OB16 - Geriatrics & Coexisting

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Life expectancy in the adult male has increased ___ years since the beginning of the 20th century.
Elderly patients account for ___% of all hospital care days in the U.S.
__ in __ patients is over the age of 65

30 years
48%
1 in 4

! Elderly & geriatric refers to pts over ___ yrs
Aged is over ___ yrs

65
80

! ____ is the maximal attainable age under optimal conditions
____ is typical longetivity under typical conditions

life span (110-115 yrs)
life expectancy

There is a ___% increase in risk for perioperative death with an age over 65

300

! Which is better a cross-sectional or longitudinal study?

longitudinal

What is stochastical in regards to aging?

Aging is a stochastical process
Stochastical is a random event with a certain amount of probability.

Are age-related changes and pathological changes synonymous?

no
(pathological changes occur d/t disease process & occur at a higher incidence with age but do not always occur)

Does gender matter in regards to systolic hypertension occuring with aging?
Why does it occur? (think heart not blood vessels)

no
-fibrosis of elastic tissues in the ventricular wall

How would an EKG appear that reflects ventricular hypertrophy?

R waves that are larger than normal in V leads
(R waves normally increase progressively from V1 to V6)

Describe how CO is changed in the elderly

CO may decline but isn't noticed at rest d/t a decrease in demand
(under load this decline becomes noticeable)

How does aging affect:
-response to beta agonists
-response to beta antagonists
-parasympathetic tone
-sympathetic tone

How does this affect them under anesthesia?

-less response to beta agonists
-preserved response to beta antagonists
-decreased parasympathetic tone
-increased sympathetic tone (to maintain CO)

when you put them to sleep & remove the basal sympathetic tone you get a bigger drop in BP

Elderly pts cannot compensate by increasing ___ & ___, then compensate by ___

cannot increase HR & CO
can vasoconstriction

Does the carotid sinus or carotid bodies respond to stretch?

carotid sinus

Why are elderly prone to orthostatic hypotension?

carotid stretch baroreceptor reflex is blunted

! How are compliance and elasticity related?

inversely proportional

The bony thorax is ___ elastic & ___ compliant with age

less elastic, more compliant

! Describe elasticity & compliance of alveoli.
How does this affect the size & stability of the alveoli?

less elastic, more compliant
alveoli become dilated & collapse before FRC is reached (CV is increased) and air trapping occurs (like COPD)

What happens to the surface area of alveoli with aging?

decreases
(from 75 m² to 60 m² by age 70)

! How do the following change with age?
-VC
-RV
-FRC
-TLC
-FEV1
-CV

-VC: ↓
-RV: ↑
-FRC: ~ (ERV drops)
-TLC: ↓ (slowly)
-FEV1: ↓
-CV: ↑ (position dependent)

PaO2 declines from 95 to ___ by age 75

73

Why is HPV blunted in the elderly?

d/t stiff parenchyma that prevent the arteries from constricting

In the elderly, renal mass is ___ mostly in the ___ & is ____ by _____

decreased mostly in the cortex & is replaced by fat & fibrotic tissue

In the elderly:
GFR ___
Cr clearance ___
creatinine production ___
serum Cr ___

GFR ↓s
Cr clearance ↓s
creatinine production ↓s
serum Cr ~

In the elderly:
Hepatic enzyme function ___
Hepatic mass ___

remains intact & functional
decreases (decreased mass is why drug clearance impaired)

In the elderly plasma esterases ___ (gender)

decrease more in men than women
(older men act like pregnant women in regards to plasma esterases)

What neurons tend to be lost more in the elderly (neuronal loss is highly selective)

those that are most metabolically active

What happens to NT production in the elderly?
What are 4 examples of NTs affected?
What happens to enzymes that metabolise NTs?
What are 2 examples?

