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Principles II, Final Exam, Elderly slides 40-52
Holy balls! There is a lot of content!
21
Nursing
Graduate
12/13/2009

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Cards

Term

How does the CNS recovery time in the elderly compare to the young?  What might increase the impact?

So why do we care?

Definition

Elderly patients often take more time, especially if they were confused or disoriented pre-op.

This could be a problem, cuz we usually send them home!

Term
What are the 3 categories of post-op cognitive disorders?
Definition

Delirium

Mild Cognitive Disorder (commonly called POCD)

Dementia

Term

How common is delirium in the elderly after surgery?

What is included in dementia?

Definition

10-15% of elderly after GA

 

Extremely rare, includes cognitive defects in multiple domains and severe impairment in occupational and social function.

Term

Post-op delirium occurs in 5-50% of the elderly, presenting on POD 1-3.

MANY factors are thought to play in this.  I'm not sure entirely how to phrase this as a question, so list as many of the factors you can think of, and there's probably at least 5 more.

Definition

Cellular proteins altered by potent inhaled agents

Central cholinergic insufficiency

Microemboli

Preexisting subclinical dementia

Hypoxia

Fever

Infection (UTI, sinusitis, pneumonia)

Electrolyte abnormalities, Anemia

Pain

Sleep deprivation

Unfamiliar environment

Term
"Deterioration of intellectual function presenting as impaired memory or concentration" is the definition of what?
Definition
Postoperative cognitive dysfunction
Term
How severe is POCD usually?  How long does it usually take to manifest?
Definition

Usually mild

May not be detected until days to weeks after surgery, and duration may be several weeks or permanent

Term
Why is POCD difficult to diagnose?
Definition
The diagnosis must be corroborated with neuropsychological testing and can only be made if there is evidence of greater memory loss than one would expect due to normal aging.  This means the pt has to be tested prior to surgery and at least several weeks after surgery to determine if cognitive decline has occurred.  
Term
What are some contributing factors to POCD?  (there are 6)
Definition

Drug effects

Pain

Hypothermia

Underlying dementia

Metabolic disturbances

Severity of surgery

Low levels of neurotransmitters (acetylcholine) may contribute

Term
If low levels of acetylcholine may make POCD worse, what drugs specifically can impact this?  Of this class of drugs, which one probably wouldn't impact?  
Definition
Central acting anticholinergics (scopalamine, atropine).  Glycopyrolate does not cross the BBB, so it should not.
Term

True of false:

The incidence of POCD is less if using regional with sedation than GA

Definition
False.  Equal incidence
Term
Which is more likely to impact POCD: the surgery, or the anesthesia?
Definition
Animal studies suggest that anesthesia alone, without surgery, can impair learning for weeks in older animals.
Term
Risk factors for POCD can be grouped into 3 different categories.  What are they?
Definition

High-risk patients (Pts already moving toward dementia... the stress of surgery can push them over their "functional cliff")

High-risk surgical procedures (cardiac or ortho)

High-risk anesthetic techniques

Term
What are 3 big implications of post-op neurocognitive disorders?
Definition

Loss of independence

Withdrawal from society

Death

Term
True or false:  At hospital discharge, cognitive decline is a predictor of worse long-term cognitive outcome?
Definition
True dat--those with pump head just don't do as well.
Term

How might the BIS affect mortality rates?

 

How does TIVA compare to GA?

Definition

Risk-adjusted mortality rates decreased when the BIS was consistently used.  One study indicated a 19% increase for mortality for each hour the BIS was below 45!

 

GA increased the risk of death by 3X

Term

Regarding musculoskeletal changes in the elderly, answer true or false to the following:

1.  Increased muscle mass

2.  Neuromuscular junction thickens

3.  Nicotinic receptors remain constant in number

4.  Skin atrophies

5.  Veins are frail

6.  Positioning presents no more of a challenge with the elderly than anyone else

 

Definition

1.  False--it's reduced (which is why creatine levels remain constant)

2.  True

3.  False.  There is an extra-junctional spread of nicotinic receptors

4.  True

5.  True

6.  Of course this is false--the arthritic joints and buffalo humps make everything more difficult

 

Term
What happens to the muscle mass and body fat percentages in old folks, and how does this impact the distribution of water and fat soluble drugs?  (yes, that's lots of questions in one sentence.  Deal with it, bitches.)
Definition

Decreased muscle mass

Increased body fat

Decreased volume of distribution for water soluble drugs

Increased volume of distribution for fat soluble drugs

Term

What happens to the drug plasma concentration for water and fat soluble drugs?

What happens to the elimination half-life?

Definition

Increased plasma concentration for water soluble drugs, decreased for fat soluble.

Increased elimination of water soluble drugs, decreased elim. of fat soluble.

Term
What happens to albumin levels, and how does this impact drug levels?  Does albumin bind more to acids or bases?  What binds to the other?
Definition
Decreased albumin levels, leading to increased plasma concentrations.  Albumin binds more to acids, whereas alpha 1 acid glycoprotein levels INCREASE, which binds basic drugs.
Term

Lets talk about the onset of volatiles.

1.  What will happen to the onset if cardiac output is decreased?

2.  What will happen if there is a V:Q abnormality?

3.  What happens to the myocardial depressant effect of volatiles in old people?

4.  Why is recovery delayed? 

Definition

1.  Onset will be increased

2.  Onset will be delayed

3.  The myocardial depressant effect is exaggerated

4.  Due to increased volume of distribution in fat, decreased hepatic function, decreased pulmonary gas exchange

Term

Do dose requirements change for old people for induction drugs (propofol, etomidate, barbs, opioids, and benzos)?

What about succs and NDMR?

Definition

Usually require lower doses of induction agents--usually 50% less benzos.

 

Succs and NDMRs are unaltered with aging, but with a decreased cardiac output and slow muscle blood flow, they may as much as double the longevity.

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