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104 Cards in this Set
- Front
- Back
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What is the definition of aging?
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not all age-related changes are necessarily present in an older person, no 2 individuals age at the same rate
may include chronological, physiological, and clinical age |
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What is chronological age?
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- most convenient measure, widely used in clinical settings and aging research
- medicare, most important mechanism for payment of health for elderly, eligible at age 65 |
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What subcategories are the groups of older adults divided into?
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young old 65-74
mid old 75-84 oldest old 85+ |
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What is physiological age?
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- biological age
- progressive changes of physiologic system w age during postmaturation period of life - with decr physiologic reserve, older adults cannot mount an adequate compensatory response to an insult (surgery, new onset disease process, catastrophic psychosocial event) |
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What are the normal signs of aging?
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loss of height
gray hair wrinkles in skin reduced mvmt coordination |
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What is clinical age?
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emphasizes that intrinsic physiolgic aging, extrinsic factors, as well as disease processes all contribute significantly to decr physiologic reserve, reduced functional capacity, and altered homeostasis in older adults
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What are the changes in the brain associated with aging?
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- volume of cortical gray matter decreases w age
- aging incr CSF and incr ICP - reduced NTs (dopamine, ACh, NE, 5HT3 -- glutamate not affected) - memory declines in 40% after age 60 - CBF decr (15-20% CO) in proportion to neural tissue - preserved cerebral autoregulation of blood flow - hydrostatic pressure incr |
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Elderly pts need a ____ dose of LAs with peripheral nerve blocks.
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lower
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The process of aging causes anatomic changes of the extradural space which constricts the vertebral canal, making it more difficult to...
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thread an epidural catheter
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Lipophilic drugs will have a _____ volume of distribution, and will last (shorter/longer).
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larger, longer
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Renal failure pts will have a ____ volume of distribution.
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higher
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Dehydrated elderly pts will have a _____ volume of distribution.
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lower
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What drugs are lipophilic and have a higher volume of distribution in the elderly?
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fentanyl, propofol -- give lower doses!
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In the elderly, hydrophilic drugs will have a ____ volume of distribution.
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lower
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The elderly have a sensitivity to centrally acting anticholinergic agents such as...
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scopolamine and atropine
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Brain sensitivity to most anesthetic agents ____ With age.
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increases
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How are benzodiazepine pharmacodynamics different in the elderly?
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- no change in benzo binding properties of GABA receptors
- ability of midazolam to MODULATE GABA receptor function (can bind but not causing a change/conveying info) varies w age - suggests alterations in signal transduction |
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In the elderly, a decr in muscle mass and an incr in percentage of body fat leads to..
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a decrease in total body water
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In the elderly, decreased volume of distribution for water-soluble drugs can lead to...
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higher plasma concentration
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In the elderly, increased volume of distribution for lipid-soluble drugs can lead to...
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lower plasma concentrations
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Thiopental is ____ soluble.
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lipid
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In the elderly, dosage for local and general anesthetic are _____.
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reduced
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In the elderly, epidural anesthetic tends to result in a more extensive ____ spread, but with a shorter ______ and _____.
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more extensive cephalad spread,
shorter duration of analgesia and motor block |
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Cognitive dysfunction in the elderly postop is multi-factorial and includes...
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drug effects
pain underlying dementia hypoxemia metabolic disturbances lower levels of NTs (ACh) |
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What are the age-related cardiac physiologic changes in the elderly?
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- decr arterial elasticity (incr afterload, incr SBP, LV hypertrophy)
- decr adrenergic activity (decr resting HR, decr 1 bpm per yr over 50; decr max HR, decr baroreceptor reflex) - 20-30% decr in blood volume |
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What are the common cardiac pathophysiologies in the elderly?
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- atherosclerosis
- CAD - essential HTN - CHF - cardiac arrhythmias |
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In the absence of disease, what CV functions are preserved in the elderly?
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- DBP (unchanged or decr)
- CO - resting systolic cardiac function |
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Diminished cardiac reserve in the elderly may manifest as ...
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exaggerated drops in BP during induction of general anesthesia
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Prolonged circulation time in the elderly delays _____ but speeds _____.
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delays onset of IV drugs,
speeds induction w IAs (IAs dont need circulation, just lung to brain transfer) |
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Elderly pts have less ability to increase their HR to respond to....
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hypovolemia, hypotension, hypoxia
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What are the age-related RESPIRATORY physiologic changes?
