1
Q
what are the factors that influence perioperative outcomes in the the older adult?
A
- emergency surgery
- number of comorbidities
- type of surgical procedure
2
Q
T/F: aging is synonymous with poor physiologic function
A
FALSE
3
Q
what are the CV changes that occur in the geriatric patient
A
- heart and CV system less complaint 2. reduced capacity to increase HR in response to HoTN, hypovolemia, & hypoxia (end organ adrenergic responsiveness)
- prolonged circulation time
- calcification of cardiac conduction system and valves
- decreased venous and arterial compliance
- decreased sensitivity of baroreceptors
- more vulnerable to periop cardiac events
- frequently associated with CV coexisting dz: htn, hld, CAD, and CHF
4
Q
prolonged circulation time in geriatric pts, will cause _________ inhalational induction, and ____________ IV induction
A
faster; slower
5
Q
respiratory changes in the geriatric patient
A
- decreased chest wall compliance
- loss of elastic recoil
- reduced functional alveolar surface area
- increased lung compliance
- decreased ventilatory response to hypoxemia and hypercarbia
- progressive decrease in laryngeal/pharyngeal support and protective reflexes
- increased risk of postoperative pulmonary complications
6
Q
what are the postop pulmonary complications in the geriatric patient
A
- atelectasis
- bronchospasm
- exacerbation chronic lung disease
- PNA
- prolonged mechanical ventilation 6. postoperative respiratory failure
7
Q
closing volume exceeds FRC at approximately ________ years of age in the erect position, and at ___________ years of age in the supine position
A
65; 45
8
Q
what are some dynamic and static lung changes in the geriatric patient
A
- decrease in vital capacity
- increase in residual volume
- increase in FRC with decreases in inspiratory reserve volume and expiratory reserve volume
- decrease in FVC
- decrease in FEV1
9
Q
T/F: TLC remains unchanged with age or may slightly decrease
A
TRUE
10
Q
with the geriatric population, GFR decreases about ____________%
A
25-50
11
Q
what is the cause of decreased GFR in elderly patients?
A
decreased renal mass and decreased renal blood flow
12
Q
what is the result of decreased GFR in the elderly patients?
A
- fluid overload
- accumulation of drugs/metabolites excreted by the kidneys
- decreased drug elimination
- electrolyte imbalances
- dehydration
13
Q
after 40 years of age, renal blood flow decreases about ________% per decade
A
10
14
Q
renal changes with aging (geriatric)
A
- decrease GFR 25-50%
- serum Cr unchanged if no renal failure d/t declining skM mass
- increased risk CKD
- decrease in renal blood flow
15
Q
why is the geriatric patient at increased risk of CKD
A
- Coexisting Dz
- Fraility
- complex medical regimens and polypharmacy
16
Q
what are the hepatic changes in the geriatric patient
A
- decrease in liver mass ~ 20-40%
- decreased drug metabolism
- decreased serum albumin
- increased alpha-1 acid glycoprotein
17
Q
the decrease in albumin in the geriatric patients causes decreased binding of _________ drugs, like ____________ and ___________
A
acidic; benzodiazepines; opoids
18
Q
alpha 1-amino glycoproteins increase in the elderly, AAGs, bind ____________ drugs like __________
A
basic; local anesthetics
19
Q
when you are dosing drugs in the elderly, the dosing is dependent on ______________ and ______________
A
hepatic metabolism; concomitant liver Dz
20
Q
what is the most notable endocrine organ to impact the aging adult pt and cause postoperative morbidity
A
pancreas
21
Q
what are the changes to the endocrine system in the geriatric patient
A
- decline in number and fx of pancreatic islet beta cells (insulin)
- peripheral insulin resistance
- often compromises multiple organ systems
22
Q
peripheral insulin resistance in the geriatric pt, puts pt at risk for ____________ and ___________ dz
A
HTN; CV
23
Q
peripheral insulin resistance in the geriatric patient, increases the risk for what types of perioperative complications?
