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Term geriatrics was introduced at the start of the 20 century and since then life expectancy for adult males has increased by more than ___years. The elderly patients will account for more than __% of all hospital cases in the US
At least __ in every 4 patients undergoing surgery is 65years or older
1 in every 4
There are different definitions but in general elderly is defined as 65years or greater. ____-___% of the population of advanced countries are elderly if we use this definition
What is life span according to Barash?
- life span is a species specific idealized relatively fixed maximum attainable age under optimum conditions.
- Human life span has been pretty constant at about 110-115years for the last 20 centuries.
What is life expectancy?
- In contrast to life span, life expectancy describes typical longevity in a society.
- This number has changed such that the age of the boding populous has increased.
- The year 2000 (according to miller) the life expectancy was 76.5years.
What is the "vicious cycle of aging"???
- Decline of the mitochondria (cell powerhouse & the site of oxidative phosphorylation) may be responsible for deterioration of organ function.
- Free radicals are a byproduct of oxidative phosphorylation and increased levels of free radicals within the mitochondria may go on to disrupt that oxidative phosphorylation and as the ability to scavenge the byproducts of aerobic metabolism declines it creates this vicious cycle of aging within the mitochondria
Where is mitochondrial deterioration particularly evident (in the viscous cycle of aging)?
- The mitochondrial deterioration may be particularly evident in cardiac and nervous system tissues.
- Also the DNA in the mitochondria is more susceptible than the DNA in the cell nucleus to damage.
Why might calorie restriction be beneficial as we age?
- One theory of terminal aging and death is that we run out of energy because the mitochondria are less and less effective.
- One thought is that calorie restriction may be beneficial because it decreases the oxidative damage in the metabolic pathways
Many of the age related changes that we see are d/t damage to protein. How does this effect the cardiovascular and pulmonary systems?
- Remember the multiple roles of proteins in our bodies, one of those types of proteins was collagen.
- As we age the collagen becomes stiffer and as elastin, elastic tissue is removed it gets replaced w/the stiffer collagen.
- Within the cardiovascular system, arteries, veins, and the heart, will all stiffen w/age but in contrast in the lung there is the loss of elastin and that loss of elastin there doesn’t get replaced w/collagen.
TRUE or FALSE. The degenerative changes as we age that aren’t universal, or don’t increase in severity or magnitude in proportion to chronologic age are probably not the result of aging per say but rather the signs of age related disease.
The change in organ function that we see w/aging appears to be linear, when do they first appear?
- First apparent in around the 4th decade of life.
- Function continues to decrease in years after that, initially there are more subtle changes in functional decline and men become more dramatic at the 7th decade an beyond.
What is the organ system functional reserve?
- The difference between the maximum capacity and the basal function
- This is in essence the safety margin available to meet additional demands that come up (or cardiac output, CO2 elimination) that come up w/trauma and disease.
- The functional reserve is progressively decreased as we age and so the elderly patient will have an increased susceptibility to stress and disease induced decompensation.
What body composition changes do we see in the elderly?
- These really reflect a loss of skeletal muscle so atrophy of metabolically active areas, there will be a decline of metabolically active areas in the brain, liver, and the kidney.
- And an increase in adipose
Included if we look at the changes that occur w/aging will be an initial weight gain (in men about ____% and ___% in women) by the age of 60years. And then return to equal values or below that of young adulthood.
The composition changes are somewhat different in men and women, what are they?
- As men will undergo more of a multi compartment loss of tissue mass (Both adipose and bone)
- Women experience a dramatic increase in total body lipid while loosing bone mass and intracellular water.
As a result of the body composition changes, basal metabolic requirements will
decrease by __-__%. What does this mean for us intra-op?
10-15%; will be a decrease in body heat production
So in elderly patients core temperature decreases _______as fast as in young adults
Liver will decrease in size w/age. It will decrease in size by about _____% by the age of 80. This results in a ___-___% decrease in hepatic blood flow, about ____% per decade.
40%; 20-40%; 10%
What happens to the clearance of a drug if it's dependent on the liver?
- It decreases.
- Phase 1 drug biotransformation and bile secretion may be modestly reduced with age.
- And although this may effect drug metabolism, the liver reserve should still be adequate in the absence of disease.
- Bear in mind this is somewhat variable and we can’t really quantify it, in general there is a decreased clearance of any drug dependent on hepatic biotransformation.
