuroplasticity
b) Short-term cognitive improvement
c) Disruption of cell membranes over time
d) Repair of damaged synapses

Answer 73

c) Disruption of cell membranes over time.

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Question 74

What were the effects of Halothane administration regarding amyloid β in mice?

A) Both young and old mice had improved memory and learning.
B) Young mice had improved memory/learning, while old mice had accelerated dementia.
C) Old mice showed no change in dementia progression, but young mice experienced memory loss.
D) Both young and old mice showed no significant effects on amyloid β levels.

Answer 74

B) Young mice had improved memory/learning, while old mice had accelerated dementia.

… unclear translation to humans; other factors clearly involved

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Question 75

Which class of medications can cause a significant increase in amyloid plaques?

A) Beta-blockers
B) Volatile anesthetics
C) Benzodiazepines
D) Anticholinergics

Answer 75

B) Volatile anesthetics

Halothane

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Question 76

What is a neurofibrillary tangle?

A) Accumulation of amyloid β plaques in the brain
B) Phosphorylated and aggregated τ (tau) proteins
C) Misfolded prion proteins affecting neural function
D) A build-up of alpha-synuclein in the neurons

Answer 76

B) Phosphorylated and aggregated τ (tau) proteins

Slide 29

Question 77

What is destabilized by neurofibrillary tangles?

A) Synaptic connections
B) Neuronal membranes
C) Microtubules
D) Neurotransmitter release

Answer 77

C) Microtubules

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Question 78

Decreases in temperature by ___ °C will increase the amount of τ protein.

A) 1-2 °C
B) 2-3 °C
C) 3-4 °C
D) 4-5 °C

Answer 78

B) 2-3 °C

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Question 79

Repeated exposure to which drugs will cause an increase in phosphorylated τ protein? Select 3

A) Propofol
B) Halothane
C) Isoflurane
D) Nitrous
E) Desflurane
F) Sevoflurane

Answer 79

B) Halothane
C) Isoflurane
F) Sevoflurane

Slide 29

Question 80

As amyloid and tau protein levels increase, what is the typical progression of symptoms in neurodegenerative diseases?

A) Decreased memory loss and increased physical mobility
B) Mild cognitive impairment progressing to dementia
C) Immediate onset of severe dementia without prior symptoms
D) Motor impairment with no cognitive decline

Answer 80

B) Mild cognitive impairment progressing to dementia

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Question 81

The release of what ion is exaggerated due to anesthesia and which receptors are involved?

A) Na⁺ from voltage-gated sodium channels
B) K⁺ from potassium leak channels
C) Ca⁺⁺ from ryanodine and IP₃ receptors of the endoplasmic reticulum
D) Cl⁻ from GABA-A receptors

Answer 81

C) Ca⁺⁺ from ryanodine and IP₃ receptors of the endoplasmic reticulum

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Question 82

Exaggerated Ca⁺⁺ release in the brain is thought to be linked to ______________.

A) Improved cognitive function
B) Neurotoxicity
C) Muscle relaxation
D) Enhanced memory retention

Answer 82

B) Neurotoxicity

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Question 83

Dantrolene, due to its calcium channel blocking effects, can cause significant ______________.

A) Cardiac arrhythmias
B) Skeletal muscle weakness
C) Increased muscle tone
D) Hypercalcemia

Answer 83

B) Skeletal muscle weakness

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Question 84

Neuroinflammation contributes to cognitive decline through the release of which inflammatory factors? (Select all that apply-3)

A) Cytokines
B) IL-6
C) TNFα
D) Dopamine
E) Serotonin
F) Acetylcholine

Answer 84

A) Cytokines
B) IL-6
C) TNFα

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Question 85

Which of the following anesthesia drugs are capable of modulating inflammation? (Select 3)

A) Dexamethasone
B) Lidocaine
C) Propofol
D) Toradol
E) Fentanyl

Answer 85

A) Dexamethasone
B) Lidocaine
D) Toradol

Slide 32

Question 86

Which study first supported the theory of anesthesia-related post-operative cognitive dysfunction (POCD)?

A) Smith 1980
B) Jones 1995
C) Bedford 1955
D) Johnson 1970

Answer 86

C) Bedford 1955

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Question 87

General anesthesia (especially in older populations) is thought to contribute to ___.

A) Improved memory retention
B) Enhanced cognitive function
C) Post-operative cognitive dysfunction
D) Increased motor skills

Answer 87

C) Post-operative cognitive dysfunction

Slide 35

Question 88

Anesthesia is ___ for POCD, whilst surgery is likely __.

