Geriatrics (Mordecai) Exam II Flashcards
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
B) 2030
Slide 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
C) 2 billion
*baby boomers are now advanced in their age. *
Slide 2
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%
B) 12%, 33% (1/3rd), 44%
Slide 2
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
A) surgeries, longer
Slide 2
True or False
Aging is a universal and progressive physiological process.
B) It is a universal and progressive physiological process.
Slide 3
Aging results in _______ homeostatic imbalance.
A) Increased
B) Decreased
C) Stable
D) No change in
A) Increased
Mordecai - *Their fluid and electrolyte shifts and things like that are going to become more and more compromised with time *
Slide 3
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
A) Decreased functional capacity
C) Decreased end-organ reserve
Slide 3
Aging leads to an increased incidence of ________.
A) Enhanced homeostatic balance
B) Reduced disease processes
C) Pathophysiological processes
D) Physiological processes
C) Pathophysiological processes
Slide 3
What percentage of people over 60 years old experience memory decline?
A) 30%
B) 40%
C) 50%
D) 60%
B) 40%
Slide 5
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
C) Not inevitable
Slide 5
In the elderly population, cerebral atrophy is characterized by a reduction in _ matter and neuronal shrinkage.
A) Red
B) Grey
C) White
D) Yellow
B) Grey
(only a small neuron loss)
Slide 6
In the aging process, there is a decrease in ___ matter, leading to functional changes.
A) White
B) Black
C) Red
D) Brown
A) White
Slide 6
Decreases in white matter in the aging brain leads to an increase in ___ size.
A) Cortical
B) Cerebral
C) Ventricular
D) Hippocampal
C) Ventricular
Slide 6
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
A) Mobility
B) Memory
E) Balance
Slide 6
The coupling of cerebral metabolic rate of oxygen (CMRO2) and cerebral blood flow (CBF) remains ___ on EEG waveforms in animal studies of aging.
A) Increased
B) Decreased
C) Unchanged
D) Irregular
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.
Slide 7
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
A) Dopamine
C) Acetylcholine (ACh)
D) Norepinephrine
E) Serotonin
Glutamate is unchanged.
slide 7
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
A) Decreased epidural space
C) Increased permeability of the dura
slide 8
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
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
slide 8
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, dorsal
D) Myelinated, ventral
D) Myelinated, ventral
Slide 8
In elderly patients, the distance between **Inter-Schwann cells ** ___ in the peripheral nervous system.
A) Increased
B) Decreased
C) Unchanged
D) Variable
B) Decreased
slide 9
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
D) Conduction velocity
slide 9
Elderly patients are more sensitive to both ___ and ___ nerve blocks.
A) Neuraxial, peripheral
B) Sympathetic, parasympathetic
C) Central, autonomic
D) Motor, sensory
A) Neuraxial, peripheral
Slide 9
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
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
Slide 10
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
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.
Slide 10
In elderly patients, the number of myocytes in the heart ___.
A) Remains unchanged
B) Increases
C) Decreases
D) Doubles
C) Decreases
Slide 10
Aging leads to a decrease in ______ cells, making elderly patients more susceptible to arrhythmias.
A) AV node
B) SA node
C) Myocyte
D) Purkinje
B) SA node
M - these patients become more susceptible to arrhythmias, particularly tachy and Brady syndromes.
Slide 10
With aging, the aortic valve becomes ___.
A) Thickened and calcified
B) Thinner and more flexible
C) More elastic
D) Narrower but soft
A) Thickened and calcified
Slide 10
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
A) Higher ventricular filling pressures
Slide 11
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
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. *
Slide 11
True or False
Elderly are more prone to decompensation during during neuroaxial anesthesia
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. *
Slide 11
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
A) Breakdown of collagen and elastin
Slide 12
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
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
Slide 12
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
A) Increased afterload and diastolic dysfunction
Slide 12
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
B) Increased lung compliance
Slide 13
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
D) Early airway collapse of small airways during exhalation
Slide 13
The early collapse of small airways during exhalation in elderly patients leads to ___.
