Geri Anes 2010

Front 1

At what age is a person elderly? Old, Old?

Back 1

Elderly, > or = 65
Old, old >, = 85

Front 2

The aging process can be attributed at a cellular level by what?

Back 2

Oxidative Stress within the mitocondria

Front 3

How does oxidative stress within the mitocondria contribute to the "cycle of aging"?

Back 3

The oxidative stress damages the metabolic machinery needed to provide adequate bioenergetic capacity for full organ system functional reserve.

Front 4

What are some of the physical attributes that happen in the elderly?

Back 4

Loss of bone mass, tissue and organ functional reserve and subcutaneous fat. Also at increased risk for disease, infection and injury.

Front 5

By how much has the life expectancy increased since the beginning of the 20th century?

Back 5

30 year increase in the life expectancy of the adult.

Front 6

What % of hospital care days are attributed to the elderly?

Back 6

48%

Front 7

What are the anatomic and functional changes with body composition in the elderly?

Back 7

Anatomic: loss of skeletal muscle and other lean tissue, ↑ lipid fraction.
Fct: prolonged drug effects, ↓ metab & heat production, ↓ resting CO.

Front 8

What are the anatomic and functional changes with the nervous system in the elderly?

Back 8

Anatomic: Loss of neuronal tissue mass, deafferentation, reduced CNS transmitter activity.
Fct:↓ neural plasticity, ↓ anesthetic require. Impaired autonomic homeostasis.

Front 9

What are the anatomic and functional changes in the cardiovascular system in the elderly?

Back 9

Anatomic: ↓ elasticity, reduced B-adrenergic responsiveness
Fct: ↓ cardiac & arterial compliance, ↓ maximal heart rate & CO.

Front 10

What are the anatomic and functional changes in the Pulmonary system in the elderly?

Back 10

Anatomic: ↑ thoracic stiffness, ↓ lung recoil, reduced alveolar surface area
Fct: Reduced VC, ↑ WOB, impaired efficiency of gas exchange.

Front 11

What are the anatomic and functional changes in the renal/hepatic system in the elderly?

Back 11

Anatomic: ↓ vascularity & perfusion, loss of tissue mass
Fct: ↓ drug clearance, inability to withstand salt or water loads

Front 12

What are the anatomic and functional changes in the blood & immune systems in the elderly?

Back 12

Anatomic: thymic involution, resorption of bone marrow
Fct: ↓ immune competence, loss of hematopoietic reserve.

Front 13

What happens to a healthy aging person at rest with systolic BP?

Back 13

Increases in both male and female

Front 14

What happens to a healthy aging male at rest with LVEDV/LVESV?

Back 14

Increases in male.
Unchanged in female.

Front 15

What happens to a healthy aging person at rest with EF & HR?

Back 15

Unchanged in male and female.

Front 16

What happens to a healthy aging male at rest with SV?

Back 16

Increased in male.
Unchanged in female.

Front 17

What happens to a healthy aging female at rest with CO?

Back 17

Decreased in female.
Unchanged in male.

Front 18

What % of hospital care days are attributed to the elderly?

Back 18

48%

Front 19

What can effect "functional reserve" in an elderly person?

Back 19

Variable from person to person. Stress, disease, polypharm, or surgical intervention. Many elderly are fine until stress hits. Functional reserve is NOT linear as you age.

Front 20

What is the main reason that functional reserve decreases with age?

Back 20

Erosion of homeostatic mechanisms

Front 21

What happens to heart rate variability in the elderly and why?

Back 21

LOSS of HR variability b/c of ↓ B-adrenergic receptors & impaired intracellular signaling. Blunted response to atropine.

Front 22

What are some of the vascular changes associated with the elderly?

Back 22

Loss of & destruction of elastic tissues-esp in vascular, but everywhere. ↓ arterial compliance, ↓ B-adrenergic receptors= ↓ vasodilation, ↑ SVR=HTN

Front 23

By age 80, what % of elderly have CAD? Angina?

Back 23

CAD= 50%
Angina= 25%
Incidence of CAD increases exponentially w/ age

Front 24

How does DM facilitate CAD and what are DM's effects CV wise?

Back 24

DM facilitates atherosclerosis of coronary arteries. Associated with autonomic neuropathy, vasodiliation of coronary arteries impaired.

Front 25

What happens to elderly conducting airways structurally and functionally?

Back 25

Loss of: elastin, collagen & water, & pharyngeal muscular support which leads to OSA.
↑ diamter of trachea & central airway = ↑ RV
↓airway reflexes= ↑ risk of aspiration.

Front 26

What happens to elderly lung parenchyma?