-decreased
-ACh, NE, Dopamine, Tyrosine
-increased activity
-COMT, MAO

Why would a low MAP be even more detrimental in the elderly? (think neuro)

the CBF autoregulation curve is often right-shifted but remains intact
(from 50-150 MAP to 80-180 to maintain constant CBF)

How is the hyperventilation-CO₂ response to CBF affected by age?

it remains intact

What are meissner's corpuscles & how are they altered by aging?

mechanoreceptors (ie touch, pain)
exponentially decreased (less sensation)

! In the elderly:
The number of motor end plates ____
The number of ACh receptors ____
NMB doses ____

decreases
increases (negates the change)
stay the same

The afferentiation threshold ____ in the elderly
Which sensory modality is affected the most/least

most: laryngeal reflex & taste
least: simple pain

In the elderly:
Adrenal mass size ___
NE concentrations ___
β-adrenergic response ___
α-adrenergic response ___

decrease
increase 2-3x (paradoxically)
decreases
stays the same

Why is CHF in the elderly so concerning to providing anesthesia?

-have high adrenergic tone & low reserve that when blunted can lead to catastrophic results

! The volume of distribution of water soluble drugs in the elderly is ___
Vd of lipid soluble drugs is ___

Why?

decreased (more sensitive to versed)
increased (longer duration of fentanyl)

less body water, more body fat

____ is what the drug does to the body
____ is what the body does to the drug

pharmacodynamics (d to b)
pharmacokinetics (b to d)

Know this chart backwards & forwards
(X axis, slope, potency, Y axis, etc.)

Why are elderly more sensitive to volatile anesthetics?

less brain mass to anesthetize

Which volatile anesthetic might be best in the elderly?

desflurane
-low b:g PC = rapid equilibrium

What is the fundamental principle to follow in providing anesthesia to geriatrics?

work toward prompt and complete post op recovery (LOC, temp, etc.)

What type of anesthesia delivery is ideal for TURP because it will help in early detection of TURP syndrome?

spinal
(but BP changes must be anticipated)
(TURP syndrome = hyponatremia d/t irrigation fluids)

MAC of volatiles should be decreased ___ to ___ % per decade

4-6%

___ levels may be predictive of risk for perioperative morbidity & mortality d/t co-existing disease in the elderly

albumin

____ may be more important than illness indices, and may be used as an index of success post operatively

functional status
(exercise tolerance, etc.)

Anesthetic technique is much less important than good ____ in elderly pts

hemodynamic control

Organ function declines ___% per year starting at age __

1% starting at age 30

! Does plasma creatinine increase in the elderly?

no
(GFR decreases but creatinine production also decreases d/t less muscle mass)

Elderly are prone to ___-natremia

hyponatremia
(less able to retain sodium with declined renal function)

You need to be careful not to tilt the head back too far when intubating elderly d/t ____ insufficiency

vertebrobasilar artery may be insufficient (can cause stroke if occluded)

How would you adjust preop med dosages in the elderly?

be careful, start with lower dose
(better would be to let MDs order & have nurses give)

What should you consider first with postop confusion in the elderly? (x2)

hypoxia?
hypercarbia?

____ is the most important risk factor for delirium
What is the pathophysiology of delirium?
Delirium is a common complication of ____

co existing dimentia
disturbance in neurotransmitter activity
dimentia

How is delirium treated?

identify & treat the cause if possible
(ie physostigmine for anticholinergic syndrome)

Post op delirium occurs in 10-60% of ___ surgeries
Delirium risk also increases with ___ & ___ surgeries

10-60% of hip fracture surgeries
bypass & cataract

Dimentia occurs in just 1% of people at age ___
It ____ every ___ yrs
30-50% incidence at ___ yrs

60
doubles every 5 years
at 85 yrs

Determine if the following are cortical or sub-cortical dementias (picture)

Name 3 cortical dementias
What are the differences between each?

