Geriatric care

Question	Answer
Definition	anyone over 65 years and older
Cardiovascular changes	decreased arterial elasticity, elevated afterload, systolic BP, left ventricular hypertrophy decreased adrenergic activity, decreased heart rate, maximal heart rate, baroreceptor reflex
Cardio pathology	arteriosclerosis coronary artery disease hypertension congestive cardiac failure cardiac arrhythmias (AF) aortiv stenosis
Respiratory changes	drying of mucous membranes, decreased pulmonary elasticity, decreased alveolar surface tension, V/Q mismatching Increased chest wall rigidity Decreased muscle strength decrease cough, maximal breathing capacity
respiratory pathology	COPD, emphysema, chronic bronchitis, pneumonia, lung cancer
Renal changes	reduced bladder capacity and weakened muscles, decreased renal blood flow, GFR rate, decreased tubular function - impaired na and fluid handling, drug excretion, decreased renin-aldosterone responsiveness - impaired K handling
Gastrointestinal changes	decreased digestive gland secretions, mucous thicker - dysphagia, loss of teeth - digestion probelms, delays in gastric emptying - decreased peristalsis, gastric motility, changes in body water and mass - implications for drugs
Integumentary changes	vulnerable to mild mechanical stress, decrease elastin fibres, collagen - heat loss, barrier function less effective - bruising, water loss, infection
Musculoskeletal changes	progressive loss of muscle strength, joint pain/stiffness - care when positioning, bone breakdown overcomes bone building - osteoporosis
Nervous system changes	loss of neurones, decreased reaction time, changes in sleep patterns, less rapid eye movements (REM) and deep sleep
Pharmacological changes	pharmacokinetics - what body does to drug, absorption, distribution, metabolism, elimination Pharmacodynamics - what drug does to body, physical interaction, receptors, enzymes systems
Changes in body composition effecting distribution and elimination	increased body fat - prolonged effect and extends elimination time Decreased skeletal muscle mass - increased o2 consumption, decreased production heat, secondary to pharmacokinetic changes * not more sensitive to muscle relaxants, as fewer receptors at neuromuscular junction
Changes in body composition	decreased intracellular water decreased plasma volume, hypertension, on diuretics,
Pharmacokinetic change volume distribution, distribution, elimination	volume distribution - same concentration of fluid and drug present in plasma distribution - decreased total body weight and 2 x increased mean body fat = vd is diminished, higher plasma concentration vd is larger for lipid soluble drugs - lower plasma concentrations elimination - is effected by vd, if vd increased, half life will be prolonged
Pharmacokinetic changes clearance, plasma protein binding	clearance - renal and hepatic decline with age, prolonged duration of action Plasma protein binding - effects distribution and elimination, albumin decreases with age (binds opiods, benzos, barbiturates) Alpha-1 -acid glycoprotein (binds LA) is increased Plasma bound drugs cannot interact with end organ receptors ad are unavailable for metabolism and excretion
Pharmacodynamic changes inhalational agents	MAC - minimum alveolar concentration, reduction onset, V/Q mismatch, increased myocardial depression, increased vd, increased body fat, decrease hepatic function * MAC awake is lower in elderly, thus recovery time is prolonged in older patients * volatiles potentiate non-depolarising muscle relaxants (NDMR)
Pharmacologic changes - IV agents	lower doses for barbiturates, opiods, benzos e.g - thiopentone - brain concentration associated with EEG, vd increased opioids- smaller initial vd, prolonged elimination, increased brain sensitivity Midazolam - lipid soluble in body, vd large, elimination slowed, increased sensitivity at receptor level * Decreased MAC volatiles, reduced infusion rates propofol, potentiates NDMR
Pharmacologic changes muscle relaxants LA	muscle relaxants - prolonged onset due to decrease in CO, slow muscle blood flow, dependant on renal excretion, decrease in drug clearance LA- prolonged elimination, decrease excreation, dependent on hepatic excretion * duration of all muscle relaxants prolonged by - dehydration, hypokalaemia, hypoproteinaemia, hypothermia
Pharmacologic changes	lower drug doses required to achieve same end points in elderly use less drugs where possible use alternate drugs to treat HTN intraop, to avoid myocardial depression and prolonged emergence use balanced analgesic techniques to decrease resp depression choose less invasive procedure where possible
Intraoperative considerations	sharing of info - team time out anaesthetic considerations positioning/aware of sensory deficits hydration/fluid balance pressure area care/diathermy position warming/continence management pain management
Post op considerations	usual ABCs pain management delirium - return of hearing aids, glasses fluids, hypotension management pressure area care, skin care hypothermia management psychological care
Post op delirium	characterised by incoherent thought and speech disorientation impaired memory attention adverse effects: increased morbidity, delayed function recovery and prolonged hospital stay, reversible
Do we or Don't we	Ethical dilemma Moral debate quality of life vs expectations disease course vs life expectancy state of independence personal motivation surgical risks, non-operative management

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	Created by Elizabeth Then over 6 years ago