Back 26

↓ alveolar surface area & elastic recoil. Impaired defenses: ↓ mucociliary fct, ↓ T cell homeostasis.

Front 27

True or False...
Loss of elastin happens not only in the CV and resp systems...but throughout the entire body.

Back 27

True

Front 28

How do pulmonary mechanics change in the elderly?

Back 28

Chest wall stiffens, compliance ↓.
↓ respiratory muscle strength.
↑ pulmonary arterial pressures & PVR

Front 29

What changes happen to the elderly lung volumes and capacities? VC, RV FRC, max expir flow?

Back 29

↑ RV (20ml/yr b/c of chest wall stiffnes,loss of elastic recoil, & ↓ force generation by resp muscles)
↓ VC (20ml/yr)
↓ maximum expiratory flow
Minimal change in FRC

Front 30

Gas exchange changes in the elderly is demonstrated by...

Back 30

↓ diffusing capacity of carbon monoxide & oxygen
Impaired V/Q match & ↑ A-a gradient.
↑ physiologic dead space d/t V/Q mismatch, but b/c carbon dioxide production is ↓, arterial levels don't ↑

Front 31

True or False?
The elderly are just as sensitive to hypercapnia as the young adult.

Back 31

FALSE. The elderly have a decreased response to hypercapnia (increased CO2).

Front 32

CNS changes in the elder include...

Back 32

-progressive loss of neurons
-brain atrophy
-↓ neurotransmitters (except glutmate).
-↑ volume of intracranial cerebrospinal fluid.

Front 33

True or False...
Storage, comprehension is preserved well into the 80's.

Back 33

True

Front 34

True or False...
Short term memory, visual and auditory rxn time are decreased in the elderly.

Back 34

true

Front 35

True or False...
Retrieval of information in the elderly is faster.

Back 35

False, it is slower. Use it or loose it mentality is true.

Front 36

Decreased CNS cerebral changes in the elderly r/t to the brain are...

Back 36

↓ cerebral blood flow
↓ cerebral metabolic rate
↓ neurotransmitter activity
cognitive dysfct changes
Augoregulation of CBF is maintained.

Front 37

What makes treating pain difficult in the elderly r/t the CNS?

Back 37

Both sensitivity to CNS depression and the threshold for pain sensation increase with age.

Front 38

What is the most important factor in predicting post-op dysfct/delirium?

Back 38

Pre-op fct deficit

Front 39

The elderly peripheral nervous system changes

Back 39

-Deterioration of electrical conduction.
-↓ electrical conduction velocity
-disseminated neurogenic atrophy of musclec

Front 40

The autonomic nervous system in the elderly...

Back 40

-progressive loss of spinal cord neurons & cellular neuronal elements in PNS and SNS ganglia.
-↑ catecholamine content in adrenal gland
-↑ plasma norepi levels
-↓ tachycardic response to exercise stress
-attenuated baroreceptive responsiveness-can't compensate

Front 41

True or false...
Even though norepi levels are increased in the elderly, they are not always responsive to the increased norepi levels

Back 41

True, takes elderly longer to recover from stress (ex: intubation).

Front 42

What happens to the elder person b/c they have altered baroreceptor responsiveness?

Back 42

The elderly can't compensate-intervascular volume depletion and HTN= liable BP and variation from homeostatic set points.

Front 43

What happens to glomerular filtration in the elder?

Back 43

Progressive glomerular loss (30% of tissue mass lost by age 80).
Glomerular sclerosis (more severe HTN, DM)
-usually enough left to compensate.

Front 44

True or false?
Maximal concentration ability increases in the elderly as they age.

Back 44

False...Maximal concentration ability decreases (the tubular fluid).

Front 45

The elder person has relative insensitivity and impaired response to ...(2 things)

Back 45

ADH (less sensitive to )
Aldosterone (what does this do...)

Front 46

What is the most common electrolyte balance in the elderly?

Back 46

Hyponatremia...occurring in 10-20% of hospitalized elders.

Front 47

Factors contributing to electrolyte imbalance in the elder...

Back 47

↓ GFR
↓ free water clearance
diuretic administration
poor oral intake

Front 48

Which is tolerated well? Acute or chronic hyponatremia?

Back 48

Chronic tolerated well. Acute HypoNa+ is when we see CNS changes and N/V/sz.

Front 49

By how much does hepatic fct decrease?

Back 49

40% of tissue ↓ by age 80, ↓ in hepatic blood flow 10% per decade.
Enzyme activity unchanged, but delayed biotransformation b/c of loss of tissue mass.

