Test 2: Geriatrics (pt 3/3) Flashcards
Generally, all medications given to an older adult are administered in a ______dose. (!!!)
Lower
What are the pharmacokinetic changes that lead to exaggerated responses and a prolonged duration of action in the elderly?
Changes in volume of distribution, renal/hepatic clearance rates, compartmental redistribution, and elimination 1/2 lives
What are the pharmacodynamic changes that lead to exaggerated responses and a prolonged duration of action in the elderly?
Altered receptor density and binding, changes in signal transduction, and impaired cellular responses
The minimal alveolar concentration (MAC) of inhalational agents decreases roughly ____% per decade from the MAC value of 40-year-old adults
6.7%
What is the NM blocking agent of choice for the older adult and why?
Cisatracurium, because it undergoes Hoffman elimination and ester hydrolysis and is not organ dependent.
What are the anesthetic considerations associated with administering propofol to an older adult?
Hypotension, prolonged recovery, increased brain sensitivity
What are the dose adjustments needed when giving propofol to an older adult?
-Decrease bolus and infusion by 50%
-Manufacturer recommends 1-1.5 mg/kg bolus for induction
What are the anesthetic considerations associated with administering etomidate to an older adult?
Increased brain sensitivity, greater hemodynamic stability
What are the dose adjustments needed when giving etomidate to an older adult?
Decrease bolus by 50%
What are the anesthetic considerations associated with administering opioids to an older adult?
-Increased brain sensitivity
-profound physiologic effects
-slower onset and delayed recovery
-consider route of metabolism and metabolites
-avoid meperidine
What are the dose adjustments needed when giving opioids to an older adult?
Decrease bolus by 50%
What are the anesthetic considerations associated with administering Midazolam to an older adult?
Increased brain sensitivity, avoid per Beers Criteria
What are the dose adjustments needed when giving Midazolam to an older adult?
AVOID
Decrease dose by 75%
What are the anesthetic considerations associated with administering Nondepolarizing MRs to an older adult?
-Slower onset and delayed recovery
-consider route of metabolism and metabolites
-Avoid long-acting NDMRs
What are the dose adjustments needed when giving Non-depolarizing MRs to an older adult?
No significant changes with intubating dose
Maintenance dose per PNS twitch response
What are the anesthetic considerations associated with administering Depolarizing MRs to an older adult?
Slower onset and delayed recovery
What are the dose adjustments needed when giving Depolarizing MRs to an older adult?
No dose adjustment
What are the 4 basic principles in ethical decision making that apply to the older adult? (Same as for all patients)
1) Autonomy
2) Beneficence
3) Nonmaleficence
4) Justice
What is autonomy?
The patient’s right to self-determination
-Informed consent, advanced directives (DNR)
What is beneficence?
An obligation or responsibility to help the patient. To do good
What is nonmaleficence?
To not intentionally harm the patient. Do no harm
What is justice?
To treat the patient fairly (regardless of age, race, cultural beliefs, religion, disease process, resuscitation status, etc)
A major neurocognitive disorder characterized by memory change or decline in memory, language, problem-solving, and other cognitive skills that affect a person’s ability to perform everyday activities.
Dementia
What are common causes of dementia?
-Alzheimer’s Dz
-Vascular Dementia
-Parkinson’s Dz
All types of dementia are associated with:
Behavioral, cognitive, and/or functional decline
A comprehensive assessment of cognition includes:
-Assessment of decision-making capacity
-Assess cognition using Mini-Cog test as per recent ACS/AGS guidelines or the MoCA
-Identify risk factors for developing postoperative delirium
-Identify reversible causes of dementia
-Communication and coordination of care with geriatrician when appropriate
A slowly progressive brain disease characterized by beta-amyloid protein deposits, intracellular neurofibrillary tangles, and loss of neurons.
-Most common cause of dementia (60-80%)
Alzheimer’s Dz
-Risk factors: HTN and DM
-10% of dementia cases
-Location, number, and size of infarcts is directly r/t the degree of decline
Vascular Dementia
What is mixed dementia?
Vascular infarcts found with Alzheimer’s Dz
A progressive degenerative disorder of the basal ganglia associated with a deficiency in dopamine
-Behavioral, cognitive, and functional decline
Parkinson’s Dz
What are causes of reversible dementia?
-medications
-alcohol
-metabolic disorders
-depression
-CNS neoplasms
-normal-pressure hydrocephalus
The anesthetic plan should be based on what?
-patient condition
-surgery
-baseline neurologic impairment
The use of benzodiazepines and antihistamines are associated with the development of _____, and should be avoided during the perioperative period.
Delirium
Which patients may benefit from the use of Regional Anesthesia?
-Poorly controlled preop pain
-Chronic opioid users
-Anticipated high postop opioid requirements
What are the most frequently occurring neurologic phenomena in older adults?
Postoperative Delirium and Postoperative Cognitive Dysfunction (POCD)
Characterized by disruption of perception, thinking, memory, psychomotor behavior, sleep-wake cycle, consciousness, and attention.
Postoperative Delirium
Postoperative Delirium is associated with an increased risk of:
-Periop mortality
-Institutionalization
-Dementia
What are risk factors for postop delirium?
-Renal insufficiency
-Metabolic derangements
-Poorly controlled pain
-Polypharmacy (psychoactive drugs)
-Functional impairment
-Urinary retention
-Foley catheter
-Use of benzos and antihistamines and anticholinergics
A predictor for postoperative delirium. Associated with an increased risk for cardiac events and death.
-Continue antidepressants perioperatively
Depression
An array of cognitive impairments such as memory deficits, difficulty with concentration, impaired comprehension, and delayed psychomotor speed.
-Subtle onset, deficits may not present for weeks to months after surgery
-Inability to work, decline in ADLs, need for assisted care
Postoperative Cognitive Dysfunction
How do you prevent postoperative cognitive dysfunction?
-Maintain oxygenation & cerebral perfusion
-Surgeries should be as short or as minimally invasive as possible
-Multimodal pain mgmt plan