Within the kidney there’s progressive loss of glomeruli. The renal cortical mass will decrease by __-__% and by the age of 80 there is a loss of up to ___% of glomeruli
Renal blood flow goes along and decreases w/age ___% or so or ____%/decade beginning in early adulthood.
Glomerular filtration progressively declines by about _______ after the 4th decade. Because of this drug doses should be adjusted beginning at about age 60year.
Why might a normal serum creatinine in a geriatric patient not necessarily mean normal renal function???
- In spite of the fact that there is decrease in skeletal muscle, serum creatinine levels remain in the normal range so normal serum creatinine levels don’t assure normal renal function.
- To identify renal dysfunction we really want to measure the creatinine clearance, and remember that formula incorporates age.
We can maximally concentrate our urine up to about 1200-1400mOsm. The elderly patient that can’t do this as well, and can neither eliminate excess sodium nor conserve Na when necessary. Why is this??
- Part of this may be d/t a decrease in aldosterone secretion.
- There’s also a relative insensitivity of the collecting ducts to ADH. The ADH levels are actually increased in the elderly.
So if max urinary concentration at age 30years is about _____mOsm/kg at the age of 100years it’s approx. _________mOsm/kg.
Hyponatremia is common in the elderly. Define the levels.
- < 135 mEq/L
- < 125 mEq/L = mild – mod
- < 120 mEq/L = severe
Hyponatremia is the most common, occurring in ___-___% of hospitalized elderly patients.
What are the reasons for hyponatremia in the elderly?
There are many reasons for this: reduced glomerular filtration, decreased free water clearance, diuretic administration and poor oral intake.
What type of insulin dysfunction is commonly seen in the elderly?
- Aging is associated w/increased insulin resistance esp. in skeletal muscle
- So may need perioperative insulin treatment.
- Metabolically all elderly patients have a decreased ability to handle a glucose load.
- This is thought not be a decrease in insulin secretion but rather an antagonism of insulin or an impaired insulin function, not the amount but rather that it’s not working properly.
What happens with aldosterone and ADH in the elderly?
Decrease in aldosterone secretion and relatively insensitivity of collecting ducts to ADH.
There are anatomic changes in the heart that translate to physiologic changes. Describe these.
- Loss in the number of myocytes and the wall of the LV will thicken.
- Decrease in the density of the conduction system fibers
- Decrease in the # of cells in the SA node.
All of these together will cause an increase in myocardial stiffness and decreased contractility, increased filling pressures, and decreased beta adrenergic sensitivity.
The elderly patient will also experience a loss of normal heart rate variability. Why is this and what are it's implications?
- Barash: not d/t down regulation but rather to an impaired intracellular signaling. There will be less of a response to either endogenous or exogenous catecholamines.
- Wont respond normally to many pharmacologic agents. So the response to atropine will be markedly blunted, as will be the response to isopruel.
- Baroreflex HR control is also decreased and that results in poor BP control.
What are the vasculature changes we see in the elderly?
- Loss of elastin & collagen
- ↓ compliance
- ↑ MAP & pulse pressure
What kind of hypertension do we see in the elderly?
The incidence of systolic hypertension is high in this population, almost a linear increase in systolic BP between the ages of 30-80 years. Accompanied by a decrease in diastolic pressure and so an increase pulse pressure.
What is the significance of diastolic dysfunction w/a stiff LV
- that there is an increase importance of end diastolic ventricular volume.
- Such things like decreased venous return that gets associated with mechanical ventilation, blood loss, vasodilating drugs, or w/arrhythmias can further exacerbate the problem.
What ANS changes do we see in the elderly?
- ↑ SNS activity
- ↓ β adrenergic responsiveness
- --↓ receptor affinity & ↓ signaling
There is a decrease in max HR and a decrease in peak EF. There is a decrease in baroreflex responsiveness in patients.
Although the sympathetic component may be well maintained, the parasympathetic component becomes impaired w/age.
How do the ANS changes in the elderly contribute to labile BPs we see intra-op?
- One of the things that happens is there is a decline in beta adrenergic receptor mediated vasodilation. But alpha adrenergic receptor mediated vasoconstriction doesn’t seem to change w/age.
- So as a result, there’s unopposed vasoconstriction. So all these changes in the ANS further contribute to exacerbate the labile HDs that are seen intraoperatively.
