geriatric anesthesia

1. Dr. Tushar Chokshi
M.D. (Anesthesia)

2. Lecture outline
 Introduction
 Normal physiological changes associated
with ageing and its Anaesthesia
Implication
 Pre-operative Assessment
 Pharmacokinetics and Pharmacodynamics
in the elderly
 Take Home Message
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3. Who are Geriatric Patients
Most of the world countries have
accepted the chronological age of 65
and more as a definition of geriatric
patients ( Three Groups)
Elderly ------ Age 65 to 74
Aged -------- Age 75 to 84
Very Old ---- Age 85 and more
Old age is not a disease
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30 40 50 60 70 80

5. Realities for the geriatric patients in Health
* In India around 200 millions (15 %) people are > 65 years
* They account for almost half of hospital care days
* 25-35% surgical cases and procedures done on this age group
* Life expectancy in India now 70-72 yrs
* Medical diseases are most common in this group
* Demographical data indicate the elderly people are most
rapidly growing in population
• Use of health care services by elderly disproportionately
higher than younger patients
• The mortality rates for patients aged 80-84 is 3 %, 85-90 is 6 %
and above 90 year is 10 % in major surgeries
But all geriatric patients are not created equal !
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Guinness Book of World Records
( Anesthesia given to Oldest Patient)
Laurie Randall
Age -102 years
Surgery – Revision of Hip Replacement
Anesthesia – Epidural
Duration – 2 Hours
Pinderfields Hospital in Wakefield, West Yorks, UK
2 February 2012

7. Age-Related Physiological Changes
Three Groups of Physiological
Changes
1) Changes in autonomic
functions and cellular
homeostasis e.g.
temperature, blood volumes
and Endocrine changes
2) Reduction in organic mass
e.g. brain, liver, kidneys,
bones and muscles
3) Reduction in organic
functional reserve e.g. lungs
and heart
Systems Affected
• Cardiovascular system
• Respiratory System
• Genitourinary System
• Gastrointestinal System
• Endocrine System
• Skin and Musculoskeletal
System
• Nervous System
• Body temperature regulation
• Immune System
• Psychological Changes
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Cardio-Vascular Changes

9. Cardio-Vascular Changes
• Heart – Cardiac output Decrease 1 % per year after 30 years
of age (at 80 year age CO is half that of a 20 year old person)
• Blood Pressure – BP increase 1 mm of hg every year after 50
years as a normal consequence of aging. Systolic will increase
and Diastolic remains unchanged or increase. ( Who data
says around 50 % are Hypertensive in geriatric age group )
• Arteriosclerosis and Coronary Artery Disease
Thickening of arterial walls and Loss of elasticity
Loss of SA node cells causing slowed conduction
Myocytes death without replacement leading to increase risk
of myocardial infarction
• Decreased response to beta-receptor stimulation
• ECG Slightly increased PR, QRS and Q-T intervals
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10. Changes and its Effects
Changes
• Arterial wall thickening, stiffening
& decrease compliance
• Left ventricular and atrial
Hypertrophy
• Sclerosis of atrial and mitral
valves
• Decrease Beta adrenergic
response
• Decrease baroreceptor sensitivity
• Decrease SA node automaticity
• Diastolic Dysfunction
Effects
• Decrease exercise tolerance
leading to easy fatigability
• Coronary artery Disease
• Congestive Heart failure
• Risk of arrhythmias
• Diminished peripheral pulse
and cold extremities
• Increased blood pressure
• Postural Hypotension
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Thickened arterial wall
Narrow lumen
Sclerosis of atrial and
mitral valves
SA node
Dysfunction
Increased Stiffness and Endothelial Dysfunction
arrhythmia
Diastolic
Dysfunction

