GERIATRIC ANAESTHESIA

1. BY-A chandrasekhar
Moderator-Dr.LAKSHMI(HOD)

2. INTRODUCTION
 Elderly-fastest growing population globally.
 India → census registrar general of india from
independence 18 million→78 million in 2001→150
million in mid century
 More than 50% of them require two or more surgeries
in lifetime.

3. Guinness Book of World Records
tm
c 3
( 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

4. Lecture outline
 1- Define the geriatric population
 2- enumerate the anesthetic problems for a Ger. Pt.
 3. Physiological changes & anaesthesia concerns,
Pharmacological drug alterations required in Ger. Pts
 4- peri-operative management - pre,inta,post op
management & complications

5. Who are Geriatric
Patients
tm
c 5
Most of the world countries have
accepted the chronological age of 65
and more
patients
as a definition of geriatric
( Three Groups)
Elderly ------ Age 65 to 74
Aged -------- Age 75 to 84
Very Old ---- Age 85 and more
Old age is not a disease

6. THEORIES FOR AGING
 1)FREE RADICAL(OXIDANTS) DAMAGE THEORY
 -widely accepted
 - oxidation of cell membrane,cytoplasmic & nuclear
protein & DNA
- ANTI – OXIDANTS-
vitamins(ACE),ceruloplasmin,tranferin,enzymes(catal
ase,glutathione,SOD),sirtuin(RED WINE)
 2)INCREASE CROSS LINKAGE OF COLLAGEN

7. Concept of aging...
 Aging is a universal and progressive physiologic
phenomenon characterized by degenerative changes
in both the structure and functional reserve of organs
and tissues
 Two important principles of aging are
 1) progressive loss of functional reserve in all organ
system
 2) The extent and onset of these changes vary from
person to person

8. FRAILTY..
Frailty refers to a loss of physiologic reserve that makes a
person more vulnerable to disability during and after
stress.
Components: Mobility, Muscle weakness, Poor exercise
tolerance, Unstable balance and Factors related to body
composition like weight loss, malnutrition, muscle wasting
-Incidence= 6.9% in people older than 65 years
 The greatest challenge facing the medical profession is to
maintain function for as long as possible.
Our goal for successful aging is that the physical and
mental abilities remain at a level sufficient to maintain a
lifestyle that is enjoyable and productive

9. AGE RELATED PROBLEMS
 Hypertension
 Diabetes mellitus
 Heart disease
 Malignancy
 Myocardial ischemia
 Cerebral vascular accident
 Chronic renal insufficiency, Liverdysfunction
 COPD, Pneumonia
 Dementia- Alzheimer’s disease = 6-8% older than 65 years
 -Presence of cognitive deficit, agitation
 -Predictor of postoperative delirium

10. Contd..
 Parkinson’s disease- 3% older than 65 years
 -Classic triad= tremor, muscle rigidity, brady-
kinesia
 -postoperative risk of aspiration
 Poly-pharmacy- Average patients takes 8 different drugs per day
whichare directly proportional to adverse drug reactions with
incidence of 5%-35%.
 Depression- 10% older than 65 years
 Immobility- Decreases muscle mass which influence pulmonary
function
 Dehydration- Associated with hypernatremia and infection like
pneumonia
 Alcoholism- Manifest as accident, postoperative pneumonia

11. Contd..
 Hypothermia
 Chronic pain- Assessment of pain complicated by
social, emotional, cognitive and subjective issues.
Arthritis, bone fracture, musculoskeletal
 Thus the anesthesiologists is the only care giver
prior to surgery to look at the patients as a whole
and aware of preoperative risk factors and
probable perioperative adverse outcomes and
assist the surgical team in handling identified
outcomes.