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- decr pulmonary elasticity (decr alveolar surface area, incr RV, incr Closing capacity (leads to atelectasis), VQ mismatch, decr arterial O2 tension)
- incr chest wall rigidity - decr muscle strength (decr cough, decr maximal breathing capacity) - blunted response to hypercapnia/ hypoxia |
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What are the common RESPIRATORY pathophysiologies of the elderly?
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emphysema, chronic bronchitis, pneumonia, lung CA
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In the elderly, mask ventilation may be _____.
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difficult (endentulous)
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The elderly have a ____ Risk of aspiration pneumonia and hypoxia.
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increased
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The elderly may experience ______ from VQ mismatch.
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shunting
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In the elderly, decr FRC and incr Closing volume leads to...
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more atelectasis
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In the elderly, post op pain and analgesics contribute to a reduction in _____ and impaired clearance of _____.
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tidal volume,
impaired clearance of secretions through normal cough mechanisms |
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How is HPV shunting different in the elderly?
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response is blunted
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The elderly have a greater sensitivity to narcotic induced...
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respiratory depression
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What should the preop eval entail for elderly pts?
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- H/P
- CXR - Spirometry - ABG, ECG, exercise/stress test, echo, labs |
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How is O2 consumption different in the elderly?
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basal and maximal O2 consumption declines
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How is heat production and loss affected with aging?
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heat production decr
heat loss incr |
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What occurs in hypothalamic temperature regulating centers with aging?
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resets to a lower level
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Elderly patients have _____ insulin resistance, ____ response to beta-adrenergic agents, and _____ NE levels.
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incr insulin resistace
decr response to beta agents incr NE levels |
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How is GI function affected with aging?
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- decr liver mass
- decr hepatic blood flow - decr hepatic function reserve - decr biotransformation rate and albumin production - decr plasma cholinesterase (in men) - incr gastric pH - prolonged gastric emptying |
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What are the age-related RENAL physiological changes with aging?
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- decr RBF: decr renal plasma flow, decr GFR
- decr renal mass - decr tubular function: impaired Na handling, decr concentrating ability, decr diluting capacity, impaired fluid capacity, decr drug excretion - decr renin-aldosterone responsiveness (impaired K excretion) |
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In the elderly, impaired renal Na handling can lead to...
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over or under excretion fo Na (And accompanying fluid)
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What are the common RENAL pathophysiologies of the elderly?
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- diabetic nephropathy
- HTN nephropathy - prostatic obstruction - CHF |
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Why is serum Cr level unchanged w aging?
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decr in muscle mass accompanies it
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How are BUN and ability to reabsorb glucose changed in the elderly?
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incr BUN
decr ability to reabsorb glucose |
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What are the musculoskeletal changes associated with aging?
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- muscle mass reduced
- NMJ thickens - skin atrophies - veins frail - arthritic joints interfere w positioning and regional anesthesia |
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Albumin, which tends to bind ____ Drugs, will ____ with age.
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acidic, decreases
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AAG, which binds ____ Drugs, will ____ with age.
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basic, increase
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MAC anesthesia requirements _____ with age.
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decrease -- 4% per decade over 40 yrs old
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The onset of IAs will be faster if... and delayed if....
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faster if CO is depressed
and it will be delayed if signification VQ mismatch |
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With aging, the myocardial depressing effects of IAs are _____.
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exaggerated
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Isoflurane reduces ____ and ____ in the elderly.
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CO, HR
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In the elderly, recovery from IAs may be _____.
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prolonged
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How is the thiopental dose different in the elderly?
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1/2 induction dose needed for octogenarian, as compared w 20 yr old
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How is diazepam administration different in the elderly?
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VD is larger and elimination is longer
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How is lorazepam administration different in the elderly?
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elim half life remains relatively unchanged
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How is the administration of muscle relaxants different in the elderly?
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- succ and non-depol. are unaltered
- decr CO my cause up to 2-fold prolongation in onset - non depol MRs that depend on renal excretion may be delayed - non depol MRs that depend on hepatic excretion may have prolonged half life and duration of action |
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the periop plan must take into account the ____ and ____ changes of aging as they impact surgical and anesthetic management
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psychological and physiological
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What are the common Nervous System changes related to aging?
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-decreased CBF and brain mass
-degenration of peripheral nerve cells leads to prolonged conduction velocity and muscle atrophy -increased threshold for sensory modalities -pain perception changes are poorly understood -dose requirements of many anesthetic agents decrease |
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make sure to allow sufficient ____ for IV drugs to circulate from the IV site to the heart to the brain before you ____ again!
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time
dose |
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decrease in the neurotransmitters dopamine, acetylcholine, norepi and serotonin causes...?
