Wk 11: Geriatrics Flashcards
1
Q
Geriatrics is the area of medicine that supports those who could be considered _________, while “elderly” is a description of an _____ group
A
elderly
age
2
Q
Elderly = ____ years and older
-______ adults
-________
-________ citizen
A
65
Older adults
Elderly
Senior Citizen
3
Q
Increase of ____% in the last 50 years (US)
2030: projected ____ million
2050: projected ____ million
Arizona: ___% are older adults
A
300%
73 million
83 million
19.3%
4
Q
Elderly prone to:
-Progressive decline of _______ functions
-Age-related ________ disease
-Increase in ____ physical status
A
baseline
comorbid
ASA
5
Q
Factors that influence perioperative outcomes
-_________ surgery
-Number of __________
-_______ of surgical procedure
A
Emergency
comorbidities
Type
6
Q
Most common postoperative complications
-_________
-_________
-_________
A
Cardiac
Pulmonary
Neurologic
7
Q
Best Practice Guideline Optimal Preoperative Assessment for the Elderly Surgical Patient
-________ ability capacity
-__________ making capacity
-____________
-Risk for postoperative __________
-________ and ________ abuse
-__________
-_________
-________
-___________ status
-Medications (BEERS CRITERIA) review rx, herbal, OTC meds)
-Patient ___________
A
cognitive ability capacity
decision making capacity
depression
risk for postoperative delirium
alcohol and substance abuse
cardiac
pulmonary
frailty
functional status
Medications
Patient counseling
8
Q
________ Criteria American Geriatric Society
For use in all ambulatory, acute, and institutionalized settings of care for populations aged _____ and older in the US
A
Beer’s
65
9
Q
Beer’s Criteria
Improve ________ selection, educate ________ and _______, reduce adverse ______ events and serve as a tool for evaluating ______ of care, ____, and patterns of _____ use of older adult
A
medication
clinicians
patients
drug
quality
cost
drug
10
Q
Beer’s Criteria
-DC meds that have potential reaction with ___________
-DC nonessential meds that increase _________ _______
-Identify meds on _______ criteria
-Avoid _________ (GI bleed, AKI)
-Avoid__________ for analgesia (delirium)
-use caution with ________ or with strong __________ effects
A
anesthesia
surgical risk
Beer’s
Ketorolac
Meperidine
Antihistamines
Anticholinergic
11
Q
Aging and Physiological Function
-Aging not synonymous with poor_________ health
-__________ age no longer an indicator or morbidity and mortality
-Age ____ peak age, then gradually declines
A
physiological
Chronological
30
12
Q
Cardiovascular Changes in Elderly
-______ most common cardiac complication and leading cause of death in postoperative period
-Most common CV diseases: (4)
A
MI
HTN, hyperlipidemia, CAD, Congestive heart failure
13
Q
Cardiovascular Changes in Elderly
___________ cardiac assessment for non-cardiac surgery
A
Complete
14
Q
CV Changes
- Structural and ________ changes in heart, _______, and _____
A
functional, vessels, ANS
15
Q
CV Changes
Heart and vascular system less ______-> ventricular ________ and ________ ejection time -> _______ dysfunction
A
compliant
hypertrophy
PROLONGED
diastolic
16
Q
CV Changes
Prolonged circulation time causes a _____ induction time with inhaled agents, but ______ the onset of intravenous drugs
A
faster
delays
17
Q
CV Changes
______ conduction system: _____, _____, ______ (pacemakers)
A
Calcified
Afib
SSS
blocks
18
Q
CV Changes
Faster ________ of pulse pressure waveform d/t ____ __________ and _______ __________
A
propagation
LV hypertrophy
arterial stiffening
19
Q
CV Changes
_____ afterload
______ SBP
A
Increased
Increased
20
Q
Age-Related CV Changes (Anesthetic Implications)
Myocardial hypertrophy: failure to maintain _________ (_____ )
A
preload (CHF)
21
Q
Age-Related CV Changes (Anesthetic Implications)
Myocardial stiffening: Ventricular _______ dependent on atrial pressure
A
failure
22
Q
Age-Related CV Changes (Anesthetic Implications)
Reduced _____ relaxation: ________ dysfunction
A
LV
diastolic
23
Q
Age-Related CV Changes (Anesthetic Implications)
Reduced ____ - receptor responsiveness: ________, _________
A
beta
Hypotension
Frank-Starling (increased dependence on)
24
Q
Age-Related CV Changes (Anesthetic Implications)