A) Protective; the main cause
B) Causative; additive
C) Irrelevant; the sole cause
D) Neutral; the main contributor

Answer 88

B) Causative; additive
Mordecai: Anesthesia alone is causative, like a lot of our drugs are going to have a prolonged effect on the central nervous system, especially in patients that are already compromised. Surgery is additive because you’re adding the inflammatory mediators on top of the drugs and so patients have unknown or differing vulnerabilities.

Slide 36

Question 89

Which of the following are recommended strategies to minimize anesthesia-related complications? (Select 3 that apply)

A) Using neuraxial/regional anesthesia when possible
B) Using long-acting neuromuscular blocking drugs (NMBDs) without reversal
C) Opioid sparing strategies
D) Neutralizing stomach acid with non-particulates

Answer 89

A) Using neuraxial/regional anesthesia when possible
C) Opioid sparing strategies
D) Neutralizing stomach acid with non-particulates

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Question 90

Which measures should be taken to improve patient safety during anesthesia? (Select 4 that apply)

A) Avoid long-acting NMBDs and reverse adequately
B) Administer opioids at the highest recommended dose
C) Consider using EEG-based titration
D) Pad skin and nerves
E) Avoid hypotension

Answer 90

A) Avoid long-acting NMBDs and reverse adequately
C) Consider using EEG-based titration
D) Pad skin and nerves
E) Avoid hypotension

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Question 91

What occurs to drugs due to decreased cardiac output secondary to aging? (Select 3 that apply)

A) Faster distribution to the site of action
B) Slower distribution to the site of action
C) Slower redistribution
D) Slower distribution to metabolic organs
E) Increased rate of metabolism

Answer 91

B) Slower distribution to the site of action
C) Slower redistribution
D) Slower distribution to metabolic organs

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Question 92

What neuromuscular junction changes contribute to drug challenges in an aging patient? (Select 4 that apply)

A) Increased concentration of ACh receptors
B) Increased distance between axon and motor end plate
C) Decreased concentration of ACh receptors
D) Decreased ACh in presynaptic vesicles
E) Decreased ACh release
F) Increased ACh release
G) Decreased distance between axon and motor end plate

Answer 92

B) Increased distance between axon and motor end plate
C) Decreased concentration of ACh receptors
D) Decreased ACh in presynaptic vesicles
E) Decreased ACh release

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Question 93

What drug changes are seen in an aging patient regarding kidney/liver-dependent metabolism? (Select 3 that apply)

A) Prolonged drug effect
B) Increased drug need during maintenance
C) Decreased drug need during maintenance
D) Delayed recovery phase for non-depolarizers
E) Faster drug clearance

Answer 93

A) Prolonged drug effect
C) Decreased drug need during maintenance
D) Delayed recovery phase for non-depolarizers

Mordecai: Now the drugs that are not kidney and liver dependent, we’re not gonna see a significant prolongation in their effect. Essentially, the dosing requirements are the same during maintenance and there’s no delay in their recovery phase of certain drugs like succinylcholine, cisatracurium and rummy fentanyl drugs that are not metabolized to the kidney and liver. You’re not gonna have to worry quite as much about the hanging on longer.

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Question 94

The mortality rate for pulmonary resection in patients aged 80-92 years old is ____.

A) 1%
B) 3%
C) 5%
D) 10%

Answer 94

B) 3%

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Question 95

For older patients undergoing pulmonary resection, ____ is considered to have an acceptable mortality rate and ____ is associated with excessive mortality.

A) Wedge resection; lobectomy
B) Pneumonectomy; tracheostomy
C) Lobectomy; pneumonectomy
D) Segmentectomy; bronchoscopy

Answer 95

C) Lobectomy; pneumonectomy

Lobectomy mortality acceptable
Pneumonectomy mortality excessive

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Question 96

In the preoperative assessment for thoracic surgery, what condition must be ruled out using a transthoracic echocardiogram?

A) Pulmonary embolism
B) Pulmonary hypertension
C) Coronary artery disease
D) Aortic stenosis

Answer 96

B) Pulmonary hypertension

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Question 97

If an older patient has moderate/poor exercise tolerance or a history of coronary artery disease, what is the next recommended step in the preoperative assessment?

A) Immediate lung resection surgery
B) Coronary angiography
C) Myocardial perfusion imaging
D) Case-specific management

Answer 97

C) Myocardial perfusion imaging
(dobutamine stress echo or thallium scan)

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Question 98

True or False

Patients with excellent exercise tolerance and no history of coronary artery disease can proceed to lung resection surgery.

Answer 98

True

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Question 99

In patients at increased risk after coronary angiography, which of the following interventions may be recommended before proceeding with thoracic surgery?