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a decreased ability to respond stress
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elderly have are sensitive to centrally acting anticholinergics like ____ and ___ because of decreased neurotransmitters
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scopolamine and atropine
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delirium, dementia and depression are predictors of ____ patient outcome
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poor
(age, poor cognitive fxn, poor physical condition, alcohol abuse, AAA, non cardiac surgery, abnormal Na K or glucose) |
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delirium occurs ___ to ___ % of the time after general surgery. This number increases to 28-61% after orthopedic surgery due to fatty emboli being released.
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10-15%
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the length of stay for patients with delirium increases by ___%
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60
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what are the major symptoms of delirium?
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-abrupt change in cognition and consciousness
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Do not give ____ to elderly pts because it increases their risk of delirium 2-7x that of other opioids (long acting)
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meperidine
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____ and long acting ____ also increase the risk of post op delirium
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barbituates and benzos
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when an elderly person gets a spinal anesthetic it will?
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last longer
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fibrosis of the SA node, atrophy of pathways, loss of pacemaker cells, sick sinus syndrome, hemi-blocks, BBB, SV and vent ectopy put elderly patients at risk for?
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arrhythmias
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Recent MI, uncompensated CHF, unstable ischemic heart disease and certain rhythm disorders are?
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the strongest predictors of adverse cardiac events
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unstable coronary syndrome, decompensated CHF, and severe valvular disease are all?
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major clinical predictors
*evaluate and treat prior to elective non cardiac surgery |
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mild angina, prior MI, compensated CHF and DM (realatively controlled) are all?
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intermediate clinical predictors
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advancing age, abnormal EKG, rhythm other than sinus, low functional capacity, hx of CVA and uncontrolled HTN are all?
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minor clinical predictors
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functional capacity based on expenditure is measured by ____?
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METs
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eating, dressing, walking 1-2 blocks and light house work is?
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1-4 METs
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climbing stairs, walking up a hill, heavy house work, golf, bowling, tennis and dancing is?
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4-10 METs
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continuing beta blocker therapy is important because it has shown to reduce...?
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long term (6 month) mortality rates
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Antihypertensives should be continued during the periop period except?
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ACE inhibitors-hold the am of surgery
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Continue beta blocker and ____ even if the pt is NPO.
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clonidine
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Arthritis of the TMJ/C-spine makes for a?
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challenging intubation
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the lack of upper teeth can actually help with _____ of vocal cords during laryngoscopy.
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visualization
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to prevent periop hypoxia ____ FiO2 concentrations, give PEEP and provide aggressive pulmonary ____.
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increase
toileting |
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pulmonary disease ____ the risk of periop complications.
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increases
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preop functional level is a reliable ____ of pulmonary complications periop
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predictor
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patients with severe preexisiting respiratory disease, following major abdominal and chest surgery should potentially?
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be left intubated after surgery
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more agressive ___ ____ should be considered for patients with existing lung conditions
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pain management
(epidurals, intercostal blocks) |
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the additive effect of the supine position, general anethesia and thoracic or abd incisions leads to ____ FRC and ____ airways resistance
Because of this the elderly are predisposed to _____, _____ and infection |
decreased
increased atelectasis hypoxemia |
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Keep elderly patients covered and ____
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warm!
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adverse effects of hypothermia include (8)
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-bleeding
-decreased immune fxn -decreased wound strength -impaired platelet fxn -inhibition of clotting cascade -decreased drug metabolism and clearance -increased risk of infection -increased incidence of MI |
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Arthritic joints may become problematic with ____ and ____.
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positioning and regional anesthesia
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Joint mobility should be assess when?
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prior to induction
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With positioning it is important to watch for nerve _____ or over _____.
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compression
stretching |
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Atlanto-occipital degeneration may make airway manipulation more difficult due to?
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cervical stenosis/spondylosis
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benzos like midazolam and diazepam can contribute to prolonged ____.
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confusion
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____ can contribute to increased secretions, bronchodilation, increased ICP and increased delirium
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ketamine
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Etomidate is less cardiac ____ than propofol
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depressing
-rapid recovery from hydrolysis to inactive metabolites -clearance is hepatic and blood flow dependent -high incidence of post op N&V -depression of adrenocortical fxn |
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Induction dose of propofol in the elderly is?
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1.2-1.7 mg/kg
-rapid onset -lasts 5-10 mins -produces dose dependent CV and resp depression |
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How can hypotensive effects of propofol be minimized?
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push it slowly and titrate it to effect
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