12. Anaesthesia Implication
• Hypotension and Bradycardia should be kept in
mind during induction
• For emergency Anesthesia BP up to 180/110
mm of hg should be allowed
• Heart Rate up to 50 at rest is allowed for induction
• Minor ECG changes are not threatening for
anesthesia induction
• Ejection Fraction up to 45 % is normal for geriatric
age group without any symptoms
• Use of Beta blockers and Anti platelets in pre
operative period gives more cardio stability in
old heart
Remember old heart can not compensate decrease CO or increase heart rates
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Respiratory Changes

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Reduced gas Exchange
Increase Wall Rupture
Alveolar Size increase
Alveolar changes in Older Lungs

17. Changes and its effects
Changes
• Decrease respiratory muscle
strength and elasticity
• Stiffer chest wall, AP diameter
increase
• In alveolar oxygen, no change
• In arterial oxygen, progressive
decrease
• Ventilation perfusion
mismatch
• Every year, 25 ml of decreased
VC and 25 ml increased RV
after 20 years of age
Effects
• Functional capacity declines
• Decrease cough reflex and
airway ciliary action
• Frequent airway collapse
• Reduced Compliance
• Snoring and Sleep apnea
common
• Higher chances of aspiration
• Increased risk of infection and
bronchospasm with airway
obstruction
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18. Anesthetic Implications
• Advice to stop smoking at least 2 weeks
before planned surgery and anesthesia
• Proper Antibiotic & Anti-aspiration prophylaxis
• Educate older people for deep breathing and
coughing reflex preoperatively
• Oxygen-Oxygen-Oxygen therapy in Pre-Intra-
Post anesthesia period
• Avoid or reduce doses of Opoids
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Genitourinary Changes

20. Genitourinary System Changes
Kidneys
--Gradual decrease in volume and weight of kidneys with aging
--Renal blood flow decrease, GFR decrease
--Decrease in total glomeruli leading to age related decrease in
creatinine clearance (no change in serum creatinine with advance age )
--Age related increase in blood urea nitrogen
Bladder
--Urinary incontinence found in almost 20 % population more than 65
years
--Capacity of bladder decrease & late sensation leading to overflow
incontinence
Prostate
--Enlargement of prostate in 90% male more then 65 years age, but only
10 % have symptomatic hyperplasia require surgery
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21. Anesthesia Implication
• Age related Renal changes interferes with the excretion
of anesthesia drugs
• Because of bladder and prostatic changes urinary
catheterization is prime importance in major
anesthesia and surgery
• Renal insufficiency, dehydration and renal failure
common in elderly, so prompt actions to be taken
• Geriatric patients allowed clear fluid at least two
hours before anesthesia
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Gastrointestinal Changes

23. Gastrointestinal System Changes
Esophagus --Decrease in strength of muscles of mastication, taste and thirst
--Presbyesophagus ( disturbances of esophageal activity )
--Decrease peristaltic movement & delayed transit time
leading to dysphagia
--Relaxed lower sphincter leading to chances of aspiration
Stomach
--Atrophic gastritis , which increase with age
--Increase heart burn in because of chronic
enterogastric bile reflux
Colon
--Decrease in colonic motility leading to constipation and
increase storage capacity
--Laxative abuse is very common
Liver and Billiary Tract
-- Decrease in liver weight and blood flow by 20 %, but no change in
Liver Function Tests
--Catalytic enzymes activity decrease
--Synthesis of protein binding and coagulation factors decreases
-- Drug metabolism is slow in old age group
-- Billiary tract disease are common
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24. Anesthetic Implications
• Correct Fluid, Electrolytes and Nutritional
imbalance accordingly because of GUT changes
• Increased risk of gastric aspiration(PPI cover) and
NSAID induce ulcers (avoid)
• Keep in mind about constipation & complain of
constant abdominal disturbance Post-Op
• Decrease metabolism of anesthesia drugs and
risk of adverse drug reactions because of liver
changes
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Endocrine Changes