Select 2
A) Increased anatomic dead space
B) Decreased closing capacity
C) Decreased gas exchange
D) Reduced oxygenation needs
E) Increased closing capacity
A) Increased anatomic dead space
E) Increased closing capacity
Slide 13
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
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…
slide 13
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
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.
Slide 14
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
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. *
Slide 14
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
A) Decreased vital capacity
B) Increased closing capacity
D) Increased residual volume
Slide 15
As elderly patients age, the total lung capacity ___.
A) Increases dramatically
B) Remains about the same
C) Decreases significantly
D) Fluctuates unpredictably
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.
Slide 15
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%
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. *
Slide 16
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
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. *
Slide 16
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
D) Less protective upper airway reflexes
E) Decreased esophageal motility
M - that puts them at a little bit of an aspiration risk.
Slide 16
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
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.
slide 17
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
A) Increased shunting
C) Decreased arterial oxygenation
Most important mechanism of action for alveolar-arterial oxygen gradient
Slide 17
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
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
Slide 18
Elderly patients often experience a decreased _____ in their kidneys, which can be exacerbated by comorbidities
A) Creatinine
B) A1C
C) BUN
D) GFR
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
Slide 18
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
B) Aldosterone
D) Vasopressin
F) Renin
M - this is gonna affect some of our drugs, especially the ones that are cleared through the kidneys.
Slide 18
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
B) UTIs
D) Urinary retention
Slide 18
As the liver function declines with age, which metabolic pathway is most affected?
A) Phase I
B) Phase II
C) Conjugation
D) Acetylation
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
Slide 19
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
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.
Slide 19
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
A) Promethazine
B) Prochlorperazine
D) Metoclopramide
Select 19
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
A) Decrease in muscle mass
C) Impaired wound healing
D) Osteoarthritis development
Subcutaneous fat thins
Slide 20
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
B) Elderly patients have a lower vasoconstriction threshold by about 1°C
Slide 21
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
D) Over 90 years old
Slide 23
Regarding operative risk, the** Djokovi and Hedley-Whyte** study found that which factor predicted mortality?
A) Age
B) ECG
C) ASA
D) Weight
C) ASA status
Select 23
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
B) Uncorrectable comorbidities
Select 23
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
B) Nursing home residents
Select 23
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
A) Recent fall
slide 24
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
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.
Slide 24
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
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
Slide 24
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
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. *
Slide 24
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
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
Slide 25
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
a) Dysfunctional anti-inflammatory response
b) Exaggerated neuroinflammation - and exaggerated acceleration of Alzheimers Disease (AD) pathology
Slide 25
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
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. *
Slide 25
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
d) Anti-inflammatory response
Slide 25
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
c) Transient neuroinflammation
d) Short-term cognitive decline
Slide 25
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
a) Amyloid β,
b) Tau,
d) Calcium,
e) Neuroinflammation - neuroinflammatory factors, things like tissue necrosis factor, interleukin
Slide 26
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
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
Slide 27
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
c) Extracellular space.
Slide 27
True or False
Amyloid-β is known to be toxic
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.
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
c) Disruption of cell membranes over time.
Slide 27
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.
B) Young mice had improved memory/learning, while old mice had accelerated dementia.
… unclear translation to humans; other factors clearly involved
Slide 28
Which class of medications can cause a significant increase in amyloid plaques?
A) Beta-blockers
B) Volatile anesthetics
C) Benzodiazepines
D) Anticholinergics
B) Volatile anesthetics
Halothane
Slide 28
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
B) Phosphorylated and aggregated τ (tau) proteins
Slide 29
What is destabilized by neurofibrillary tangles?
A) Synaptic connections
B) Neuronal membranes
C) Microtubules
D) Neurotransmitter release
C) Microtubules
Slide 29
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
B) 2-3 °C
Slide 29
Repeated exposure to which drugs will cause an increase in phosphorylated τ protein?
A) Propofol
B) Halothane
C) Isoflurane
D) Midazolam
E) Fentanyl
G) Sevoflurane
B) Halothane
C) Isoflurane
G) Sevoflurane
Slide 29
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
B) Mild cognitive impairment progressing to dementia
Slide 30
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
C) Ca⁺⁺ from ryanodine and IP₃ receptors of the endoplasmic reticulum
Slide 31
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
B) Neurotoxicity
Slide 31
Dantrolene, due to its calcium channel blocking effects, can cause significant ______________.