Front 50

What decreases in the elders body composition?

Back 50

↓ total body water and lean body mass.

Front 51

What happens to the elders fat in relationship to body composition?

Back 51

↓ SUBcutaneous fat
↑ total body fat

Front 52

True or False?
Healthy, active elders have little to no change in plasma volume.

Back 52

True. Actually have ↑ plasma concentration than a person of that size should have.

Front 53

Elders have decreased albumin levels, what does it mean in relation to pharmacokinetics and acid drugs?

Back 53

Acid drugs bind to albumin, so ↓ albumin levels means ↑ free drug. Esp propofol.

Front 54

True or False...
Elders have a ↓ clearance in relation to pharmacokinetics.

Back 54

True. They don't metabolize as well.

Front 55

A pharmacodynamic issue in elders is ↑ sensitivity to drugs. What contributes more to this issue...Vd or receptor issue?

Back 55

Vd more of the problem than the receptor issue.

Front 56

In barbiturates in the elderly, what makes them have ↑ Vd?

Back 56

B/c of ↑ adipose tissues so longer duration of action, however Vd of central compartment is ↓ (↓ intravascular water) so higher plasma levels.

Front 57

What changes are made to the dose when giving barbiturates to the elderly?

Back 57

Decreased does d/t kinetic changes.

Front 58

What are physiologic changes of aging and pharmacologic implications with propofol in the elderly?

Back 58

-hemodynamic effects (↓BP) limit the use in the elderly
-similar kinetic changes to barbs
-enhanced hypnotic (pharmdynam) effect.

Front 59

What are physiologic changes of aging and pharmacologic implications with etomidate in the elderly?

Back 59

-altered kinetics but not pharmacodynamics.
-good hemodynamic stability.

Front 60

Elderly peeps have ↑ sensitivity (pharmdyam) to benzos...what dose should an 80 yo receive compared to a 20 yo?

Back 60

80 yo should receive 1/4 that of a 20 yo.

Front 61

What other concerns should you have with benzos and other drugs in the elderly?

Back 61

-Polypharm (other CNS depressants)

Front 62

What pharmakokinetic concerns should you have with benzos in the elderly?

Back 62

-↓ clearance (pharmkin)
-Terminal 1/2 life doubles in the elderly

Front 63

What concerns does diazepam have in the elderly?

Back 63

-diazepam has active metabolites.
-IV diazepam may cause thrombophelbitis or thrombosis more frequently in the elderly.

Front 64

The elderly have______ sensitivity to _____ opioids.

Back 64

increased, ALL

Front 65

Pharmacokinetic changes are d/t changes in body composition for what opioid family?

Back 65

Fentanyl family

Front 66

Morphine is metabolized to ________metabolite.

Back 66

ACTIVE

Front 67

Clearance of morphine is ______for both the parent drug and the ________.

Back 67

↓, metabolite.

Front 68

How much does MAC ↓ with age per decade in the elderly?

Back 68

4-6% per decade over age 40.

Front 69

Theories as to why MAC ↓ with age...

Back 69

↓ Cerebral metabolic rate, CBF, neuronal count (shrinkage).

Front 70

What considerations what might you have during induction and emergence with the elderly?

Back 70

-Slow uptake if V/Q abnormalities
-Alternations in cardiac output ("slowed circ time" b/c of slow CO=slow effect to work).

Front 71

Considerations of volatile anesthetics on the CV system in the elderly are...

Back 71

-Myocardial depression exaggerated.
-Less tachycardia from isoflurane or desflurane.
-autoregulation is ↑ (but very slightly).

Front 72

Considerations of volatile anesthetics on the respiratory system in the elderly are...

Back 72

-↓ ventilatory response to hypoxia or hypercarbia.

Front 73

Non-depolarizing muscle relaxants in the elderly have a ______ onset. Why?

Back 73

Delayed. Onset time is ↑ d/t ↓ CO & ↓ muscle blood flow.

Front 74

In the elderly you have to be careful with priming technique why?

Back 74

Because of ↑ risk of aspiration & desaturation.

Front 75

With NMB, metabolism & clearance are _______ d/t ___ hepatic blow flow & ____ GFR if dependent on liver and kidney.

Back 75

prolonged, ↓, ↓

Front 76

Prolonged metabolism and clearance are less likely wit what NMB?

Back 76

Atracurium and cis-atracurium.

Front 77

Is succinynlcholine ok to use in the elderly? What should you check and what drugs should you look out for?

Back 77

OK to use if you check K+ first. Watch out of echothipate (no sch, used in glaucoma).