Pick's Disease = degeneration of frontal & temporal lobe
Alzheimers = a diffuse degeneration
Frontal Lobar = frontal lobe degeneration

Name 3 sub-cortical dimentias

Parkinson's
Huntington's (genetic)
Creutzfeldt Jacob's (caused by eating human brain)

What are 4 potentially treatable causes of dementia?

aids
neurosyphilis
Vit B12 deficiency
mental depression

The CT scan shows ___ & ___ in alzheimer's pts

ventricular dilation & cortical atrophy

___ is characterized by a selective destruction of cholinergic neurons in the brain occuring early in the disease
Choline acetyltransferase is decreased as much as __%

Alzheimer's
90%

What neurotransmitter is involved in Alzheimer's disease?

decreased ACh

How is the anesthetic plan altered for alzheimer's pts? (x2)

-avoid centrally acting drugs (sedation, atropine, etc.)
-use minimal anesthesia & use drugs that don't last long

____: pathologically excessive (and often incoherent) talking
____: meaningless repetition of another person's spoken words as a symptom of a psychiatric disorder
____: involuntary repetition of words, phrases, or sentences

Logorrhea
Echolalia
Palilalia

___ is a frontal lobe cortical dementia that occurs less often than Alzheimer's & impairs the ability to plan & initiate goals & is associated with logorrhea, echolalia, & palalia

Pick's disease

_____ is a progressive infectious dementia

Creutzfeld-Jakob disease

_____ can cause dementia, gait disturbances, urinary incontinence, & cognitive declines & is treated by placing a shunt

normal pressure hydrocephalus

Parkinson's disease is characterized by the loss of ____ fibers normally present in the ____ of the brain

dopaminergic fibers in the substantia nigra

Males between the age of 40-70 are more prone to getting ____

Parkinson's disease

The following are symptoms of Parkinson's:
-___ spontaneous movements
-___ of extremities
-___ immobility
-___ gait
-rhythmic resting ___ (___ rolling)
-___ skin
-p___ abnormalities
-___ crisis
-d___ & d___

-decreased spontaneous movements
-rigidity of extremities
-facial immobility
-shuffling gait
-rhythmic resting tremor (pill rolling)
-oily skin
-pupillary abnormalities
-oculogyric crisis
-dementia & depression

What happens if levadopa is withheld preop in an Parkinson's pt?

can lead to skeletal muscle rigidity that can impair breathing

___ & ___ can occur in Parkinson's pts d/t the disease & the treatment (levadopa, MAOIs)

labile BP
dysrhythmias

____ dysfunction in Parkinson's pts can lead to increased risk for aspiration

autonomic dysfunction

____ help to control resting tremors in Parkinson's pts
____ crosses the BBB & is converted to dopamine
____ increases the central delivery of levodopa

anticholinergics
Levodopa
Carbidopa (Sinemet)

____ is a good premedication & for intraop sedation in Alzheimer's pts

diphenhydramine

What vasopressors should/shouldn't you use in Parkinson's pts?
Why?

Use direct-acting
They are often on MAOI or COMT inhibitors & indirect acting agents would cause issues

Ketamine + Parkinson's =

exaggerated sympathetic response

How does prolonged bedrest affect hemodynamics?

decreases circulating plasma volume
(decreased CO & ortho hypoTN)

! Vomitting & diarrhea cause ___-tonic dehydration

isotonic
(balance of water & Na loss)

! Sweating causes ___-tonic dehydration

hypertonic
(water loss exceeds sodium loss)

! Diuretics cause ___-tonic dehydration

hypotonic
(Na loss exceeds water loss)

! Hyper- vs hypo-tonic dehydration Na levels

hypo- Na less than 135 mEq/L
Iso- normal Na
hyper- Na greater than 145 mEq/L

Bun/Cr ratio ___ indicated dehydration

>25

Glaucoma with an IOP greater than ___ mmHg can cause retinal ischemia

21

___ is an age-related condition where the lens of the eye becomes stiff

presbyopia

Progeria is also called ____-____ syndrome, an autosomal recessive disorder

Hutchinson-Gilford syndrome
(premature aging)

Mean survival of progeria is ___ years

13
(death by 25 is common)

___ is a form of osteoarthrytis of the spine

spondylosis

Women lose ~50% of cancellous bone & 30% of cortical bone in their lifetime d/t osteoporosis
Men lose ~30% cancellous, 20% cortical
What is cancellous?

cancellous = spinal column & end of long bones

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