12. PHYSIOLOGICAL CHANGES
DURING OLD AGE

13. Age-Related Physiological
Changes
tm
c 13
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
Three Groups of Physiological Systems Affected
Changes
• Cardiovascular system
• Respiratory System
• Genitourinary System
• Gastrointestinal System
• Endocrine System
• Skin and Musculoskeletal
System
• Nervous System
• Body temperature regulation
• Immune System
• Psychological Changes

14. A. CVS & ANS
1.Decline in the responsiveness of β- receptors
plasma catecholamine level unchanged
decrease in beta-adrenergic receptors density
20% decrease of maximal HR
2. Decreases in arterial compliance results in increased
Systemic Vascular Resistance
3.Progressive replacement of functional cardiac and
vascular tissue by stiff, fibrotic material
elevated afterload
elevated systolic BP, diastolic pressure changes little
LV hypertrophy, hypertension

15. 4. Loss of contractile strength and efficiency, decreased organ perfusion.
5. Heart valves become fibrotic and sclerotic resulting in thickening and
reduced flexibility.
6. Decreased cardiac output, stroke volume, ejection fraction, decreased
coronary artery blood flow
7. Impaired diastolic filling due to prolonged contraction and a slowed
relaxation
8. Decreased baroreceptor reflex lead to increased risk of orthostatic
hypotension and syncope

16. 10.Decreased compliance of vessels hinder response to
changes in intravascular volume during position changes or
third space loss
11.Cardiac conduction system becomes fibrotic lead to loss of SA
nodal cells and prone to dysarrhythmia
12.Thermoregulation affected by autonomic impairment lead to
inadequate heat production and conservation results heat stroke
and hypothermia
These factors render the elderly patients less capable of
defending their CO and BP against the usual perioperative
challenges.

17. Cardio-Vascular Changes
tm
c 17
• 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

18. Thickened arterial wall
Sclerosis of atrialand
mitral valves
SA node
Dysfunction
Narrow lumen
Increased Stiffness and EndothelialDysfunction
Diastolic
Dysfunction
arrhythmia
tm
c 18

19. Fig 1 Cardiac adjustments to arterial stiffening during ageing.
MDO2=myocardial oxygen supply. MVO2=myocardial
oxygen demand.

20. Fig 2 Cardiac response to increased flow demand in the young and the elderly.
The young meet the increased flow demand primarily by β‐adrenoceptor‐mediated augmentation of heart rate and contractility, thus
preserving preload reserve. In contrast, the elderly employ primarily the preload reserve to augment cardiac performance, thereby
losing additional cardiovascular reserve and becoming susceptible to cardiacinsufficiency.

21. Anaesthesia Implication
tm
c 21
• Hypotension
mind during
and Bradycardia should be kept in
induction
• For emergency
mm of hg should
Anesthesia BP up to 180/110
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

22.  1.ANATOMICAL:
 Loss of muscular pharyngeal support→↓in
function of pharyngeal and laryngeal
function
 Loss of ciliary function
-Flattening of diaphgram
 Chostochondral joint calcification making
chest less compliant

23.  Thorax changes shape with age.
 Kyphosis of the thoracic spine is the first change
and is due principally to osteoporotic vertebral
collapse
 This causes A-P diameter of the chest to increase at
the expense of lateral diameter, leading to barrel
chest deformity with apparent increased heart
 Thus respiratory system consist of combination of
restrictive and obstructive lung disease.

25. Respiratory System
 Changes in control of respiration, lung structure, mechanics, and pulmonary blood flow
place the elderlypatients at increased risk for perioperative pulmonary complications.
 A) Centrally: Ventilatory responses to hypoxia, hypercapnia, and mechanical stress are
impaired secondary to reduced CNS activity. The respiratory depressant effects of BZD,
opioids,and volatileanestheticsareexaggerated.
 B) Structural changesin the lung withaging include:
.. lossof elasticrecoil withenlargementof therespiratorybronchiolesand alveolarducts
.. tendencyforearlycollapseof thesmall airwayson exhalation.
.. progressive lossof alveolarsurfacearea.
 Thefunctional resultsof thesechangesare
.. Increased anatomic DS .. decreased diffusing capacity
.. increased closing capacity
 Functionally, thechestwall becomeslesscompliant,and work of breathing is increased.

