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APEX > Unit 11 - Geriatrics > Flashcards

Unit 11 - Geriatrics Flashcards

1
Q

most significant risk factor for developing cancer

A

old age

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2
Q

metabolic equivalent =

A

metabolic rate of a specific physical activity / metabolic rate at rest

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3
Q

1 MET = ____ mL O2/kg/min

A

3.5

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4
Q

a “yes” to what 2 questions indicates the patient is ok for surgery without the need for additional cardiac testing

A
  1. Can you walk up a flight of steps without stopping?
  2. Are you able to walk 4 blocks without stopping?
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5
Q

activities that = 1 MET

A
  • self care activities
  • working at computer
  • walking 2 blocks slowly
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6
Q

activities that = 2 METs

A
  • climbing a flight of stairs w/o stopping
  • walking 1-2 blocks uphill
  • light housework
  • raking leaves
  • gardening
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7
Q

approx oxygen consumption assoc with 4 METs

A

~1000 mL O2/min

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8
Q

approx oxygen consumption assoc with 4 METs

A

~1000 mL O2/min

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9
Q

METs assoc with poor, good, and outstanding functional capacity

A

1 MET = poor
4 METs = good
10 METs = outstanding

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10
Q

may be a better tool to predict functional status vs. METs

A

DSA - duke activity status index

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11
Q

how is frailty characterized

A

decreased reserve coupled with reduced resistance to stress (physiologic, physical, or psychosocial)

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12
Q

for every MET a patient can achieve, mortality decreases by:

A

11%

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13
Q

why do geriatric patients have an increased Vm

A

increased dead space necessitates an ↑ Vm to maintain a normal PaCo2

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14
Q

key resp changes in geriatric patients:
* Vm
* lung compliance
* lung elasticity
* chest wall compliance
* response to hypercarbia & hypoxia
* protective reflexes
* upper airway tone

A
  • Vm & lung compliance increased
  • the rest are decreased
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15
Q

why are geriatric patients at increased risk of respiratory failure

A

decreased PaO2, lung elasticity, and chest wall compliance all decrease pulmonary reserve

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16
Q

consequences of loss of elastic recoil in elderly pts

A

promotes small airway collapse

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17
Q

consequences of small airway collapse in geriatric patients

A

↑ dead space
↓ alveolar surface area
↑ V/Q mismatch
↑ A-a gradient
↓ PaO2
Altered lung volumes & capacities

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18
Q

what causes gas trapping in geriatric patients

A

The aged lung tissue has high compliance (it’s easy to inflate) BUT it has low elasticity (it’s harder for it to return to its original shape)

RV increases

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19
Q

what causes decreased chest wall compliance in geriatric pts

A

↑ Calcification of joints
↑ Diaphragmatic flattening
↑ A-P diameter
↓ Intervertebral disc height
↓ Respiratory muscle strength (↓ muscle mass)
↓ Lung elastic recoil

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20
Q

why are geriatric patients less responseive to hypercarbia & hypoxia

A

The chemoreceptors are less sensitive to changes is pH, PaCO2, and PaO2

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21
Q

why are geriatric patients at increased risk of aspiration

A

Reduced efficiency of cough and swallowing
* Greater stimulus is required to elicit the cough reflex
* ↑ Risk of aspiration

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22
Q

consequences of decreased upper airway tone in geriatric patients

A

Decreased respiratory muscle strength
↑ Risk of respiratory failure
↑ Risk of upper airway obstruction

Consider PAP or BiPAP in at-risk patients

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23
Q

why do geriatric patients have an increased FRC

A
  • reduced elastic recoil allows lungs to overfill with gas
  • increases RV and therefore FRC

RV = volime that remains in lugns after full exhalation

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24
Q

at what age does Closing capacity surpasses FRC in supine position

A

~45 yrs

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25
Q

at what age does CC surpass FRC when standing

A

~65 yrs

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26
Q

consequence of CC surpassing FRC in geriatric pt

A

small airways will collapse during tidal breathing

sets the stage for V/Q mismatch, increased anatomic dead space, and a reduction in PaO2

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27
Q

consequence of CC surpassing FRC in geriatric pt

A

small airways will collapse during tidal breathing

sets the stage for V/Q mismatch, increased anatomic dead space, and a reduction in PaO2

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28
Q

lung volumes that are increased in geriatric pts

A

RV
FRC
CC

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29
Q

lung volumes that are decreased in geriatric pts

A

VC
ERV

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30
Q

TLC in geriatric patients

A

unchanged

↑ RV + ↓ VC = 0 net change

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31
Q

what causes decreased VC in geriatric patients

A
  • reduced lung elastic recoil
  • increased chest wall stiffness
  • weaker respiratory muscles
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32
Q