Conduction _________: severe _________ with potent opioids, decreased _____
A
abnormalities
bradycardia
cardiac output
25
Age-Related CV Changes (Anesthetic Implications)
Stiff ______: labile ____
arteries
BP
26
Age-Related CV Changes (Anesthetic Implications)
Stiff _____: changes in blood volume
-> ______ changes in cardiac _______
veins
exaggerated
filling
27
Starling's Law
As a result of the decreased contractile response to beta-adrenergic stimulation, the elderly depend on _____ -_______ to maintain cardiac output
Frank-Starling
28
Starling's Law
______ _______ of the heart increases in response to an increase in the _______ of blood filling the heart (end diastolic volume) when all other factors remain constant
Stroke volume
volume
29
Starling's Law
The more cardiac muscle is _______, the harder they _________
Rubber band analogy
stretched
contract
30
Heart Rate
_______ amounts of catecholamines-> _____ end-organ adrenergic response
increased
decreased
31
Heart Rate
________ capacity to _______ heart rate response to hypotension, hypovolemia, hypoxia
Decreased
Increase
32
Heart Rate
________ of conduction system-> loss of ____ node cells-> ___, ___, ____ and _____ degree blocks-> pacemaker
calcification
SA
afib
SSS
1st and 2nd
33
Heart Rate
________ of valvular system-> (_____ and _____) valvular stenosis/regurgitation
calcification
aortic
mitral
34
Heart Rate
Sympathetic nervous system activity _____ d/t ____ amounts of catecholamines
increases
increased
35
Circulation time (prolonged)
INDUCTION
__________ inhalation time d/t _______ cardiac output
_________ intravenous time (decreases propofol by ___%)
faster
lower
Slower
50
36
Circulation time (prolonged)
EMERGENCE
_________ d/t lower cardiac output
Slower
37
Lung Volume Changes
Loss of _______ ______ _______ of the lung
Reduced functional ______ _______ _______ available for gas exchange
elastic tissue recoil
alveolar surface area
38
Lung Volume Changes
_______ in vital capacity
_______ in residual volume
_______ in functional residual capacity
(FRC)
_______ in inspiratory reserve volume and expiratory reserve volume
Decrease in VC
Increase in RV
Increase in FRC
Decrease in inspiratory reserve
volume and expiratory reserve
volume
39
Lung Volume Changes
Overall impaired efficiency of ______ ______
gas exchange
40
Closing Capacity
Closing volume is the volume towards the end of a ______ _______
forced expiration
41
Closing Capacity
Closing volume exceeds FRC at _____ years in erect position
Closing volume exceeds FRC at ____ years in supine position
65
45
42
Chest wall compliance _______
decreases
43
Chest Wall Compliance decreases
_______ of the chest wall, _________and __________ joints
Calcification
intervertebral
intercostal
44
Chest Wall Compliance decreases
______ intercostal mass
_______ chest wall compliance
_______ of the diaphragm
Loss of intervertebral _______, changes in spinal __________
decreased
decreased
flattening
height
lordosis
45
Pulmonary Changes
Impaired gas exchange therefore PaO2 _______ with age
PaO2 = ______- ( ____ x age) mm/Hg
declines
100
0.4
46
Airway Anatomic Differences
-Decrease in _____ and _____ support: obstruction
-_________: Poor mask ventilation
-_________: Decreased ROM
- Decrease in protective ______ reflexes: Increased risk of _________
laryngeal
pharyngeal
Edentulous
Arthritis
laryngeal
aspiration
47
Postoperative Pulmonary Complications
_____ alone and co-existing _______ disease = increased PPC
Age
pulmonary
48
PPC's include:
-____________
-____________
-exacerbation of ________ disease
-_______ lung disease
-______________
- Prolonged __________ _________
-Postop respiratory ____________
Atelectasis
Bronchospasm
underlying
chronic
pneumonia
mechanical ventilation
failure
49
Renal function
Serum creatinine remains stable: A normal creatinine level in the elderly should not be interpreted as an _______ of renal impairment
absence
50
Renal function
Progressive ________ of renal tissue. ______ renal mass and ________ of vascular structures: decreased renal ____ ______ and _____ ______ _______
atrophy
decreased
sclerosis
blood flow
glomerular filtration rate
51
Renal function