26. 1.Resting PaO2 declines with age at a rate
described by PaO2=100-(0.4×age)mmHg
Mean PaO2 declines from 95 at age 20 to 73 at
age 75 years
 Hence Gas exchange efficiency declines with age
2.Loss of muscle mass with weakening of the
muscles of respiration
 -FEV1 decreases progressively with aging (30ml
per year)
 -Ratio of FEV to FEV1 of the elderly decreases.
 -The diaphragmatic function declines with age

27. tmc
1

28.  Closing capacity increases with age. The change in the relationship between
FRC and CC cause an increased ventilation-perfusion mismatch (increased
Shunt) and represent the most important mechanism for the increase in
alveolar-arterial oxygen gradient.
formula P(A–a)O2 = 3 + (0.21
xpatient'sage)
 In younger individuals, CC is belowFRC.
 At 44 years of age, CC equals FRC in the supine position,
 At 66 years of age, CC equals FRC in the upright position.
 Increased closing capacity and depletion of muscle mass causes a
progressive decrease in FEV1 by 6% to 8% perdecade.
 Hypoxic pulmonary vasoconstriction is blunted and may cause difficulty
with one-lung ventilation.
Intra-pleural pressure increases with age

29. tmc
1
Reduced gas Exchange
Increase Wall Rupture
Alveolar Size increase
Alveolar changes in OlderLungs

30. tm
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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

31.  

32.  At rest elderly have to workharder because
of less compliant chest wall
 Ventilatory response to hypoxemia and
hypercapnia are decrease so ABG monitoring
would be more reliable sign in assesing
respiratory function
 Post op age associated muscular weakness
will reduce their ability to cough forcibly
and remove secretions thus chances of post
op pulmonary complications are high

33. tm
c 33
Anesthetic Implications-;-RS
• 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

34. tm
c 34
Gastrointestinal System
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

35. tm
c 35
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

36. C. Nervous System
1. Brain size decreased by 20% beyond 80 years
2. General loss of neuronal substance
3. Decrease in the number of peripheral neurons
4. Depletion of dopamine, norepinephrine, tyrosine, serotonin results
depression, loss of memory, motor dysfunction
5. CBF and cerebral oxygen consumption(CMRO2) is decreased in
proportion to the decrease in brain mass. Cerebral autoregulation is
well maintained in geriatric patients without prior neurological disease
6. Increased latency of sleep, increased periods of wakefulness during
night
7. Generalized increase in thresholds for all forms of perception

37. 8. Decline in number and density of motor end plate units due
to increase in atypical extrajunctional cholinergic receptors.
So dose of NMB drugs are slightly increased
 CNS is target organ for virtually every anaesthetic agent.
9. Age related diseases such as cerebral arteriosclerosis,
Alzheimer’s and Parkinson’s disease are more common
with advancing age

38. Physiological changes
 Memory decline occurs in > 40% of individuals older than age 60 years.
 There is a decrease in the volume of gray and white matter. The decrease
in gray matter volume is thought to be secondary to neuronal shrinkage or
neuronal loss. Such loss results in gyral atrophy and increased ventricular
size.
 Decreases in brain reserve are
manifested by :
-increased sensitivity to anesthetic
medications
-increased risk for perioperative delirium and postoperative cognitive
dysfunction.

39.  Neuraxial changes:
a)reduction of the area of the epidural space, increased permeability of
the dura, and decreased volume of CSF.
b)The diameterand numberof myelinated fibers in the dorsal and
ventral nerve roots are decreased.
c)decreased conduction velocity in peripheral nerves.
 These changes tend to make elderly individuals more sensitive to
neuraxial andPNBs

40. tm
c 40
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

41. RENAL
1. Decreased renal mass by 30% older than 80 years mainly in
the cortex due to glomerulosclerosis results decreased renal
blood flow and GFR. This causes delay in drug clearance
and prolong the clinical effects of drugs
2. Decreased tubular function reserve
3. Reduced abilities to concentrate urine or conserve sodium
4. Renal vascularity reduced and CO is redistributed
predisposing to renal ischemia in peri-anaesthetic period