How can we optimize CO in the elderly?
Ventricular filling is key but diastolic filling impaired (LV hypertrophy and decreased LV compliance) so atrial contraction is important
Incidence of coronary artery disease increases exponentially with age so that by the age of 80, about___ of all elderly patients have some degree of CAD; ____% have angina
DM not only facilitates atherosclerosis of the coronary arteries and associated autonomic neuropathy. How does DM affect the coronaries?
Can impair coronary dilation by sympathetic stimulation.
What happens to the conducting airways as we age? (think aspiration)
- In the conducting airways there will be a loss of elastin, collagen, and water, and consequently a loss of pharyngeal muscle support which can lead to upper airway obstruction.
- There will also be an increase in the diameter of the trachea in the central airway which will increase residual volume and decrease in airway reflexes which will puts the patient at increased risk for aspiration
What happens to the lung parenchyma as we age?
- The loss of elasticity will also result in increased alveolar compliance and small airway collapse and air trapping.
- Within the lung parenchyma there will be a decrease in alveolar surface area of about 30% at the age of 80 compared to age 20 d/t fusion of alveoli.
There is a decrease in alveolar surface area of about ____% at the age of 80 compared to age 20 d/t fusion of alveoli.
The functional results of the anatomic changes include an ______ in anatomic dead space, ___________ diffusing capacity and an ______closing capacity and of course all of these lead to impaired gas exchange.
increase, decreased, increased
What happens to the thoracic cage as we age?
- kyphosis and vertebral collapse and costochondrial calcifications so that there will be ultimately a decrease in chest wall compliance.
- This can offset the increased compliance d/t the loss of elastin so that net pulmonary compliance is almost unchanged.
What causes the increased closing capacity seen with age?
- Although the decrease in elasticity of the lung makes it easier for the lung to inflate but the small airways don’t have enough intrinsic stiffness d/t this loss of elastin.
- So they need the surrounding tissues to tether them in order to stay open. As these surrounding tissues loose their capacity to support the lung tissue, the lung has to inflate more in order to provide the outward pull in order to keep the airways open. This greater need for lung inflation is reflected in the previous mentioned increase in closing capacity with age
In younger people, closing capacity is less then FRC. At age ___ it’s equal to FRC in the supine position, at age ___it’s equal to FRC in the upright position
So the closing capacity usually exceeds FRC in the mid 60s. And eventually exceeds TV w/increasing age.
How does closing capacity effect the V/Q ratio?
- When closing capacity approaches TV, V/Q mismatch occurs.
- When FRC is less than closing capacity, shunt increases, and PaO2 decreases, so impaired oxygenation.
- HPV is also blunted in the geriatric patient
The TLC doesn’t change significantly w/age, RV increases approx. __-___%/decade or about __ml/yr because of increased chest wall stiffness and loss of elastic recoil together with decreased force generated by the respiratory muscles.
Why do we see airway closure during normal TV breathing in the elderly?
The FRC remains unchanged or increases and closing volume and closing capacity increase. So airway closure tends to occur during normal TV breathing, particularly in cigarette smokers
The Vital Capacity declines progressively w/age at a rate of about ___ml/yr.
The pulmonary changes result in arterial oxygen tension levels decreasing by __ml mmHg per decade after the age of 20.
The ventilatory response to both hypoxia and hypercapnia will both decrease significantly. Barash reporting approx. a ___% decrease in ventilatory response to hypercapnia and he says there is an even greater decrease in response to hypoxia, esp. at night.
The brain mass will start to decrease at around the age of ___ and the loss accelerates in later years
The weight of an 80yr olds brain is reduced at about __% or more such that at autopsy the average weight of an 80yr old brain is approx. ___% lower than that of a 30 year old.
There is a progressive loss of neurons as we age, what types of neurons do we loose the most?
- The types of neurons that are lost will vary according to function such that those involved w/NT synthesis will also undergo the greatest degree of attrition.
- And those associated with more complex aspects of intelligence and language don’t appear to decline w/age.
There will be a decrease in CBF in proportion to the decrease in tissue mass. Decreased by about ___-___% of young adults.
What happens to CMR and autoregulation of CBF in the elderly?
- There will be a decrease in CMR, auto regulation of CBF is often maintained in the elderly.
- However patients with untreated HTN have higher ranges of auto regulatory perfusion pressure.