A) Surgical revascularization
B) Immediate lung resection surgery
C) Transthoracic echocardiogram
D) Ventilation-perfusion scan

Answer 99

A) Surgical revascularization

but if patient are deemded to be low risk, then they could proceed on with surgery

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Question 100

How is predicted post-operative FEV₁ (ppo FEV₁) calculated?

A) (Preop FEV₁ %) x (1 - % of body weight / 100)
B) (Preop FEV₁ %) x (1 - % of lung tissue removed / 100)
C) (Preop FEV₁ %) ÷ (1 - % of lung tissue removed / 100)
D) (Preop FEV₁ %) ÷ (1 - % of total lung capacity)

Answer 100

B) (Preop FEV₁ %) x (1 - % of lung tissue removed / 100)

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Question 101

How many lung segments are there in total?

A) 30
B) 35
C) 42
D) 50

Answer 101

C) 42

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Question 102

There are __ lung segments in the left upper lobe (LUL) and __ lung segments in the left lower lobe (LLL).

A) 5; 5
B) 10; 10
C) 8; 8
D) 6; 4

Answer 102

B) 10; 10

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Question 103

How many lung segments are in the right lower lobe (RLL)?

A) 8
B) 10
C) 12
D) 14

Answer 103

C) 12

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Question 104

How many lung segments are in the right upper lobe (RUL)?

A) 4
B) 5
C) 6
D) 8

Answer 104

C) 6

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Question 105

How many lung segments are in the right middle lobe (RML)?

A) 2
B) 4
C) 5
D) 6

Answer 105

B) 4

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Question 106

Calculate

The right middle lobe and right lower lobe are resected in a critically ill patient. How much lung tissue was removed in this surgery?

Answer 106

16/42 = 38%

4 (RML) + 12 (RLL) = 16
total segment = 42

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Question 107

Calculate

Predict the post-operative FEV₁ for a patient who had their right lower lobe removed. The patients preoperative FEV₁ is 70%.

Answer 107

(Preop FEV₁ %) x (1 - % of lung tissue removed/100)
Preop FEV₁ %= 70
% lung tissue removed = 12 (RLL) / 42 (total) = 28.5% → 29%

PPO FEV₁ =70 x ( 1 - 29/100) = 50

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Question 108

Which of the following is part of the “triad” for prethoracotomy respiratory assessment?

A) Respiratory mechanics, Cardiopulmonary reserve, Lung parenchymal function
B) Lung elasticity, Respiratory mechanics, Vascular tone
C) Cardiopulmonary reserve, Diaphragmatic contraction, Lung compliance
D) Lung parenchymal function, Diaphragmatic strength, Cardiovascular endurance

Answer 108

A) Respiratory mechanics, Cardiopulmonary reserve, Lung parenchymal function

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Question 109

If a patient’s predicted postoperative FEV₁ (ppoFEV₁) is greater than 40%, what is the recommended anesthetic management?

A) Extubate in the operating room if the patient is alert, warm, and comfortable
B) Consider extubation based on exercise tolerance and DLCO
C) Stage weaning from mechanical ventilation
D) Keep the patient on mechanical ventilation for 24 hours

Answer 109

A) Extubate in the operating room if the patient is alert, warm, and comfortable (AWaC)

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Question 110

For patients with a ppoFEV₁ between 30-40%, what factors should be considered when deciding on extubation?

A) Blood pressure, heart rate, V/Q scan and respiratory rate
B) Exercise tolerance, DLCO, V/Q scan, and associated diseases
C) Oxygen saturation, respiratory effort, DLCO, and pain levels
D) Neurological status, kidney function, associated diseasesand electrolyte balance

Answer 110

B) Exercise tolerance, DLCO, V/Q scan, and associated diseases

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Question 111

How would the CRNA manage extubation on a post-thoracotomy patient if the ppoFEV₁ is less than 30%? (Select 2 that apply)

A) Immediate extubation in the operating room
B) Staged weaning from the ventilator
C) Consider extubation if ppoFEV₁ is >20% and thoracic epidural anesthesia is in place
D) Perform tracheostomy before extubation
E) Extubate only if oxygen saturation remains above 95%

Answer 111

B) Staged weaning from the ventilator

C) Consider extubation if ppoFEV₁ is >20% and thoracic epidural anesthesia is in place

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Question 112

What is the definition of Postoperative Cognitive Dysfunction (POCD)?

A) A temporary decline in memory and focus following surgery
B) Decline in cognitive function that persists beyond the period expected
C) A loss of consciousness during the postoperative period
D) A psychological disorder triggered by surgery

Answer 112

B) An objectively measured decline in cognitive function that persists beyond the period expected

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