FRC is determined by the balance between what 2 things

A
  1. lung elastic recoil
  2. chest wall compliance
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33
Q

what causes chest wall stiffness in geriatric pts

A
  • arthritic changes in costovertebral joints
  • intercostal cartilage calcification
  • atrophy of intercostal muscles
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34
Q

IRV in geriatric patients

A

decreased

↑ FRC reduces IRV

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35
Q

ERV in geriatric patients

A

decreased

↑ RV reduces ERV

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36
Q

ERV in geriatric patients

A

decreased

↑ RV reduces ERV

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37
Q

FEV & FEV1 in geriatric patients

A

decreased

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38
Q

most common coexisting disease in the elderly

A

cardiac disease

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39
Q

4 most common CV conditions in geriatric pts

A
  1. hypertension
  2. CAD
  3. CHF
  4. myocardial ischemia
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40
Q

2 best indicators of cardiac reserve

A
  • Exercise tolerance
  • ability to perform daily living activities
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41
Q

lung volumes that are decreased with age

A

VC
ERV
IRV
FEV
FEV1

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42
Q

lung volumes that are increased in geriatric pts

A

RV
FRC
CC

43
Q

causes of increased BP in geriatric pts related to aging

A
  • loss of elastin and increased collagin
  • increased SVR and afterload
44
Q

hypertrophy assoc with aging

A

concentric

increased LV thickness

45
Q

hypertrophy assoc with aging

A

concentric

increased LV thickness

myocytes that die are not replaced - cells that remain increase in size

46
Q

why do geriatric patients experience greater BP lability with induction or acute blood loss

A

vascular stiffness = decreased venous capacitance

47
Q

why does diastolic dysfunction develop with age

A

impaired relaxation

48
Q

what increases risk of A-fib in geriatric patients

A

Atria generate higher pressure to prime the non-compliant ventricle = atrial enlargement and risk of atrial fibrillation

49
Q

why are geriatric patient at increased risk of dysrhythmias

A
  • fibrosis of conduction system
  • loss of SA node tissue
50
Q

dysrhythmias geriatric pts are at increased risk for

A
  • A-fib
  • 1st degree block
  • 2nd degree block
  • sick sinus syndrome
51
Q

BP changes in geriatric patients

A
  • increased SBP, DBP, and PP
  • Arterial stiffness increases SBP to a greater degree than DBP
52
Q

why is aging assoc with reduced exercise tolerance and cardiac reserve

A

diminished ability to increase stroke volume

leads to decreased CO

53
Q

HR changes in geriatric patients

A
  • ↓ Responsiveness to catecholamines
  • ↓ Response to hypotension, hypovolemia, and hypoxia
  • Decrease in maximal HR
54
Q

maximal HR calculation

A

220 - age

55
Q

VTE risk in geriatric patients

A

increased - meet all 3 components of Virchow’s triad

  1. Venous stasis
  2. Hypercoagulability
  3. Endothelial dysfunction
56
Q

response to catecholamines with age

A

decreased

57
Q

why are geriatric pts at increased risk of orthostatic hypotension

A

decreased baroreceptor responsiveness

58
Q

SNS and PNS tone in geriatric pts

A

SNS = increased
PNS = decreased

59
Q

why is SNS tone increased in geriatric pts

A

Higher norepinephrine concentration in the plasma

This effect is blunted by reduced beta receptor sensitivity and reduced coupling with adenylate cyclase

60
Q

beta receptors in geriatric population

A

reduced sensitivity d/t reduced receptor affinity & changes in signal transduction

61
Q

change in MAC with age

A

decreases 6% every decade after age 40

62
Q

consequences of decreased baroreceptor responsiveness in geriatric pts

A

increases risk of:
* Orthostatic hypotension

* Syncope
* Greater degree of hemodynamic compromise following sympathectomy

63
Q

why are geriatric pts at increased risk of hypothermia

A

impaired thermoregulation

64
Q

neurotransmitter activity changes in geriatric pts

A

Reduced activity of Ach, NE, DA, and GABA

Number of receptors may be reduced

65
Q

neurotransmitter activity changes in geriatric pts

A

Reduced activity of Ach, NE, DA, and GABA

Number of receptors may be reduced

66
Q

changes in peripheral nerves with age

A
  • Reduced number of myelinated nerves
  • Degeneration of nerves that remain reduces function
67
Q

onset of postop delirium

A

early postop

68
Q

most common periop CNS complication in geriatric pts

A

postop delirium

69
Q

presentation of postop delirium

A

Disordered behavior, perception, memory, psychomotor skills

70
Q

presentation of Postoperative Cognitive Dysfunction

A

Impaired concentration, comprehension, psychomotor skills

71
Q

risk factors for postop delirium

A

DELIRIUM:
* Drugs (use rapidly metabolized drugs)
* Electrolyte imbalance
* Lack of drugs (withdrawal)
* Infection (UTI and respiratory)
* Reduced sensory input
* Intracranial dysfunction
* Urinary retention and fecal impaction
* Myocardial event, male gender

72
Q

risk factors for postop cognitive dysfunction

A

Advanced age (most significant)
Pre-existing cognitive deficit
Cardiac surgery
Long duration of surgery
High ASA status
Low level of education
Anesthetic agents ???