A
- CVA
- MI
- Ketoacidosis
- infection
24
Q
50% of skM mass and strength is lost by age ______
A
80
25
changes in body composition in the geriatric adult
1. decrease in basal metabolic rate
2. skM mass and strength decline
3. increase in body fat distribution
4. decrease in dermal and epidermal thickness of skin
5. decrease in total body water with blood volume decrease 20-30%
26
what causes the decrease in basal metabolic rate in geriatric adults?
1. decreased physical activity
2. decrease in testosterone and GH
27
D/t the decrease in total body water in elderly adults this will cause what ________________
hypotension with position changes
28
impairment in thermoregulation in the elderly adult
1. decrease in hypothalamus function 2. hypothermia is pronounced and lasts longer
3. produce less heat per kg/body weight
29
CNS changes in the elderly adult
1. progressive loss of neurons
2. decrease neurotransmitter activity,
3.decrease number myelinated nerve fibers
4. decreased brain volume
5. increased sensitivity to CNS depressant/anesthetic agents
30
_____________ may be beneficial in the elderly patient to guide titration to anesthesia and speed recovery times.
BIS
31
what could be used in elderly patients to help decrease incidence of postoperative delirium and postop cognitive dysfunction
BIS
32
what areas of the brain lose the most neurons, and brain volume in the elderly patient
cerebral cortex
frontal lobes
33
considerations with neuraxial anesthesia in the elderly patient
1. risk for neural damage secondary to decreased # of myelinated nerve fibers 2. anatomic changes contribute to difficulty with needle placement: SAB and epidural
3. decrease dose of local anesthetic
34
T/F: regional anesthesia is discontinued in the elderly pt
FALSE
35
why is it a good idea to decrease the dose of local anesthetic in neuraxial anesthesia in the elderly population
1. dura more permeable
2. CSF specific gravity increases
3. CSF volume decreased
36
legally relevant criterion for decision making capacity for informed consent with geriatric populations
1. understand treatment options
2. appreciate/acknowledge medical condition and likely outcomes
3. exhibit reasons and engaging in rational discussion about treatment options
4. clearly choosing a preferred tx option
37
______________ is a perioperative risk factor for complications and mortality in the elderly adult
fraility
38
what is fraility
a biologic state associated with multisystem physiologic deterioration. leads to increased vulnerability to adverse outcomes
39
what is primary frailty d/t
the intrinsic process of aging
40
what is secondary frailty d/t
the end stage of chronic illness (CHF, COPD). caused by inflammation and wasting
41
what are the physiological parameters used to test frailty
1. grip weakness
2. weight loss
3. walking speed
4. energy level
5. decrease in physical activity
42
criterion of severe nutritional risk in the geriatric surgical patient
1. BMI < 18.5
2. serum albumin <3?
3. unintentional weight loss > 10-15% within the past 6 months
43
malnutrition and protein deficiency of the elderly patient may require postponement of surgery d/t postoperative risks, which are ?