42. HEPATIC
1. Decrease in liver mass by 40% older than 80 years
2. There is a lack of correlation between structural
and functional data concerning the aging liver
3. Loss of hepatic tissues lead to delayed drug
metabolism and reduced hepatic drug clearance
4. Decreased plasma albumin concentration result
increase in drug action like thiopentone, diazepam,
midazolam, fentanyl, sufentanil

43. PROTEIN BINDING
1. Circulating level of serum protein (especially
albumin) decreases in quantity results acid drugs
that bind to albumin like diazepam, pethidine have
reduced dose requirement
2. Increased alpha 1 acid glycoprotein increases the
requirement of basic drugs like lignocaine because
reduces the free fraction of basic drugs
3. Qualitative change of serum protein reduce the
binding effectiveness of the available protein.
4. This will lead to higher free drug levels and an
enhanced delivery of the drug to the brain

44. Haematological and Immune system
1.Reduced spleen size and bone marrow
production
2.Reduced haematopoietic response to
imposed anaemia lead to life threatening
infections

45. ENDOCRINE
1.Progressive impairment of insulin function,
impaired glucose homeostasis
2.Decreased thyroxine clearance
3.Decreased renin, aldosterone production
4.Decreased vitamin D absorption
5.Increased plasma concentration of ADH

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c 46
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

47. 1.Diminished vasoconstriction and metabolic heat
production
2.Both inhalational and intravenous like propofol,
alfentanil alter the regulatory threshold that fall
body temperature by 4°C
3.Risks of intraoperative hypothermia – MI,
surgical wound infection, increased blood loss,
impaired drug metabolism

48. Skin and Musculoskeletal System Changes
Skin surface
sagging of
--Epidermis : Atrophy around face, neck, chest and extensor
of limbs
--Because of epidermis loss, prone for decubitus ulcers
--Dermis : Skin loses its elasticity resulting wrinkling and
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
tmc 28

49. tm
c 49
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)

50. 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
tm
c 50

51. tm
c 51
Anesthetic Implications
* Geriatric
psychological
patients with
changes are
difficult to handle for history
taking & physical examination.
* Anesthesiologist should calm,
cooperative and always take
help of family member in pre
assessment.

52. PHARMACOLOGY

53.  Factors that affect the pharmacologic responses of
elderly patients include changes in
 1) plasma protein binding, 2) body content,
 (3) drug metabolism, (4) pharmacodynamics.

54.  Changes in body composition with aging reflect a
decrease in lean body mass, an increase in body fat, and
a decrease in total body water.
 A decrease in TBW could lead to a smaller central
compartment and increased serum concentrations after
bolus administration of a drug. In addition, the increase in
body fat might result in a greater volume of distribution
and prolonged effect of a given medication.
 Depending on the degradation pathway,
decreases in liver and kidney reserve can affect a
drug's pharmacokinetics profile.

55. ANESTHESIA DRUGS
 Inhaled anaesthetic: Reduced MAC value and CO results rapid
induction and prolonged recovery due to altered ion channels,
synaptic activity or receptor sensitivity.
 Intravenous anaesthetic:
Thiopentone sodium=Administration of IV barbiturates produces
the peripheral vasodilatation with a moderate BP decrease.
 -With a decreased baroreceptor reflex and increased vascular
wall rigidity, the drug may cause a dangerous drop in BP.
 -In the elderly, elimination half-life is 13-25 hrs(6-12 hrs in
the young)
 -The thiopental dose requirement may decrease 25-75 percent.
 .

