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AP 1 > Test 2: Geriatrics (pt 2/3) > Flashcards

Test 2: Geriatrics (pt 2/3) Flashcards

1
Q

Older adults have a decrease in GFR of roughly _____ to ____%, secondary to what?

A

25-50% decline secondary to atrophy of kidney parenchymal tissues, deterioration of renal vascular structures, decreased renal mass, and decreased renal blood flow.

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2
Q

Due to their decreased GFR, renal patients are at risk for what?

A

1) Fluid overload
2) Accumulation of metabolites and drugs that are excreted by the kidneys
3) Decreased drug elimination (prolonged effects of a wide range of anesthetic drugs and adjuncts)
4) Electrolyte imbalances (risk of arrhythmias)
5) Dehydration

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3
Q

Serum creatinine is _____ if there is no renal failure because of decreased creatinine production from the overall declining skeletal muscle mass associated with aging.

A

Unchanged.

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4
Q

What is the best indicator of drug clearance?

A

Creatinine clearance

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5
Q

Why are the elderly at high risk for CKD?

A

1) Coexisting diseases (HTN, CVD, DM, COPD)
2) Frailty
3) Complex Medical Regimens & Polypharmacy

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6
Q

The aging adult liver decreases in mass by approximately ____ to ____% and may be attributed to the ______ in its blood flow.

A

20% to 40%; decrease

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7
Q

What affects on drug metabolism and protein binding are seen with age related hepatic changes?

A

1) Decreased drug metabolism, prolonged 1/2 life, and inc/dec distribution of medications
2) Serum albumin decreases & Alpha-1 acid glycoprotein (AA) Increases

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8
Q

Albumin primarily binds what kind of drugs?

A

Acidic drugs - like Benzos and Opioids

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9
Q

Alpha-1 Acid Glycoprotein (AAG) binds what kind of drugs?

A

Basic drugs - like Local Anesthetics

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10
Q

Due to aging, there is a _____ in number and function of the pancreatic islet beta cells that results in _______ insulin secretion.

A

decline; decreased

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11
Q

Why are the elderly more likely to be glucose tolerant or diabetic?

A

Insulin resistance occurs peripherally, which contributes to increased hepatic production of glucose and impaired breakdown of fats and proteins.

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12
Q

Peripheral Insulin Resistance (DM) increases the risk for what?

A

-CVD & HTN
-Periop and postop complications (CVA, MI, Ketoacidosis, Infection)
-Compromise in one or more organ systems

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13
Q

Why is there a decrease in the basal metabolic rate (BMR) as a result of aging?

A

-Decreased physical activity
-Decreases in testosterone & Growth Hormone

Decreased BMR has an effect on muscle mass and thermoregulation.

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14
Q

Skeletal muscle mass and strength declines with aging with _____% of skeletal mass being lost by the age of 80 years.

A

50%

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15
Q

Why is there a significant loss in body protein associated with aging?

A

-decrease in skeletal muscle mass
-alterations in carrier proteins (e.g., albumin and AAG).

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16
Q

Increased body fat with the aging adult is distributed where?

A

-Viscera
-Subcutaneous abdomen
-Intramuscular
-Intrahepatic

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17
Q

What are skin changes associated with aging?

A

-Decreased dermal and epidermal thickness of the skin (loss of collagen & elastin)
-Decrease in subcut fat and thinning of skin make them prone to skin tears and nerve injuries

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18
Q

Blood volume decreases approximately ____ to ____% by age 75 years.

A

20-30%

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19
Q

Older adults are more vulnerable to what as a result of the decrease in TBW?

A

Hypotension; difficulty compensating for position changes

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20
Q

Decreased function of the hypothalamus causes what?

A

Impairment of thermoregulation

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21
Q

Why is hypothermia more pronounced and lasts longer in the elderly?

A

-Lower BMR
-High ratio of surface to body area mass
-Less effective peripheral vasoconstriction in response to cold

22
Q

Why is hypothermia particularly detrimental in the elderly patient?

A

-Slows anesthetic elimination
-Prolongs recovery from anesthesia
-Impairs coagulation
-Impairs immune function
-Blunts the ventilatory response to CO2
-Increased shivering (which increases O2 consumption, leading to hypoxia, acidosis, and cardiac compromise)

23
Q

Older adults produce less heat per kg of body weight, predisposing them to what?

A

Being unable to maintain their heat in cool environments, and making it more difficult to restore a normal body temperature once they are hypothermic.

24
Q

What are the methods of maintaining normothermia?

A

-Prevention of heat loss
-Active warming methods
-Warm IVF/blood products
-Forced air warming devices
-HME (environmental humidity higher than 50%)

25
Q

Age-related physiologic changes of the central nervous system (CNS) are characterized by what?

A

-a progressive loss of neurons and neuronal substance
-decreased neurotransmitter activity
-decreased number of myelinated nerve fibers
-decreased brain volume

26
Q

Where are these CNS losses most prominent?