Front 78

What drugs don't have increased brain sensitivity in the elderly? (remain unchanged)

Back 78

Thiopental, etomidate,alfentanil, fentanyl, NMB (b/c of quatrary ion, can't go through BBB).

Front 79

What two agents have ↓ initial distribution volume?

Back 79

Thiopental and Etomidate.

Front 80

What do the rest of the anesthetic agents share in common with pharmacokinetics (except thiopental and etomidate)?

Back 80

↓ clearance

Front 81

What action should be taken when giving most anesthetic agents to the elderly?

Back 81

Decrease the dose.

Front 82

True or False...
Regional anesthesia (spinal, epidural) might be challenging d/t anatomic changes.

Back 82

True

Front 83

What is a concern with spinals in the elderly?

Back 83

Hypotension, which must be treated promptly.

Front 84

What is a key factor in remember the benefits of regional anesthesia and the elderly?

Back 84

Regional is only beneficial if sedation is minimal otherwise no advantage over GA for cognitive changes.

Front 85

**What is the major goal in anesthesia for the elderly?**

Back 85

The major goal is to maintain independence, to return the patient to their preop level of functioning....to speed recovery and avoid functional decline.

Front 86

Things to consider in the preoperative assessment with the elderly include....

Back 86

-evaluate functional reserve
-correlate ASA and perioperative outcome
-Assess ADL and METS
-Drug hx: adverse drug rxns ↑ exponentially w/ the # of drugs taken...drug holiday?

Front 87

Active cardiac conditions for which the patient should undergo evaluation and treatment before noncardiac surgery (class I, level of evidence: B)

Back 87

-Unstable coronary syndromes
-severe angina or recent MI
-Decompensated HR
-Significant arrhythmias-includes afib hr >100
-Severe valvular disease

Front 88

What are the basic assessment tools used in assessing a person for cardiac risk?

Back 88

VS, BPs in both arms, EKG looking for conduction disturbances & ischemia. Stress testing, ECHO, holter are further examination tests once risk has been established

Front 89

What does lead II monitor? Lead V?

Back 89

II monitors rhythms
V monitors ST changes

Front 90

Hypothermia is frequent in the elderly, and shivering on emergence can lead to ________.

Back 90

Ischemia

Front 91

What factors contribute to morbidity and mortality in the geriatric pt? ( 5 of them)

Back 91

1. Effects of aging on organ system functional reserve
2. Age related dz & treatment
3. Impaired autonomic homeostasis
4. Need for medical intervention & invasive procedures
5. Polypharmacy

Front 92

Risk of myocardial infarction is related to what in the elderly person? What is often indicated to prevent tachycardia?

Back 92

-Risk is related to PRE-op cardiac status and surgical procedure.
-tachycardia ↑ risk so B-blockade often indicated.

Front 93

What is the incidence of delirium in the old person?

Back 93

10-60%

Front 94

What are some of the predictors of cognitive dysfunction?

Back 94

***pre-op cog impairment***, ↑ age, low edu level, depression, & surgical procedure (cardiac vascular procedures), large blood loss, HCT < 30, hypoxia

Front 95

Cognitive dysfucntion can lead to what other complications post-op?

Back 95

Delayed mobilization.

Front 96

A what BIS number should providers keep below at to prevent awareness according to the article "awarness" by Kakinohana.

Back 96

Keep below 50 even though range is 40-60. Some people have awareness @ >50.

Front 97

What are some of the reasons for hypothermia in the elderly patient?

Back 97

-Impaired thermoregulation
-↓ sub-dermal tissue.
-↓ muscle mass=less heat production
-hypothermia leads to vasocontriction & HTN
-Shivering causes ischemia=↑ metabolic requirements
-Prevention is key

Front 98

What are some of the respiratory post-op complications in the elderly?

Back 98

-Hypoxemia
-V/Q mis match
-atelectasis & PNA
-aspiration
-↑ OSA
-supp O2 is needed (in everyone)

Front 99

Predictors of post-op pulmonary complications in pts undergoing elective noncardiac surgery:

Back 99

-post-op NGT
-Long GA
-COPD
-Smoking
-ETOH abuse
-Chronic steroid use
-Impaired LOC/CVA

Front 100

The incidence of malnutrition in the elderly is ______%.

Back 100

10-25%

Front 101

The incidence of depresion s/t hip fx
in the elderly is ______%.

Back 101

13

Front 102

According to the study "Preop factors associated w/ postop change in confusion...", pre-op medical conditions that predispose the elderly to confusion are....

Back 102

-Abnormal serum sodium*
-ASA status >II
-inability to mount a stress response (normal WBC)*
*amenable to therapy