Decreased GFR leads to delayed renal drug _______ ( ________ drugs), increased risk of ______
excretion
hydrophilic
CKD
52
Renal function
Decreased ability to correct alterations in ________ concentrations , ________ volume, and ______ _______
electrolyte
intravascular
free water
53
Hepatic function
Decreased liver ______ and reduced portal and hepatic _____ ______ result in decreased hepatic drug __________
mass
blood flows
clearance
54
Hepatic function
Hepatic blood flow decreases approximately ___% per decade
10
55
Hepatic function
Cytochrome ______ enzyme activity ______ with aging
P450
decreases
56
Hepatic function
Phase 1 ( ________, ________ , _______) and Phase 2 ( _________, _________, ______) reactions may be depressed with aging
Drugs metabolized via phase 1 reactions have longer ____-______
oxidation, reduction, hydrolysis
conjugation, sulfonic acid (sulfonation), acetylation
half-lives
57
Endocrine system
Decreased ______- function (decreased _______ secretion)
Increased incidence of ________
pancreatic
insulin
diabetes
58
Endocrine System
Decreased tolerance to ______ load: avoid IV ______ solutions
Increased risk of perioperative complications if history of DM > ____ years
glucose
glucose
10
59
Body Composition
Basal metabolism and _____ _______ decrease: d/t skeletal muscle _______, decreased physical activity/decreased ________
heat production
atrophy
testosterone
60
Body composition
The propensity for _________ increases because of blunted central _________ and body _________ changes
hypothermia
thermoregulation
compositional
61
Body composition
Decrease in muscle mass (___% lost by ____ years), decreased total ____ ____, coupled with ______ in body fat
50
80
body water
increase
62
Body composition
_____ the volume of distribution of water-soluble drugs and ______ it for lipid-soluble drugs
Decreases
Increases
63
Thermoregulation
Decreased _________ function (inhalation agents also inhibits temperature regulating centers in _______)
hypothalamus
hypothalamus
64
Thermoregulation
Hypothermia more pronounced and last longer d/t:
-Lower ______ _____ rate
-High ratio of surface to _____ _____ mass
-Less effective peripheral _________ in response to cold
basal metabolic
body area
vasoconstriction
65
Thermoregulation
Hypothermia (6)
Slows anesthetic _______, prolongs _______, impairs _________, impairs ______ ________, blunts ventilatory response to ______, increases risk of ________
elimination
recovery
coagulation
immune system
CO2
shivering
66
Central Nervous System
Progressive loss of ______ and _______ _______, ________ activity, and decreased brain ________ contribute to __________ anesthetic requirements for all agents
neurons
neuronal substance
neurotransmitter
volume
decreased
67
Central Nervous System
Most prominent losses are in the ______ ______ ( _______ lobes)
cerebral cortex
frontal
68
Central Nervous System
_____ CSF
____ nerve conduction velocity
Degeneration of _________ nerve cells
decreased
decreased
peripheral
69
Central Nervous System
Sensitive to:
__________ ___________
____________
___________
_____________
General anesthetics
Hypnotics
Opioids
Benzodiazepines
70
Central Nervous System
Induction dose should be decreased by ____ %, avoid _____________
50
benzodiazepines
71
Neuraxial Anesthesia
Decreased _________ nerve fibers
Dura is ______ _______ to LA
CSF volume ____________
myelinated
more permeable
decreased
72
Neuraxial Anesthesia
Time of onset ______ with more enhanced _________
Epidural test dose _____ _______ in elderly d/t beta adrenergic response
Use ____ dose of LA
Decreased
spread
less reliable
less
73
Cognitive Ability/Capability and Decision Making
Health care decision making for older patients is _____________
________ implies ________ _________
autonomy
Autonomy
mental competence
74
Cognitive Ability/Capability and Decision Making
The legal standards for competence:
-Ability to communicate a _______
-Understand relevant _________
-Appreciate the current _______ and its __________
-__________ information rationally
choice
information
situation, consequences
Manipulate
75
Cognitive Ability/Capability and Decision Making
________ and _________ difficulties frequently jeopardize informed consent in frail older patients
Cognitive