26. Endocrine System Changes
Pancreas (Glucose Homeostasis)
--Progressive deterioration in the number and function of
beta cells, but no decline in Insulin level
-- The average fasting glucose level rises 6 to 14 mg/dL
for each 10 years after age 50.
--Decrease glucose tolerance
Thyroid --Tendency for hypothyroidism
-- No change in Thyroid Function Tests
Parathyroid Gland
--No atrophy of Gland, but some fat deposition
--After 40 years PTH level in women increase leading to
bone loss problems (calcium and vitamin D reduction)
Adrenal glands
--No atrophy, but increase fibrous tissue
--Secretions of adrenal medulla increase(psychosomatic dz)
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27. Anesthesia Implication
• Hyperglycemia increase the mortality and
morbidity in old age , because of late diagnose of
DM
Hyperglycemia and Hypoglycemia both not
tolerated
• Accepted level of FBS is between 80 – 120 mg/dl
or HbA1C less than 7 (always ask for HbA1C)
• Discontinue metformine and sulfonyl ureas night
before and day of surgery( due to increase
chance of MI in hypovolemic and reserved
cardiac functions in old age)
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28. Skin and Musculoskeletal System Changes
Skin --Epidermis : Atrophy around face, neck, chest and extensor surface
of limbs
--Because of epidermis loss, prone for decubitus ulcers
--Dermis : Skin loses its elasticity resulting wrinkling and sagging of
sagging of skin
--Decreased sensitivity to pain and pressure
Skeletal
--Degenerative Joint Diseases causing disability
--Pain response is severe
--30 % Muscle mass reduced leading to decrease peripheral
metabolism of drugs, Low BMR due to weight loss
--Adipose tissue increase gradually
--Edentulism ( Gradual teeth loss)
--Osteoarthritis and Osteoporosis
--Inability to chew and poor oral health
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29. Anesthetsia Implication
• Consider difficult IPPR and Intubation
• Body temperature to be cared during anesthesia
period. Avoid excessive cold temperature in OT
and preferably cover geriatric patient fully.
• Avoid pressure ulcers and padding of pressure
points
• Handle all geriatric patients carefully to avoid
fractures and excessive manipulation during
different surgical position (Handle With Care)
• Pre operative transfer of geriatric patient from
ward to OT is always in presence of medical
attendant (in wheel chair or in supine position)
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Nervous System Changes

31. Nervous system Changes
As the nervous system is the target for virtually
every anesthetic drug, so age related changes in
nervous system have essential implications for
anesthetic management
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32. Neurologic Changes
• Weight of brain decrease
• Loss of brain cells
• Blood flow to brain
decrease
• State of confusion
• Interference with
Thinking
Reading
Interpreting
Remembering
• Sense of smell, Vision and
hearing diminish
• Impairment of Cognitive
functions increase with age
advancement
• Problems in physiological
regulation of Hypotension
and temperature
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33. Anesthesia implication
• Difficulty in Communication, Cooperation &
Coordination
• Cognitive functions to be noted pre operatively
• Old patients take more time to recover from GA
especially if they were disoriented preoperatively
• Old Patient experience varying degrees of delirium
• Sensitive to centrally acting anticholinergic agents
• The % of delirium is less with regional anesthesia,
provided there is no additional sedation
• Dose requirements for local, general & inhalation
anesthetics are reduced
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Temperature Regulation Changes

35. Temperature Regulation Changes
Elderly are prone to hypothermia because of
• Lower body metabolism
• Vasodilatation of skin blood flow
• Decrease thermo genesis capability
leading to
– Shivering
– Increase metabolic demand
– Slow drug metabolism
– Increase risk of myocardial ischemia
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36. Anesthesia Implication
• Hypothermia should be avoided
• Shivering will increase oxygen demands
• To prevent heat loss
- Use warm solutions
- Use warm Blankets
- Keep OT temperature warm
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Immune System Changes

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* Slow to respond.
* Increases risk of getting sick.
* An autoimmune disorder may develop.
* Healing is also slowed in older persons.
* The immune system's ability to detect
and correct cell defects also declines.
* increase in the risk of cancer.

