Renal Changes Due to Narcotics and Aging

The chest wall compliance ________

Minute ventilation ________ in the elderly due to increased dead space

Loss of muscle tone in airway predisposes to upper airway ________

Elderly are predisposed to postop hypoxia due to less effective ________ and swallowing

Respiratory changes in aging include emphysema, chronic bronchitis, ________, lung cancer, and TB

An edentulous patient poses a challenge during anesthesia due to difficulty in ________

Arthritis of the TMJ or cervical spine poses a challenge in anesthesia related to ________ and airway

To prevent perioperative hypoxia, actions like preoxygenation, higher FiO2, more PEEP, and pulmonary ________ can be taken

Anesthetic considerations: Preop Vd? _______ (increased)

Anesthetic considerations: Preop age > 70 caution use of _______ (Versed)

Anesthetic techniques: preferential use of spinal/epidural and regional over _______ (MAC)

Perioperative: Drug to try to avoid? _______ (anticholinergics)

Perioperative: Inhalational agents? Reduced _______ (concentration)

Postop Volume of distribution: increased _______ (fat)

Postop: anesthetics will have increased Vd, reduce doses of _______ (propofol and etomidate)

Confusion Assessment Method (CAM) developed by Dr.Sharon K.Inouye, MD, is a tool for delirium _______ (assessment)

By age 80, 50% of nephrons are lost due to ________.

Renal function declines with age, leading to decreased renal blood flow and ________.

Elderly patients with renal impairment are at risk of fluid overload, electrolyte imbalances, and accumulation of metabolites due to decreased ________.

Surgery and anesthesia in elderly patients result in increased glucose levels and insulin resistance, leading to increased ________ requirements during surgery.

Hepatic changes in aging individuals include decreased liver size, hepatic blood flow, and albumin production, as well as age-related redistribution of ________.

Elderly individuals have decreased basal metabolism, leading to decreased heat production and autonomic ________.

GI changes in aging individuals include decreased esophageal and intestinal motility, and decreased gastroesophageal ________ tone.

Elderly patients undergoing surgery are at increased risk of surgical wound infection and coagulopathy, leading to increased ________ loss.

Decrease dose & titrate slowly-propofol leads to ______

SUX: Slower onset (40%) o NDMRs depending on renal excretion are ______

Atracuruim is unaffected by ______

NDMRs doses are changed little by the process of aging ______

How about ______?

No technique has shown to be superior for the ______

Some evidence supports that older pts have better prognosis if the surgery is done under ______

Narrowing of intervertebral spaces and osteophytic growth suggests that LA less likely to spread outward and more likely to spread upward in the spinal canal o Increased permeability produces more rapid onset o Reduced clearance and prolonged elimination ½ life leads to ______ conc.

To properly guard against this occurrence and costly outcome, your peri-operative anesthetic plan should ______: o avoid anticholinergics if possible o reduce the dose of inhalation agents o avoid narcotics if possible o Alfenta/Sufenta used commonly → quicker off Geriatric Syndromes Osteoporosis Osteoarthritis, RA Parkinson’s Disease Dementia Osteoporosis Microarchitectural deterioration of bone o ↓ bone density o ↑ bone fragility o Susceptibility to fractures May be asymptomatic until a fracture occurs Loss of height/increasing kyphosis-secondary to vertebral fractures Women with fractures -50% spend time in a nursing home Peak incidence is 70 years old Associated risk factors: o o o o o -Estrogen deficiency -Increased alcohol consumption, smoker -Cancer -Calcium deficiency -Long term steroid therapy Osteoarthritis Non-pharmacologic intervention(cornerstone) Patient education, PT and OT Decrease in joint stress Acetaminophen and NSAIDs Muscle relaxants-spasms Intra-articular glucocorticoid injections Narcotics and arthroplasty Cervical OA: o Difficult intubation ▪ -Decreased mobility airway ▪ -TMJ arthritis ▪ -Cervical spine-mobility and stability ▪ -Decrease glottic opening o Consider flexion/extension x-rays if concern o Easy to fracture Parkinson’s Disease Characterized by progressive depletion dopaminergic neurons of substantia nigra from basal ganglia Age is most consistent factor o 3% of population older than 65 o 50% of people older than 85 Clinical signs when approximately 80% of dopaminergic activity is lost Imbalance between the inhibitory action of dopamine and excitatory action of acetylcholine Imbalance leads to classic triad Triad: rigidity, resting tremor, bradykinesia Anesthesia considerations: o Aspiration prophylaxis o Monitoring of respiratory function o Administer drugs as close to schedule as possible o Drugs should to avoid: phenothiazines, butyrophenones (droperidol), metoclopramide o Diphenhydramine can be effective to counter drug-induced extra-pyramidal effects o ANS dysfunction-hemodynamic monitoring as needed What is deep brain stimulation?