A

Cerebral cortex, particularly the frontal lobe

27
Q

What do these CNS losses cause?

A

Changes in mood, memory, and motor function

28
Q

Why are older patients more sensitive to CNS depressants and anesthetic agents (General anesthetics, hypnotics, opioids, and benzos)?

A

-Number of available receptors is decreased
-Blood-Brain Barrier is more permeable (also contributes to neurocognitive disorders such as Alzheimer’s Dz)

29
Q

The dose of induction agents should be decreased by as much as ____% in older patients, arguing for very meticulous titration.

A

50%

30
Q

Why should Benzodiazepines be avoided in older adults?

A

They contribute to adverse events (i.e., falls, confusion, POD).

31
Q

BIS <___ has an increase in M/M in geriatric population

A

40

32
Q

Why would BIS monitoring be beneficial in the elderly?

A

-To guide titration of anesthesia and speed recovery times
-To decrease the incidence of postop delirium and cognitive dysfunction

33
Q

What are anatomic changes in the elderly that put them at risk for complications with Neuraxial anesthesia?

A

-Decreased # of myelinated nerve fibers (risk for nerve damage)
-Decreased intervertebral disc height, narrowing of the intervertebral foramina, decreased space between the posterior spinous processes, presence of calcifications, and changes in lordosis.
-Dura is more permeable to local anesthetics
-CSF spec grav increases, and its volume decreases

34
Q

What are the dosing recommendations r/t neuraxial anesthesia in the older adult?

A

-Alterations in the nervous system may produce a more enhanced spread of local anesthetics for subarachnoid blocks
-Decreased dose of local anesthetics is recommended for subarachnoid and epidural blockade

35
Q

Are subarachnoid and epidural blocks contraindicated in the elderly patient?

A

No, but weigh pros/cons.

36
Q

What are the overall CNS changes in the older adult?

A

-Dec in gray & white matter
-Small overall loss of neurons
-Atrophy
-Increased ventricular size
-Decreased epidural space & CSF volume
-Increased dura permeability
-More sensitive to RA and Neuraxial
-Dec Dopamine, Ach, NE, and serotonin
-Intact electrical activity, cerebral metabolic rate, and cerebral blood flow

37
Q

Why are older adults more sensitive to RA and neuraxial?

A

-Decreased epidural space
-Decreased CSF volume
-Increased Dura Permeability

38
Q

What are the 4 legally relevant criterion for decision-making capacity?

A

1) Understanding his/her treatment options
2) Appreciating and acknowledging his/her medical condition and likely outcomes
3) Exhibiting reasoning and engaging in a rational discussion of his/her surgical treatment options
4) Clearly choosing a preferred treatment option

39
Q

Frail older adults are more likely to have what?

A

-Increased risk for adverse outcomes
-Decreased resistance to stressors
-Complications postoperative
-Longer hospital LOS
-Discharged to a skilled or assisted living facility

40
Q

A biologic state associated with increased vulnerability to adverse outcomes that result from decreased resistance to stressors as a result of deterioration in multiple physiologic systems.

A

Frailty

41
Q

Frailty rates have been reported to be ___ to ___% in surgical patients.

A

4.1 - 50.3%

42
Q

What is primary frailty?

A

Frailty that occurs as part of the intrinsic process of aging.

43
Q

What is secondary frailty?

A

Related to the end-stage of chronic illnesses and is caused by inflammation and wasting, for example heart failure, COPD, inflammation, and wasting associated with cancer.

44
Q

What are Fried’s physiologic parameters of frailty?

A

-grip strength
-weight loss
-walking speed
-energy level and physical activity

45
Q

How do you measure a severe nutritional risk in the geriatric surgical patient?

A

1) BMI < 18.5 kg/m2
2) Serum Albumin <3g/dL (without evidence of renal or hepatic dysfunction)
3) Unintentional weight loss >10-15% within past 6 months

46
Q

Malnutrition and protein deficiency are associated with what complications?

A

-Increased risk of postop complications (SSI, PNA)
-Increased hospital LOS
-Increased Mortality

47
Q

How do you assess functional status?

A

-Ability to perform self-care tasks or ADLS
-Ability to perform instrumental activities of daily living (preparing meals, finances, driving, etc)
-Deficits in vision/hearing

48
Q

The current level of function is a predictor for _____ outcomes.

A

Long-term

49
Q

Impaired preop functional status predicts:

A

-Longer postop recovery time
-Poor postop outcome
-Inc risk for post-op dementia
-Inc hospital LOS

50
Q

___ metabolic equivalents (METS) cardiac reserve is needed to tolerate most surgeries.

A

4

51
Q

The most important surgical outcome in the perioperative care of older adults is?

A

Avoidance of functional decline and maintenance of independence (return to baseline) !!!

AP 1 (32 decks)

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