56.  Etomidate= An imidazole IV hypnotic drug associated with
haemodynamic stability
 -May offer advantage for induction of anaesthesia in elderly
patients specially in those with limited cardiovascular reserve
 Propofol= Propofol produces greater decrease in systemic BP than
thiopental .
 -Injecting the propofol slowly with sufficient time can minimize the
effect of cardiovascular depression.
 -Studies show patients older than 80 years exhibit less post-
anesthetic mental impairment with propofol than other agents.
 -Induction: using 1.2-1.7 mg/kg in the elderly (versus 2.0-2.5
mg/kg in younger patients)

57.  Benzodiazepines: Due to decreased drug
clearance and increased brain sensitivity the
dose decreases to 75%.
 Opioids: Twice as potent in elderly patients, so
short acting opioids like fentanyl, sufentanil,
alfentanil, remifentanil are better choices.
 1/2 the bolus dose and 1/3 the infusion rate
required

58. Summar
y

59. PERI-OPERATIVE
MANAGMENT

60.  Preoperative assessment:
1. Check for concomitant disease states
2. Cognitive status, personality disturbances
3. Review for implanted devices- dentures, hearing
aid, spectacles
4. Assess the degree of functional reserve, pertinent
organ system and pt. as a whole, history and physical
examination
5. Lab. and diagnostic studies= BUN, creatinine, glucose,
Hb, coagulation profile, nutritional status, review of ECG,
chest X- ray,2D-ECHO, PFT
6. Review Current medication regimen
7. Informed consent

61. RISK ASSESMENT
 The preoperative assessment of perioperative
cardiovascular risk relies on the evaluation of
1)CLINICAL MARKERS
 Major : unstable coronary syndromes, decompensated
congestive heart failure, significant arrhythmias, severe
valvular disease
 Intermediate : mild angina pectoris, previous
myocardial infarction (>30 days old), compensated or
previous congestive heart failure, DM
 Minor : advanced age, abnormal ECG, rhythm other than
sinus, low functional capacity, history of stroke,
uncontrolled systemic hypertension

62. 2)functional capacity (1 - >10 METs)
 4 METs : can you climb a flight of stairs or walk up a hill or walk
on level ground at 4 mph ??
 3) surgery‐specific risk.
 High : emergent major operations; aortic and other major
vascular; peripheral vascular; anticipated prolonged surgical
procedures associated with large fluid shifts and/or blood loss
 intermediate : carotid endarterectomy; head and neck;
intraperitoneal and intrathoracic; orthopaedic; prostate
 low : endoscopic procedures; superficial procedures; cataract;
breast

63. INTRA OP-AIRWAY MANAGMENT
 Placement of ET tube is difficult inelderly
 Facial shape is altered, TM joint dysfunction, loose teeth/without
teethwith cervical arthritis makes exposure of larynx moredifficult
 Care should be taken during laryngoscopic examination to avoid
over extension of neck
 When rapid sequence intubation is performed cricoid pressure
should be applied
ETT have adverse effects on muco-ciliary clearance and swallowing than
laryngeal mask, but ETT provide a large tidal volume and PEEP to
prevent atelectasis.

64. INTRA OP – FLUID MANAGMENT
 Older patients may come to the OR with depleted
volume because of : NPO orders, reduced thirst,
age‐related decline in renal capacity to conserve water
and salt, disease‐associated fluid and electrolyte
losses, inadequate intravenous fluid substitution and
more frequent use of diuretics.
 Because of decreased left ventricular compliance and
limited β‐adrenoceptor responsiveness, the elderly,
particularly those with hypertension, must be expected to
be more sensitive to fluid overload.
 Careful volume assessment. (Volume Dependant yet
volume intolerant)

65. INTRA OP- DRUGS
 Elderly patients require lower doses of premedication
 Opioid premedication may be valuable
 Anticholinergic medication rarely needed
 Pretreatment with H2 antagonist, metoclopramide may be used
 Anxiety relief by benzodiazepine
 Smaller doses are needed in comparision to young adults for
induction
 Etomidate produces less hypotension than propofol.
 Hypo or hypertension or both may occur during induction, intubation
or postintubation, so performed standard technique carefully.
 α-agonist used with fluid administration in hypovolemia
 Protective gag reflex is weakened