sensory
76
Cognitive Ability/Capability and Decision Making
_______ ,_________, _________, and ________ all may interfere with the ability to make independent decisions
dementia
depression
hearing difficulties
stroke
77
Frailty
A multisytem loss of ________ reserve: more vulnerable to ________ during and after stress
physiologic
disability
78
Frailty
Clinical syndrome: ______ ______, ________, and _________
Weight loss
fatigue
weakness
79
Frailty
Chronic _________ and _________ dysregulation: key drivers in the underlying pathophysiology of this process
inflammation
endocrine
80
Frailty
The components of the frailty syndrome: (5)
-_________
-________ weakness
-Poor _______ ________
-Unstable ___________
-Factors related to body composition such as ____ ______, _______, and ______ _________
Mobility
Muscle
Exercise tolerance
balance
weight loss, malnutrition, muscle
wasting
81
Frailty is a prognostic factor in _______ _________
Unintentional ____ pound weight loss within ___ year
poor outcomes
10
1
82
Nutritional Status
Incidence of malnutrition is ____ % to ____ % in elderly patients
Changes in _____, _______, ______ income
20
40
taste
smell
decreased
83
Nutritional Status
Predisposing factors to malnutrition: _______ _____, _______, and __________
Heart failure
COPD
Cancer
84
Nutritional Status
Indicators of malnutrition include ______ _____, low ______, ______- ______ disorder (e.g. _______), and albumin less than ___g/dL
weight loss
BMI
nutrient-related (anemia)
3.5
85
Review of Medications and Polypharmacy
Polypharmacy occurs in ___% of acutely hospitalized older patients
The number of medications used is directly proportional to the likelihood of having an ______ drug reaction
Potential interaction with ________ meds
61
adverse
anesthetic
86
Ethical Issues
______ status
_______ policy
DNR
Facility
87
AANA Reconsiderations of Advance Directives
The American Association of Nurse Anesthesiology (AANA) recommends, when possible, that the patient, family, proceduralist, and anesthesia team meet during the anesthesia _____ ______ process to discuss _________ of advance directive (s) to develop the plan of care that reflects the patient's ___________
informed consent
reconsideration
wishes
88
AANA Reconsiderations of Advance Directives
________ suspension
________ suspension
_____ suspension
Full
Partial
No
89
Postoperative Delirium
_______ disorder of cognition and consciousness characterized by an _____ onset and _______ course
Transient
acute
fluctuating
90
Postoperative Delirium
Manifests acutely within ____ ____ days after surgery and can last for _____ ____/_____
first few
several days/weeks
91
Postoperative Delirium
Symptoms
-_________
-_________
-________ _________
-_________
agitation
somnolence
social withdrawal
psychosis
92
Postoperative Delirium
Risk factors (8)
-Advanced ______
-________ gender
-_________
-History of _______ abuse
-__________
-Duration of __________
-Poor _______ _______
-Abnormal _______ and ________
age
male
dementia
alcohol
depression
anesthesia
functional status
electrolytes and glucose
93
Postoperative Delirium
Treatment:
Treat any underlying ________, encouraging interaction with _______ ________, encouraging normal _____-_____ cycles, and avoiding _______ if possible
disorder
family members
sleep-wake
restraints
94
Postoperative Delirium
_________ (PO or IM) may be used for control of acute agitation
______ IV intraoperative
Haloperidol
Dexmedatomadine
95
Postoperative Delirium
Increased incidence in ____ _____ and ______ surgery
aortic heart
hip
96
Postoperative Cognitive Dysfunction
POCD is a ______ deterioration in _______, _______, and ________ of information processing associated with anesthesia and surgery
subtle
memory, attention, speed
97
Postoperative Cognitive Dysfunction
Presents _____ to ________ after surgery
weeks
months
98
Postoperative Cognitive Dysfunction
Causes: (2)
Cerebral hypoperfusion
General anesthetics
99
Postoperative Cognitive Dysfunction
______ recover from their preop cogntive state
May not
100
Dementia
Persistent and _______ impairment of cognition that interferes with ___________
progressive
activities of daily living
101
Dementia