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Psychological Changes

40. Psychological Changes
• Loss of physical strength
and abilities
• Loss of mental abilities
(confusion, dementia)
• Loss of relationships
when companions or
friends die
• Loss of self-esteem
• Loss of body image
• Loss of independence
• Loss of control over life
plans and lifestyle
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41. Anesthetic Implications
* Geriatric patients with
psychological changes are
difficult to handle for history
taking & physical examination.
* Anesthesiologist should calm,
cooperative and always take
help of family member in pre
assessment.
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42. So considering all these changes
What Old people says
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44. Preoperative evaluation
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45. Pre-operative evaluation
1) Complete History
2) Physical Examination
3) Laboratory Investigations
4) Tailor made Anaesthesia plan according to
surgery
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BEST PRACTICES FOR COMMUNICATION WITH OLDER ADULTS
1) Anaesthesiologist should make the assessment face-to-face, allowing the
patient to see lip movements when speaking; this is particularly
important if the patient has a hearing problem.
2) Voice tone should be clear, slow and slightly louder than usual.
3) The anaesthesiologist should understand by asking leading questions from the
patient or caregiver or companion.
4) One question should be asked at a time, allowing sufficient time for patient
responses. Even healthy older adults may take a little longer to process a
question and frame a response.
5) Communication should be modified to match the individual’s learning style and
incorporate language the patient uses, avoiding complex medical
terminology, acronyms, and abbreviations.
6) If the patient has cognitive impairment, assessment questions should be
verified with the assistance of the family members or primary caregiver.