66. Regional versus General Anesthesia
 Specific effects of regional anesthesia may provide some benefit.
First, regional anesthesia affects the coagulation system by preventing
postoperative inhibition of fibrinolysis. Regional anesthesia may decrease the
incidence of DVT after total hip arthroplasty.
In lower extremityrevascularization, regional anesthesia is associated with a
decreased incidence of postoperative graft thrombosiscompared with GA.
Second, the hemodynamiceffects of regional anesthesia may beassociated with
decreased blood loss in pelvicand lowerextremitysurgery.
Third, regional anesthesiadoes not require instrumentation of theairwayand
may allow patients to maintain their own airway and level of pulmonary
function.
 Use of regional anesthesia does not seem to decrease the incidence of
postoperative cognitive dysfunction compared with generalanesthesia.

67.  Difference in outcome between regional and
general anaesthesia in older patients is not clear
 Yet some specific benefits of regional
anaesthesia may provide some benefits;
 1.affects coagulation system by preventing post
op inhibition of fibrinolysis→↓incidence of DVT
or pulmonary embolism
 2.haemodynamic effects may be associated
with ↓blood loss in lower extremity surgeries
 3.does not necessitate instrumentation of
airway→lowers risk of hypoxaemia
 4.opiate sparing effect

68.  1.FOR NEURAXIAL BLOCKS:

 size of epidural space is reduced
 permeability of dura is increased
 volume of CSF decreased
 narrowing if intervertebral space and
osteophyte growth→decreases
transforaminal escape of local anaesthetics
producing an increased level of block
onset of analgesia with epidural
anaesthesia is more rapid due to increased
permeability of extraneural tissues to local
anaesthetics

69.  2.FOR LOCAL
ANAESTHESIA/PERIPHERAL NERVE
BLOCKS:
 decrease in conduction velocity of
peripheral nerves due to decrease in
inter schwann distance
 decreased no of axons in peripheral
nerves

70. Postoperative Considerations
 The incidence of common postoperative morbidities
is
17% foratelectasis,
12% for acute bronchitis,
10% forpneumonia,
6% for heart failure or myocardial
infarction (or both), 7% for
delirium,
and 1% for new focal neurologicsigns.

71. POST OP-PAIN RELIEF
 The major goal is to good pain relief by achieving adequate
analgesia. Failure to achieve analgesia associated with
adverse outcomes like sleep deprivation, respiratory
impairment, ileus, suboptimal mobilization, insulin resistance,
tachycardia and hypertension. The consequences include
longer hospitalization and increased incidence of delirium.
 Opioids is the mainstay of postoperative analgesia, but it
producing same adverse outcome like respiratory
depression, sedation, delirium, ileus.
 Adjunctive drugs –NSAIDS which reduce opioids
requirement and some of its adverse effects.
 Epidural analgesia is superior than IV therapy due to
improved cardiopulmonary outcome, more rapid return
of bowel function, earlier mobilization, better nutritional
status.

72. POST OP-HEMODYNAMICS
 ECG, hourly urine output, BP must be monitored .Direct intra-
arterial pressure and CVP in high risk patients.
 Arrhythmia –common in elderly patients due to
metabolic disturbances such as hyperventilation,
hypokalemia, hypomagnesemia, hypocalcemia,
hypoxia, hypercarbia.
 Postoperative hypothermia common in elderly. It manifests
altered metal status, delayed recovery from anaesthesia,
sluggish deep tendon reflexes, shallow respiratory pattern.
 Perioperative hypothermia aggravates surgical
bleeding due to impaired platelet function, reduced intrinsic
and extinsic clotting, increased fibrinolysis.

