2. -GERIATRIC PATIENTS
-THIS LECTURE OUTLINE
INTRODUCTION
--1-Normal physiological changes associated
with aging and its anesthesia implications
--2-Preoperative assesment
--3-Phamacokinetics and pharmaco dynamics
in the elderly
--4-Take Home message
3. -GERIATRIC PATIENTS -WHO ARE GERIATRIC PATIENTS
--Most of the world countries have
have accepted the chronological
age of 65 and more as a definition
of “Geriatric Patients”
WORLD OVER ACCEPTED THREE GROUPS
-1-Elderly--------------------Age 65 to 74
-2-Aged ---------------------Age 75 to 84
-3-Very Old -----------------Age 85 and more
OLD AGE IS NOT A DISEASE
--
5. -GERIATRIC PATIENTS
Realities for the geriatric patients in Health
--In America 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 Years
--Medical diseases are most common in this group
--Demographical data indicate the elderly people are most
rapidly
growing in the population in America
--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
--All Geriatric patients does not show
the same and equal symptoms
6. -GERIATRIC PATIENTS -GUINNESS BOOK OF WORLD RECORDS
--Anesthesia given to an old patient
--Name:-Laurie Randall
--Age:-102 years
--Surgery:-
--Name of operation:-Revision of Hip Replacement
--Anesthesia:-Epidural
--Duration of operation is two (2) hours
--Hospital where operated:-Pinderfields
--Hospital in Wakefield, west yorks, UK-2
--Date of operation:-February 2012
7. -GERIATRIC PATIENTS -Age related physiological changes
-Three Group of
Physiological
Changes
-- Systems Affected
--Changes in autonomic functions
and
cellular homeostasis e.g.
temperature, blood volumes and
Endocrine changes
--Reduction in organic mass
e.g. brain, liver, kidneys,
bones and muscles
--Reduction in organic functional
reserve e.g. lungs and heart
--Cardiovascular system
--Respiratory System
--Genitourinary System
--Gastrointestinal System
--Endocrine System
--Skin and Musculoskeletal
System
--Nervous System
--Body temperature regulation
--Immune System
--Psychological Changes
9. -GERIATRIC PATIENTS
-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 that around 50 %
patients are Hypertensive in geriatric age group
--Arteriosclerosis and Coronary Artery Disease Thickening of
arterial walls
and Loss of elasticity and 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
10. -GERIATRIC PATIENTS
--CHANGES AND ITS EFFECTS
-- Arterial wall thickening, stiffening
and 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
-- 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
-
Change
s
-
Effect
s
11. - GERIATRIC PATIENTS -CARDIO VASCULAR CHANGES AND ITS EFFECTS
Sclerosis of atrial and
mitral valves
SA node
Dysfunctio
n
Thickened arterial
wall
Narrow lumen
-Increased stiffness and endotracheal Dysfunction
12. -GERIATRIC PATIENTS
-Anesthesia Implication
--Hypotension and Brady cardia should be kept in mind during induction
--For emergency Anesthesia BP upto 18/110 mm Hg should be allowed
--Heart rate upto 50 at least is allowed for induction
--Minor ECG changes are not threatening for Anesthesia induction
--Ejection Fraction upto 45% is normal for Geriatric age group without any
symptoms
--Use of Beta Blocker and antiplatelets in pre operative period gives more
cardiovascular stabily in old heart
--Remember old Heart cannot compensate decreases in
14. -GERIATRIC PATIENTS
CHANGES IN THE BODY AND
RESPIRATORY SYSTEM
--1-There is reduction in respiratory activity
--2-There is increased rigidity of thoracic
cage
--3-Kyphosis
--4-There is increased diameter of Antero
-posterior chest
--5-Blunt cough reflex and reduced number
of cilia
--6 There is less lung expansion
15. -GERIATRIC PATIENTS
CHANGES IN THE BODY AND
RESPIRATORY SYSTEM
--Increased Residual volume
(increased air remaining in
lungs after the most complete
expiration possible
--Reduced Vital capacity
(Decreased capacity to inhale
Hold and Exhale breath
--High risk of respiratory infection
(Pneumonia)
16. -GERIATRIC PATIENTS
CHANGES IN
THE BODY AND
RESPIRATORY
SYSTEM
-Reduced Gas Exchange increase Wall
Rupture so Alveolar size increases
ALVEOR CHANGES IN OLDER LUNGS
17. -GERIATRIC PATIENTS
-CHANGES AND ITS EFFECTS
CHANGES
--1-Decrease respiratory muscle strength
and elasticity
--2-Stiffer chest wall, AP Diameter is
increased
--3-In Alveolar oxygen no change
--4-In arterial oxygen, there is progressive
decrease