________ disease is the most common cause of dementia in the elderly and affects ___% to ____% of people by age _____
Alzheimer
30% to 50%
85
102
Dementia
Delayed _________
Dementia alters ____ baseline values
emergence
BIS
103
Alzheimer's Disease
________ ___________ disorder
Most common cause of _______ in patients older than _____ years and the _______ most common cause of disease-related ______ in patients older than 65
Chronic neurodegenerative
dementia
65
fourth
death
104
Alzheimer's Disease
Hallmark pathologic findings: (2)
Diffuse amyloid rich senile plaques
Neurofibrillary tangles
105
Alzheimer's Disease
Changes in _______ and in the activity of several major _______, especially synapses involving _______ and ____ ________ receptors
synapses
neurotransmitters
acetylcholine
CNS nicotinic
106
Alzheimer's Disease
Two types: Early onset and late onset
Early onset: presents before age ____ (d/t ______ in genes)
Late onset: develops after age ______
60
mutation
60
107
Alzheimer's Disease
Develop _________ cognitive impairment, ________ as well as ______, ______, and ________
progressive
memory
apraxia
aphasia
agnosia
108
Alzheimer's Disease
No cure, treatment focuses on ______ of symptoms
Definitive diagnosis is usually made on _________ examination
control
postmortem
109
Alzheimer's Anesthetic Considerations
Treatment: __________ __________ such as tactrine, ________, _________, and _________ and ___________
cholinesterase inhibitors
donepezil
rivastigmine
galantamine
memantine
110
Alzheimer's Anesthetic Considerations
There is no one single ________ technique or ____ that is ideal in this group of patients
Patients often confused and sometimes uncooperative: ____ or _______ anesthesia challenging
anesthetic
drug
MAC
regional
111
Alzheimer's Anesthetic Considerations
______-acting sedative-hypnotic drugs, anesthetics, and opioids are preferred
Avoid ______ sedation and _____ acting ____-__________
Shorter
preop
centrally
anti-cholinergics
112
Alzheimer's Anesthetic Considerations
Prolongation of the effect of ___________ and relative resistance to ______________ muscle relaxants resulting from the use of cholinesterase inhibitors
succinylcholine
nondepolarizing
113
Osteoarthritis
The most significant anesthetic consideration in patients with osteoarthritis is _______ ______ changes
cervical spine
114
Osteoarthritis
Loss of flexibility and extensibility of the cervical spine increases the distance from the posterior portion of the ______ ______ to the anterior portion of the ________ _______. It may be difficult to apply effective _______ ______
cricoid ring
vertebral body
cricoid pressure
115
Osteoarthritis
_______ laryngoscopy may be more difficult in elderly patients, and ________ _______ intubation may be indicated when neck mobility is severely limited
Direct
fiberoptic tracheal
116
Anesthetic Management
________ decreases with age
______ in lean body mass
______ in body fat
______ in total body water
= prolong ________ medications
Albumin
decreases
increases
decreases
lipophilic
117
Anesthetic Management
____ hepatic and renal clearance
Reduce barbs ___ - ___%
Reduce ______ infusion dose
Decreased
30-40%
propofol
118
Anesthetic Management
MAC of inhalation agents decreases by ___% each ____ after age ____
6
decade
40
119
Anesthetic Management
Succinylcholine has prolonged effect in elderly ____
men
120
Acute Postoperative Pain
-Age-related decrease in ______ perception
-Alzheimer disease is associated with a decrease in reported ______
-Pain tolerance increases with the severity of _______
*MULTI-MODAL*
pain
pain
dementia
121
Which of the following can occur postoperatively and occurs acutely within hours and can last several days or weeks?
Postoperative delirium
122
The following apply to the geriatric population regarding neuraxial anesthesia
Need decreased local anesthetic
123
Which lung volume increase in the geriatric?
Residual volume (RV)
Functional residual capacity (FRC)
124
How would you dose propofol on a geriatric patient?
Decrease dose by 50%
125
Hepatic changes in geriatric include (3)
Hepatic blood flow decreases by 10% per decade
Cytochrome P450 enzyme activity decreases
Serum albumin decreases