73. COMPLICATIONS
 Cardiovascular- MI, cardiac arrest, AF, hypertension
 pulmonary- pneumonia, prolonged intubation, re-
intubation
 central nervous system- Stroke, TIA, Postoperative
cognitive decline
 Renal dysfunction –Due to drugs such as
Aminoglycosides, ACEI , NSAIDS or hypovolemia
/ cardiac dysfunction
 wound infection

74.  HYPOTHERMIA:
 Manifests as altered mental status
 delayed recovery from
 anaesthesia
 sluggish DTRs
 slow respiratory pattern
 Leads to metabolic disturbances
 ↓liver and kidney perfusion
 induce coagulopathy
 Management:mild→warming with blankets
 and warm rooms
 severe:active warming methods such as use
of warm iv fluids and surface warming with continuous
core temperature monitoring

75. POST OP-PSYCHOLOGICAL ISSUES
 Postoperative confusion due to neurological problems, sepsis,
metabolic disturbances- hypoxia, hypercarbia, acidosis,
hypoglycemia,hyponatremia, renal and liver dysfunction.
 Postoperative delirium= 10% after major surgery
 Diagnostic and statistical manual of mental disorders (DSM-IV)
 Disturbance of consciousness
 Change in cognition that cannot be better accounted for by a
preexisting or evolving dementia
The disturbance develops over a short time
 Evidence from the history, physical examination, lab finding
that the disturbance is caused by direct physiologic
consequences of a medical condition

76.  Precipitating factors for postoperative delirium
1. Age > 65 years and male gender
2. Cognitive impairment, Functional impairment, Sensory impairment
3. Poly-pharmacy, alcoholism, sedatives, narcotics, anticholinergic
4. Co-morbidity
5. Major surgeries
6. ICU admission
7. Pain, Sleep deprivation, Immobility, dehydration
8. Metabolic and electrolyte disorders
9. Greater intra-operative blood loss, More postoperative blood
transfusion

77.  Post-Operative Delirium (POD) •
 DSM-MS IV: A change in mental status,
characterized by: –
 a prominent disturbance of attention and
reduced clarity of awareness of the
environment;
 an acute onset, developing within hours to
days, and tends to fluctuate during the
course of the day.

78.  Main clinical features
 • Acute onset
 • Fluctuating course
 • Inattention
 • Disorganized thinking
 • Alteration in consciousness
 • Cognitive deficit (memory, orientation,
executive functions)
 • Hallucinations
 • Psychomotor disturbances
 • Lethargy (hypoactive delirium)

79. Postoperative Cognitive Dysfunction (POCD)
 • Deterioration of intellectual function presenting as
impaired memory or concentration.
 • Not detected until days or weeks after
anesthesia
 • Duration of several weeks to permanent
 • Diagnosis is only warranted if:
 – corroborated with
neuropsychological testing
 – evidence of greater memory loss than
one would expect due to normal aging

80.  • POCD
  – Common in all age groups at hospital
discharge (33- 44%)
  – 3 months after surgery the POC incidence was:
 • 4-5% in those younger than 65
 • 13% in adults older than 60 years
particularly on those with lower educational
achievement
•Associated with increased one-year
mortality

81. WAYS TO IMPROVE ANAESTHESIA IN OLDER PATIENTS
1. Proper preoperative evaluation
2. Be aware of contracted volume and hypotension on
induction
3. Assume diastolic dysfunction
4. Administer beta blocker pre/intra/postoperative
5. Look for renal/ hepatic function
6. Tight glucose control
7. Administer antibiotic on time
8. Use lower doses of anaesthetic agents
9. Vigilant intraoperative monitoring
10.Postoperative pain control , delirium management

82. CONCLUSION
 Elderly patients are uniquely vulnerable and particularly sensitive to
the stress of trauma, hospitalization, surgery and anesthesia.
 Accordingly, minimizing perioperative risk in geriatric patients
requires:
 meticulous preoperative assessment of organ function and
 reserve,
 meticulous intraoperative management of coexisting disorders,
 Careful drug selection & dosage titration,
 Careful fluid therapy,
 RA better than GA
 Proper psychological preparation &
management and alert postop. pain control.

83.  Chronological age is a poor predictorof physiological
age

84.  AGE is issue an of MIND
over MATTER.
 If u don’t mind, it doesnt
matter.

85. THANK YOU FOR UR PATIENCE