73
Q

treatment of postop delirium in geriatric pts

A

Treat underlying cause
Antipsychotics
Minimize polypharmacy

74
Q

treatment of postop cognitive dysfunction

A

No specific treatment

Most cases are mild and tend to resolve after ~ 3 months

75
Q

onset of postop cognitive dysfunction

A

weeks to months postop

76
Q

changes in geriatric pts that affect neuraxial anesthesia

A
  • ↓ CSF volume
  • ↓ volume of epidural space
  • ↓ diameter of dorsal & ventral nerve roots
  • ↑ permeability of dura
77
Q

peripheral changes in geriatric pts that affect neuraxial anesthesia

A
  • ↓ inter Schwann cell distance
  • ↓ conduction velocity
78
Q

why are geriatric patients at risk for greater block height with epidural anesthesia

A
  • decreased epidural space volume = greater LA spread
  • dura is more permeable to LAs
79
Q

why are geriatric pts at risk of greater block height with spinal anesthesia

A
  • decreased CSF volume = greater spread
  • dura more permeable to LAs

give ↓ dose

80
Q

why are geriatric patients at increased risk of false negative response to epidural test dose

A

↓ myocardial sensitivity to catecholamines

81
Q

why are geriatric pts predisposed to fluid overload and dehydration

A

impaired:
* sodium handling
* ability to concentrate urine
* capacity to dilute urine

82
Q

serum Cr changes in elderly pts

A

no change
* GFR decreases with age (theoretically should ↑ serum Cr)
* Muscle mass also decreases with age (less Cr produced)

These 2 processes cancel each other out (net = unchanged Cr)

83
Q

RBF changes with age

A

Decreases 10% per decade

84
Q

what contributes to decreased renal mass in elderly

A
  • decreased nephrons (cortex > > > medulla)
  • loss of functioning glomeruli
85
Q

why does ability to concentrate urine decrease with age

A
  • Increased flow through medullary nephrons washes out solute, reducing osmolarity in this region
  • ↓ Concentration gradient necessary to produce concentrated urine
86
Q

reduced CrCl in elderly is a function of what 2 things

A
  • ↓ Renal blood flow brings less creatinine to the nephron per unit time
  • There are less nephrons to clear creatinine
87
Q

most sensitive indicator of renal function and drug clearance in the elderly

A

CrCl

88
Q

normal GFR in adult male

A

~125 mL/min

89
Q

changes in GFR with age

A

decreases by 1 mL/min/year after age 40

90
Q

why are elderly patients at increased risk of fluid overload

A

↓ GFR
less plasma delivered to nephrons per unit time

91
Q

why do elderly patients have a reduced response to acid load

A

reduced capacity of the renal tubules to secrete ammonium

92
Q

why does ability to conserve sodium decrease with age

A

decreased aldosterone sensitivity

93
Q

alpha 1 glycoprotein levels in elderly

A

increased

Increased reservoir for basic drugs
Insignificant in clinical practice

93
Q

alpha 1 glycoprotein levels in elderly

A

increased

Increased reservoir for basic drugs
Insignificant in clinical practice

94
Q

alpha 1 glycoprotein levels in elderly

A

increased

Increased reservoir for basic drugs
Insignificant in clinical practice

95
Q

albumin production level in elderly

A

decreased

Decreased reservoir for acidic drugs
Insignificant in clinical practice

96
Q

hepatocellular function with age

A

no change
less total enzymes produced but they function normally

97
Q

what causes decreased periop hepatic function

A
  • Reduced as a function of ↓ blood flow & ↓ liver mass
  • NOT because of impaired hepatocellular function
98
Q

changes in first pass metabolism with age

A

decreased d/t reduced hepatic mass and liver blood flow

99
Q

pseudocholinesterase production in elderly

A

decreased

Prolonged duration of succs and ester LAs
Men > women

100
Q

consequences of decreased muscle mass in elderly

A
  • ↓ Basal metabolic rate
  • ↓ Total body water
  • ↓ Blood volume
  • ↓ Plasma volume
101
Q

why do elderly patients have prolonged elimination of lipophilic drugs

A

↑ total body fat = ↑ increased Vd of lipophilic drugs

102
Q

Vd for lipophilic and hydrophilic drugs in elderly

A

increased for lipophilic
decreased for hydrophilic

APEX (54 decks)

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