1. infection
2. pna
3. increased length of stay
4. mortality
44
what is functional status
ability to perform self care or ADLs
45
current level of function in the elderly is a predictor of __________ outcomes
long-term
46
preoperative functional status assessment purpose:
1. baseline in physical capacity
2. assists in determining reasonable and individualized postoperative goals
47
how many metabolic equivalents (METS) of cardiac reserve are needed to tolerate most surgeries
4
48
___________________ is a predictor of poor postoperative outcomes
impaired preoperative functional status
49
what is the most important goals in the perioperative care of older adults (surgical outcomes)
avoidance of functional decline and maintenance of independence
50
MAC inhalation agents decrease ~ _______% per decade after 40 years of age
6.7
51
which drugs are not affected by the pharmacodynamic changes of the older adult
NMBA
52
what is the NMBA of choice in the older adult
cistracurium
53
anesthetic considerations of propofol in the older adult
1. hypotension
2. prolonged recovery
3. increased brain sensitivity
54
what dose changes should be made to propofol in the older adult
decrease bolus and infusion by 50%
55
anesthetic considerations of etomidate in the elderly population
1. increased brain sensitivity
2. greater hemodynamic stability
2. greater hemodynamic stability
56
dosing recommendations of etomidate in elderly patients
decrease bolus by 50%
57
anesthetic considerations in the elderly adult with opioids
1. increased brain sensitivity
2. profound physiologic effects
3. slower onset and delayed recovery
4. consider route of metabolism and metabolites
5. avoid meperidine
58
dosing recommendations of opioids in the elderly population
decrease bolus by 50%
59
anesthetic considerations of midazolam in the elderly population
1. increased brain sensitivity
2. avoid per Beers Criteria
60
dosing consideration of midazolam in the elderly population
1. avoid
2. if absolutely have to use, reduce dose by 75%
61
anesthetic considerations of nondepolarizing MR in the elderly population
1. slower onset and delayed recovery
2. consider route of metabolism and metabolites
3. avoid long acting NDMRs
62
dosing recommendations with NDMR in the elderly population
1. no significant changes with intubating dose
2. maintenance per PNS twitch response
63
anesthetic considerations in the elderly with depolarizing MR
slower onset and delayed recovery
64
dose recommendations of depolarizing MR in the elderly
no dose adjustment
65
autonomy
patients right to self determination
66
informed consent and advanced directives are examples of what ethical principle
autonomy
67
beneficence
an obligation or responsibility to help the patient "to do good"
68
nonmaleficence
to not intentionally harm the patient; "to do no harm"
69
justice
to treat the patient fairly and equally
70
what are the 4 most common ethical principles in health care
1. autonomy
2. beneficence
3. nonmaleficence
4. justice
71
most common type of dementia
alzehimer
72
risk factors for vascular dementia
HTN and DM
73
what is mixed dementia
vascular infarcts with Alzheimer's
74
causes of reversible dementia
1. medications
2. ETOH
3. metabolic d/o's
4. depression
5. CNS neoplasms
75
anesthetic implications of dementia
1. determine level of cognitive dysfunction
2. increased risk of aspiration
3. increased risk of postop delirium
4. avoid Benzos, antihistamine, and anticholinergics
5. multimodal pain
6. regional anesthesia in those with poorly controlled preop pain, use of chronic opioids, those with high postop opioid requirements
76
what is the predominant Risk factor for POD and POCD
age over 65
77
postoperative delirium is characterized by?
disruption of perception, thinking, memory, psychomotor behavior, sleep-wake cycle, consciousness, and attention
78
postoperative delirium has been found to increase risk of
1. perioperative mortality
2. instituitionalization
3. dementia
79
risk factors for postoperative delirium
1. renal insufficiency and metabolic derrangements
2. poorly controlled pain
3. polypharmacy (psychoactive drugs)
4. fx'al impairment
5. urinary retention and presence of a urinary catheter
80
which drugs have been found to be associated with the development of delirium, and should be avoided during the perioperative period
1. benzodiazepines
2. antihistamines
3. anticholinergics
81
T/F: antidepressants should be continued perioperatively
TRUE
82
depression is a predictor for ___________________ in the elderly
postoperative delirium
83
depression in the elderly, puts them at increased risk for _______________ and ______________
cardiac events; death
84
Postoperative cognitive dysfunction is characterized by?
an array of cognitive impairments such as:
1. memory deficits
2. difficulty with concentration
3. impaired comprehension
4. delayed psychomotor speed
85
the onset of ________________ is subtle and neurocognitive deficits and may not present themselves until week to months after surgery
POCD
86
POCD results in what effects on quality of life
1. inability to work
2. decline in ADLS
3. possible need for assistance
87
T/F: preoperative cognitive impairment may be present prior to surgery
true; - why baseline cognitive function is essential
88
prevention of POCD
1. maintain oxygenation and cerebral perfusion
2. short/minimally invasive surgical procedures
Anesthesia Principles I
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