47. How to communicate with deaf old patients
50 % geriatric patients are having hearing
problem. It is sometimes difficult to
communicate with them.
So, our medical stethoscope will help us
by reversing the ends.
Patients will communicate very nicely.
Simple but very useful way .
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48. Complete medical history
History
• CVS and RS complaints
present and past
• Routine activities
• Mental & Physical status
• Dependency
• Associated Diseases
• Drug history/Polypharmacy
• BMI / Nutrition
• Past history Op/Ane. experience
• Any alternative medicine
• Allergy
• Social and Family history
• Any habits
Tobacco/smoking/drinks
• Sleep patterns
Always see for
depression
malnutrition
immobility
dehydration
Denture
Pace maker
Any joint replacement
Any anti depressant Rx
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49. So again to repeat, in Assessment
• See whether geriatric patient is able to
perform mental, social and physical activities
• All patients must be examined in presence of
family or friends or guardian
• Always see for polypharmacy because these
group are suffering from 2 or 3 systemic dis.
• Note the cognitive functions status,
to compare pre and post op changes
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50. Different Risk factor Scales are available
for
Pre-Assessment
APCHE (Acute Physiological and Chronic
Health Evaluation) for critically ill patients
POSSUM (Physiological and Operative
Severity Score for enumeration of
Mortality and Morbidity) for surgical pts.
Goldman scales of Cardiac risk for non-
cardiac surgery
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51. General Physical Examination
• Physical examination of old patient always to
be done in warm area
• General appearance
• Head to Toe Examination for pressure points,
Joints, hearing and vision impairment
• Height / Weight
• Neck mobility, any spine deformity, teeth loss
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52. Physical Examination
EXAMINE FOR
• Vital signs
• CVS and RS system
• Oxygen Saturation
• Pain Threshold
• Breathing pattern
• Breath Holding Time
• Clock Drawing Test
• Trail Making test
SEE FOR
• Difficult Intubation
• Difficult regional anae.
• Difficult nerve blocks
• Difficult IV line
• Weight for BMI
• Drugs regularity
• Relatives’ attitude and
responsibility
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53. Investigations
Routine
Complete Haemogram
FBS/HbA1C
ECG
X-Ray Chest
Renal functions
LFTs with proteins
(all above investigations are
must for routine
anesthesia
administration)
Special
According to Positive
medical history & disease
Echocardiography for CVS
Spirometry for RS
Sonography for GIT & KUB
Other Tests according to
Systems affected
e.g. CVS/RS/GIT/URINARY
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54. So, after assessment of geriatric patient
• It is very important to determine the patient’s
status and physiologic reserve in the pre-
anesthetic evaluation.
• The risk from anesthesia is more related with
the presence of co-existing disease than with
the age of the patient.
• The condition should be optimized before
surgery with good nutrition, pharmacological
support, System wise and done without
delay, as long delays increase morbidity rates.
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55. Use of Smartphone in
assessment of geriatric patients
Android apps
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62. Pharmacodynamics
and
Pharmacokinetics
in
Elderly Patient
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63. In Geriatric Patients
• The circulating level of albumin decreases.
(binding protein for acidic drugs)
• While the level of α-1 acid glycoprotein
increases. (binding protein for basic drugs)
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64. And
• The decrease in total body water
leads to a reduction in the central
compartment and increased serum
concentrations after a bolus administration of
a drug.
• Increase in body fat
results in a greater volume of distribution of
drugs and prolonging action.
• Aging effect on hepatic and renal functions
drug metabolism will be altered
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65. So for,
Dose and Duration of Drugs
One has to remember that
Altered body composition in old age leads
-- decrease blood volume
-- decrease muscle mass
-- decrease plasma proteins
-- decrease circulatory time
-- decrease metabolism & clearance
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66. Doses of Anesthetic Agents
• Sedations – Decrease
• Induction Agents – Decrease (almost 50 % )
• Opioids – Decrease ( Remifentanyl is most potent)
• Muscle Relaxants – No change
• Inhalation Agents – Reduce MAC ( Ideal is 1.5 MAC )
• Local Anesthetics – Decrease
Note :
Ideal inhalation agent for old age is Desflurane
Ideal muscle relaxants for old age is Atracurium
Induction Agents are used according to pre-
assessment and risk of surgery
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67. Regional & Peripheral Nerve Blocks
• The duration of analgesia may be prolonged
with age advancing on the baricity, dose and
strength of the local anesthetic solution
• When GA carries great risk for the patient,
Regional Anesthesia or Nerve Blocks provide
an excellent solution
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68. To Sum-Up Pharmacology of Anaesthesia drugs
• The elderly are more sensitive to anesthetic
agents and generally require smaller doses for
the same clinical effect, and drug action is
usually prolonged.
• One arm brain circulation is about 20 seconds
and drugs to reach their maximum effect
requires 3 to 4 circulation. And in old age this
time is up to 90 seconds. So drug dose
requirement is less.
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69. Drug Strategy for the Elderly:
GO LOW !
GO SLOW !
ALWAYS FOLLOW !
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70. Some words for Fluid administration
--Elderly patient compensates poorly for
hypovolemia & over transfusion.
--After one liter of infusion, better replace blood
loss with blood transfusion
--Liberal oral intake of fluids allowed 2 to 3 hours
preoperatively
--Always keep in mind about elderly
compromised heart, poor organ perfusion and
reduction in GFR for IV fluid administration
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71. Take Home Message
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72. Decreased
Physiologic
Reserve
Provider
Lack of
Knowledge
Increased
Preexisting
Diseases
High incidence of morbidity & mortality in old age
Because of
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73. Elderly patients are vulnerable and particularly
sensitive to the stress of Trauma, Hospitalization,
Surgery and Anesthesia.
Anesthesiologists must Remember and Do
* Understanding old age physiology and pre operative
management of coexisting disorders
* Meticulous preoperative assessment of organ function
and reserve
* Careful drug selection & dosage titration,
* Careful fluid therapy
* Selection between RA & GA
* Proper psychological preparation & Management
* Good post operative pain control
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