What are the anesthesia implications for the CNS changes in the elderly?
- ↑ Sensitivity to central nervous system depression
- ↑ Threshold for pain sensation
- ↓ MAC
- Cognitive dysfunction
The best known effect of aging in the brain is that MAC decreases ___%/decade after the age of 40yrs.
We tend to accept the fact that deterioration of mental function is inevitable but recent studies suggest that storage of information, comprehension, and long term memory are well preserved into the 80s. What are there decreases in?
There is some decrease in short term memory, visual and auditory reaction time, and aspects of processing information and information retrieval.
Alzheimer's is present in __-__% of patients age 65 and older
What happens to the peripheral nervous system in the elderly?
- Electrical conduction progressively deteriorates.
- There will be a decrease in conduction velocity d/t loss of motor neuron cells the elderly patient will experience disseminated neurogenic muscle atrophy.
What happens to the adrenal mass and amount of catecholamines as we age?
- Adrenal mass ↓’s but ↑ Catecholamines
- Endogenous beta blockade
- Plasma norepinephrine levels will increase but because of whether it’s down regulation of beta receptors or some sort of intracellular signaling issues this hyper adrenergic state may not be apparent.
- The degree of tachycardic response to exercise stress is less. Max HR is less, they don’t respond as well to our normal beta agonist.
- There is little change in alpha adrenergic activity& muscarinic receptor activity
Elderly account for __% of all drug prescriptions. ___of all patients over age 70 take at least 2 different types of medications
Thre is an increae in adverse drug reactions can be seen in anywhere from __-___% of elderly patients in the hospital
The elderly require a decreae by about__ % of thiopental than d/t young, because of these kinetic changes
Propofol induction doses should also be decreased. References say anywhere from __-___% and should be dosed on lean body mass.
Why should we give less propofol if it has such a high clearance?
- Again, the patient is likely to have a smaller central volume of distribution and reduced clearance even though propofol generally has a high clearance.
- Of course propofol will also cause hypotension and depresses respiration and so the caveat is to decrease the induction dose but to also be really careful in using it during MAC anesthesia
__-___% increased sensitivity in the elderly to propofol.
Etomidate: somewhat like thiopental, there is decreased clearance. Decreased initial volume of distribution but not necessarily an increased sensitivity but again the dose should be decreased by about ___-___%.
Midazolam in the young patient, the terminal ½ life averages around 2.5hrs that increases to about ___hrs in the elderly
Geriatric patients require a lower dose to produce sedation than do the young. The IV dose of midazolam to produce sedation in an 80year old is ____ of what you would give a 20 year old.
What are our concerns for IV diazepam in the elderly?
IV injection may cause thrombophlebitis or thrombosis more frequently in the elderly than in the young patient.
So the terminal ½ life of desmethyldiazepam, which is the active metabolite of dizepam will increase from 20 hours in in the 20 year old to ___ hours in the 80 year old.
What kinds of considerations regarding opioids should we have in the elderly patient?
- ↑ sensitivity to all opioids
- Pharmacokinetic changes are due to changes in body composition for fentanyl family
What is important regarding Morphine in the elderly?
Morphine is metabolized to active metabolites and clearance is decreased for both the parent drug and the metabolite
"Don’t use meperidine in elderly, it’s a horrible drug in just about anyone." Why?
- Meperidine is metabolized to nor-meperidine which is active and can cause seizures.
- The risk of nor-meperidine induced seizure is increased in the elderly, again because of decrease clearance of the metabolite as well as the parent drug
What should we remember about induction and emergence of volatiles in the elderly?
- Slowed uptake if V/Q abnormalities
- Alterations in cardiac output (“slowed circ time)
What are the CV effects of the volatiles in the elderly?
- Myocardial depression exaggerated
- Less tachycardia from isoflurane or desflurane
- The elderly patient will not do this in the same way, they don’t have that compensatory increase in HR and so consequently there will be a decrease in CO that doesn’t get attenuated by that increase in HR
What do volatiles do to the respiratory drive in the elderly patient?
↓ ventilatory response to hypoxia or hypercarbia
The initial dose requirements of the muscle relaxants don’t appear to be changed in the elderly patient, why is onset slow???
Onset time increased 2° ↓ CO & ↓ muscle blood flow
If we prime w/MR to get a quicker onset, what must we keep in mind!