A) Cardiac arrhythmias
B) Skeletal muscle weakness
C) Increased muscle tone
D) Hypercalcemia
B) Skeletal muscle weakness
Slide 31
Neuroinflammation contributes to cognitive decline through the release of which inflammatory factors? (Select all that apply)
A) Cytokines
B) IL-6
C) TNFα
D) Dopamine
E) Serotonin
F) Acetylcholine
A) Cytokines
B) IL-6
C) TNFα
Slide 32
Which of the following anesthesia drugs are capable of modulating inflammation? (Select all that apply)
A) Dexamethasone
B) Lidocaine
C) Propofol
D) Toradol
E) Fentanyl
A) Dexamethasone
B) Lidocaine
D) Toradol
Slide 32
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
C) Bedford 1955
Slide 34
KMF
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
C) Post-operative cognitive dysfunction
Slide 35
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
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
Which of the following are recommended strategies to minimize anesthesia-related complications? (Select all 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
A) Using neuraxial/regional anesthesia when possible
C) Opioid sparing strategies
D) Neutralizing stomach acid with non-particulates
Slide 37
Which measures should be taken to improve patient safety during anesthesia? (Select all 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
A) Avoid long-acting NMBDs and reverse adequately
C) Consider using EEG-based titration
D) Pad skin and nerves
E) Avoid hypotension
Slide 37
What occurs to drugs due to decreased cardiac output secondary to aging? (Select all 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
B) Slower distribution to the site of action
C) Slower redistribution
D) Slower distribution to metabolic organs
Slide 38
What neuromuscular junction changes contribute to drug challenges in an aging patient? (Select all 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
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
Slide 39
What drug changes are seen in an aging patient regarding kidney/liver-dependent metabolism? (Select all 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
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 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.
Slide 40
The mortality rate for pulmonary resection in patients aged 80-92 years old is ____.
A) 1%
B) 3%
C) 5%
D) 10%
B) 3%
Slide 41
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
C) Lobectomy; pneumonectomy
Lobectomy mortality acceptable
Pneumonectomy mortality excessive
Slide 41
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
B) Pulmonary hypertension
Slide 42
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
C) Myocardial perfusion imaging
(dobutamine stress echo or thallium scan)
Slide 42
True or False
Patients with excellent exercise tolerance and no history of coronary artery disease can proceed to lung resection surgery.
True
Slide 42
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
A) Surgical revascularization
but if patient are deemded to be low risk, then they could proceed on with surgery
Slide 42
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)
B) (Preop FEV₁ %) x (1 - % of lung tissue removed / 100)
Slide 43
How many lung segments are there in total?
A) 30
B) 35
C) 42
D) 50
C) 42
Slide 43
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
B) 10; 10
Slide 43
How many lung segments are in the right lower lobe (RLL)?
A) 8
B) 10
C) 12
D) 14
C) 12
Slide 43
How many lung segments are in the right upper lobe (RUL)?
A) 4
B) 5
C) 6
D) 8
C) 6
Slide 43
How many lung segments are in the right middle lobe (RML)?
A) 2
B) 4
C) 5
D) 6
B) 4
Slide 43
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?
16/42 = 38%
4 (RML) + 12 (RLL) = 16
total segment = 42
Slide 43
Calculate
Predict the post-operative FEV₁ for a patient who had their right lower lobe removed. The patients preoperative FEV₁ is 70%.
(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
Slide 43
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
A) Respiratory mechanics, Cardiopulmonary reserve, Lung parenchymal function
Slide 44
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
A) Extubate in the operating room if the patient is alert, warm, and comfortable (AWaC)
Slide 45
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
B) Exercise tolerance, DLCO, V/Q scan, and associated diseases
Slide 45
How would the CRNA manage extubation on a post-thoracotomy patient if the ppoFEV₁ is less than 30%? (Select all 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%
B) Staged weaning from the ventilator
C) Consider extubation if ppoFEV₁ is >20% and thoracic epidural anesthesia is in place
Slide 45
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
B) An objectively measured decline in cognitive function that persists beyond the period expected
Slide 46