To properly guard against this occurrence and costly outcome, your peri-operative anesthetic plan should ______: o avoid anticholinergics if possible o reduce the dose of inhalation agents o avoid narcotics if possible o Alfenta/Sufenta used commonly → quicker off Geriatric Syndromes Osteoporosis Osteoarthritis, RA Parkinson’s Disease Dementia Osteoporosis Microarchitectural deterioration of bone o ↓ bone density o ↑ bone fragility o Susceptibility to fractures May be asymptomatic until a fracture occurs Loss of height/increasing kyphosis-secondary to vertebral fractures Women with fractures -50% spend time in a nursing home Peak incidence is 70 years old Associated risk factors: o o o o o -Estrogen deficiency -Increased alcohol consumption, smoker -Cancer -Calcium deficiency -Long term steroid therapy Osteoarthritis Non-pharmacologic intervention(cornerstone) Patient education, PT and OT Decrease in joint stress Acetaminophen and NSAIDs Muscle relaxants-spasms Intra-articular glucocorticoid injections Narcotics and arthroplasty Cervical OA: o Difficult intubation ▪ -Decreased mobility airway ▪ -TMJ arthritis ▪ -Cervical spine-mobility and stability ▪ -Decrease glottic opening o Consider flexion/extension x-rays if concern o Easy to fracture Parkinson’s Disease Characterized by progressive depletion dopaminergic neurons of substantia nigra from basal ganglia Age is most consistent factor o 3% of population older than 65 o 50% of people older than 85 Clinical signs when approximately 80% of dopaminergic activity is lost Imbalance between the inhibitory action of dopamine and excitatory action of acetylcholine Imbalance leads to classic triad Triad: rigidity, resting tremor, bradykinesia Anesthesia considerations: o Aspiration prophylaxis o Monitoring of respiratory function o Administer drugs as close to schedule as possible o Drugs should to avoid: phenothiazines, butyrophenones (droperidol), metoclopramide o Diphenhydramine can be effective to counter drug-induced extra-pyramidal effects o ANS dysfunction-hemodynamic monitoring as needed What is deep brain stimulation?

To properly guard against this occurrence and costly outcome, your peri-operative anesthetic plan should ______ anticholinergics if possible o reduce the dose of inhalation agents o avoid narcotics if possible o Alfenta/Sufenta used commonly → quicker off Geriatric Syndromes Osteoporosis Osteoarthritis, RA Parkinson’s Disease Dementia Osteoporosis Microarchitectural deterioration of bone o ↓ bone density o ↑ bone fragility o Susceptibility to fractures May be asymptomatic until a fracture occurs Loss of height/increasing kyphosis-secondary to vertebral fractures Women with fractures -50% spend time in a nursing home Peak incidence is 70 years old Associated risk factors: o o o o o -Estrogen deficiency -Increased alcohol consumption, smoker -Cancer -Calcium deficiency -Long term steroid therapy Osteoarthritis Non-pharmacologic intervention(cornerstone) Patient education, PT and OT Decrease in joint stress Acetaminophen and NSAIDs Muscle relaxants-spasms Intra-articular glucocorticoid injections Narcotics and arthroplasty Cervical OA: o Difficult intubation ▪ -Decreased mobility airway ▪ -TMJ arthritis ▪ -Cervical spine-mobility and stability ▪ -Decrease glottic opening o Consider flexion/extension x-rays if concern o Easy to fracture Parkinson’s Disease Characterized by progressive depletion dopaminergic neurons of substantia nigra from basal ganglia Age is most consistent factor o 3% of population older than 65 o 50% of people older than 85 Clinical signs when approximately 80% of dopaminergic activity is lost Imbalance between the inhibitory action of dopamine and excitatory action of acetylcholine Imbalance leads to classic triad Triad: rigidity, resting tremor, bradykinesia Anesthesia considerations: o Aspiration prophylaxis o Monitoring of respiratory function o Administer drugs as close to schedule as possible o Drugs should to avoid: phenothiazines, butyrophenones (droperidol), metoclopramide o Diphenhydramine can be effective to counter drug-induced extra-pyramidal effects o ANS dysfunction-hemodynamic monitoring as needed What is deep brain stimulation?

What are the anesthesia considerations for patients with Parkinson's Disease?

Why do elderly patients undergoing surgery have an increased risk of surgical wound infection and coagulopathy?

What are some of the GI changes seen in aging individuals?

How do elderly patients predispose to postoperative hypoxia?

What are the respiratory changes seen in aging individuals?

How does aging affect hepatic function?

Why should anesthetic considerations be cautious in elderly patients with renal impairment?

What are the challenges posed by an edentulous patient during anesthesia?

What are two causes of death related to aspiration in elderly patients?

What are the CNS changes in elderly patients undergoing surgery?

What is Postoperative Cognitive Dysfunction (POCD) characterized by?

What is the most common form of perioperative CNS dysfunction in elderly surgical patients?

What is the pathophysiology behind Postoperative Delirium (POD)?

What are some risk factors for developing Postoperative Delirium (POD)?

What is Osteoporosis characterized by?

What are the classic signs of Parkinson's Disease?

What are the two main factors that contribute to the risk of post-op acute renal failure in elderly patients with renal impairment?

What are the main concerns with elderly patients with renal impairment during anesthesia?

Why do elderly patients undergoing surgery have increased insulin requirements?

What is the main reason behind the loss of 50% of nephrons by age 80?

What are the common hepatic changes in aging individuals?

Why do elderly individuals have a decreased basal metabolism?

What are the GI changes commonly observed in aging individuals?

How does aging affect renal function?

What are three primary factors associated with perioperative risks in older adults?

How does body composition change with aging?

What is the primary effect of decreased plasma albumin levels in the elderly?

What age-related change affects the Volume of distribution (Vd) of drugs in the elderly?

Why is the decrease in plasma albumin levels an anesthetic concern?

What is the classic triad of symptoms in Parkinson's Disease?

What are some key anesthesia considerations for patients with Parkinson's Disease?

What is the primary concern related to osteoporosis in elderly patients during anesthesia?

What is the effect of aging on neuromuscular blocking agents (NDMRs) depending on renal excretion?

Why is the dose of local anesthetics suggested to be decreased in epidural anesthesia for the elderly?

What are the clinical signs of Parkinson's Disease when approximately 80% of dopaminergic activity is lost?

Why should phenothiazines, butyrophenones, and metoclopramide be avoided in elderly patients during anesthesia?

What is the effect of aging on renal function?

Why are elderly patients at increased risk of surgical wound infection and coagulopathy during surgery?

What are the challenges posed by arthritis of the TMJ or cervical spine in anesthesia?

What is the effect of aging on basal metabolism in elderly individuals?