Careful with priming technique because of ↑ risk of aspiration, desaturation
For muscle relaxants, Metabolism & clearance prolonged 2° ↓ hepatic blood flow & ↓ GFR if dependent on liver and kidney. So what two drugs may be better?
When is regional better than GA in the elderly?
Regional is only beneficial if sedation is minimal
What is the good and bad about regional anesthesia in the elderly?
- Bad: Anatomically challenging (Spinal & epidural placement) and Hemodynamic changes (Hypotension)
- Good: Postoperative pain managemen-->tMay reduce the need for systemic opioids
What kind of cardiac eval might we get in the elderly patient?
- EKG: conduction disturbances & ischemia
- Stress Testing
Name the SIX Factors Contributing to Perioperative Morbidity & Mortality.
- 1. Effects of aging on organ system functional reserve
- 2. Result of age-related disease & its treatment
- 3. Impaired autonomic homeostasis
- 4. Need for medical intervention & invasive procedures
- 5. Polypharmacy
- 6. Emergency surgery
whatever the cause, the doses of propofol, etomidate, barbiturates, benzodiazapines, opioids, should all be reduced by __-___% in geriatric patient.
Besides the phamacology, what are some other important considerations for the elderly perioperatively??
- Other considerations include careful fluid management, and being aware of decrease in skin and soft tissue perfusion, which make the patient more susceptible to pressure injuries.
- Careful positioning also must happen because of the higher incidence of arthritis and osteoporosis.
- Patients are more likely to get a corneal abrasion because of decreased lacrimation.
- And of course the altered thermoregulation and the impact of shivering on myocardial oxygen consumption make these issues really important in the anesthetic plan
What non-cardiac procedures are most risky for cardiac death or myocardial ischemia?
The non-cardiac surgeries involving the thorax, the abdomen, blood vessels, head and neck are associated with the highest cardiac risk involving myocardial ischemia and cardiac death
How often should we get an EKG for high risk patients?
EKG should be followed daily or even twice/day in high risk patients in the immediate post-op period.
So the incidence of post-op delirium in the elderly patients are reported from __-__%, pretty big range. It also can last for a variable period of time. Some feel that cognitive functions are impaired even ____after surgery.
Post-op cognitive function is a big consideration. It may manifest at delirium, what is this??
- Delirium being defined as a state of disturbed consciousness, with decreased attention and awareness of the environment.
- It’s sometimes under-recognized because it may be hypoactive or hyperactive.
- It’s the hypoactive that is often missed
Besides delirium, what other cognitive changes might you see in the elderly patient?
Other cognitive changes include decreased memory, decreased orientation, language problems, word finding difficulties, visual disturbances and hallucinations
What causes hypothermia in the elderly?
- Impaired thermoregulation
- Decreased sub-dermal tissue
- Decreased muscle mass (metabolically active tissue) so less heat production
Why is hypothermia bad in the elderly?
- Leads to vasoconstriction & HTN
- Shivering causes ischemia with increased metabolic requirements often exceeding capabilities
- Prevention is key!!
What are the common causes of hypoxemia?
- Atelectasis & pneumonia are common causes
- V/Q mismatch
In surgical patients age 65 and older the incidence of atelectasis is __%, that of acute bronchitis is __%, and pneumonia is ___%.
17%, 12%, 10%
List the Predictors of postop pulmonary complications in patients undergoing elective noncardiac surgery
- Postop nasogastric tube or TEE(provides a wick)
- Productive cough preop
- Long anesthetic (GA)
- Alcohol abuse
- Chronic steroid use
- Impaired LOC/CVA
The incidence of malnutrition in the elderly population is pretty high, about __-___% and that can further contribute to deconditioning.
Depression is high. About __% of elderly hip fx
patients will have a history of depression.
What should we know about the elderly and ETOH?
Alcoholism is common among elderly patients and may be the cause of an accident or a fall. It’s also a predictor of post-op pneunomia.
What can often be missed in the elderly?
Chronic pain will often go undetected and unappreciated so it’s really important to evaluate the level of pain, which is also from arthritis, and also the use of pain medications.
In the elderly, we also need to evaluate for the level of competence because autonomy really implies .....
autonomy really implies mental competence, the legal standards for competence include the ability to communicate a choice to understand relevant information, to understand the present situation and it’s consequences, and to be able to manipulate information rapidly