--5-There is ventilation / perfusion
mismatch
--6-Every year 25 ml of decreased VC and
25 ml increased RV after 20 years of age
EFFECTS
--1-Functional capacity declines
--2-Decreased cough reflex and airway
ciliary action
--3-Frequent airway collapse
--4-Reduced compliance
--5-Snoring and sleep apnea common
--6-Higher chances of Aspiration
--7-Increased risk of infection and
Bronchospasm with airway obstruction
18. -GERIATRIC PATIENTS
-ANESTHETIC IMPLICATIONS
--1-Advise to stop smoking atleast two weeks before
Planned surgery and anesthesia
--2-Proper antibiotic and proper anti aspiration
Prophylaxis
--3-Educate older people for deep breathing and
coughing reflex preoperatively
--4-Oxygen-Oxygen-Oxygen therapy in pre-intra-post
anesthesia period
--5-Avoid or reduce dosed of Opioids
20. -GERIATRIC PATIENTS
-GENITO-URINARY SYSTEM CHANGES
--KIDNEYS
--1-Gradual decrease in volume and weight of Kidneys with aging
--2-Renal Blood flow decreases, GFR Decreases
--3-Decrease in total glomeruli leading to age related decrease in Creatinine clearance
(No change in serum creatinine with advanced age)
--4-Age related increase in Blood Urea Nitrogen
--BLADDER
--1-Urinary incontinence is found in almost 20% population of patients age more then
65 years capacity of Bladder decreases and late sensation leading to overflow
incontinence
--PROSTATE
--1-Enlargment of prostate in 90% Male more then 65 years age, but only 10% have
symptomatic hyperplasia requires surgery
21. - GERIATRIC PATIENTS
-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
23. -GERIATRIC PATIENTS -GASTRO-INTESTINAL SYSTEM CHANGES
ESOPHAGUS
--1-Decreases in strength of muscles of Mastication, Taste and Thirst
--2-Presbyesophagus (Disturbances of esophageal activity)
--3-Decrease peristaltic movement and Delay its transit time leading to Dysphagia
--4-Relaxed lower sphincter leading to chances of aspiration
STOMACH
--1-Atropine Gastritis, which increases with age
--2-Increase Heart burn in because of chronic enterogastric bile reflux
COLON
--1-Decrease in chronic motility leading to constipation and increase storage capacity
--2-Laxative abuse is very common
LIVER AND BILIARY TRACT
--1-Decrease in liver weight and blood flow by 20% BUT no change in liver function tests
--2-Catalytic enzymes activity decrease
--3-Synthesis of protein binding and coagulation factors decreases
--4-Drug Metabolism is slow in old age group
--5-Biliary Tract diseases are common
24. -GERIATRIC PATIENTS
-ANESTHETIC IMPLICATIONS
--1-Correct Fluid, Electrolyte and Nutritional imbalance accordingly
because of GUT changes
--2-Increased risk of Gastric aspiration (PPI cover) and NSAID induced
ulcers (avoid)
--3-Keep in mind about constipation and complain of constant abdominal
disturbance post operative
--4-Decrease metabolism of anesthesia drugs and risk of adverse drug
reactions because of liver changes
26. -GERIATRIC PATIENTS -ENDOCRINE SYSTEM CHANGES
PANCREAS (GLUCOSE HOMEO STASIS)
--1-Progressive deterioration in the number and function of “BETA” cells, but no decline in insulin
level
--2-The average fasting level of glucose rises 6 to 14 mg / dL for each 10 years after age 50
--3-Decrease Glucose tolerance
THYROID
--1-Tendency for Hypothyroidism
--2-No change in Thyroid function tests
PARATHYROID GLAND
--1-No atrophy of gland, BUT there is some Fat deposition
--2-After 40 years PTH level in women increase leading to bone loss problems(calcium and vitamin
D reduction)
ADRENAL GLANDS
--1-No atrophy but increase in fibrous tissue
--2-Secretions of adrenal Medulla increase(psychosomatic
27. -GERIATRIC PATIENTS
-ANESTHESIA IMPLICATIONS
--1-Hyperglycemia increase the mortality and morbidity in old age because of
late diagnosis of DM.
Hyperglycemia and Hypoglycemia both not tolerated
--2-Accepted level of FBS is between 80 to 120 mg / dL or HbA1C less then 7
(always ask for HbA1C)
--3-Disconinue metformin and sulfonylurea's night before the day of surgery
(Due to increase chance of MI in Hypovolemic and reserved cardiac
functions in old age)
28. -GERIATRIC PATIENTS SKIN AND
MUSCULOSKELETAL
SYSTEM CHANGES
SKIN
--EPIDERMIS:-Atrophy arround 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 skin
--Decreased sensitivity to pain and pressure
SKELETAL
--1-Degenerative joint diseases causing disability
--2-Pain response is severe
--3-30% Muscle mass reduced leading to decreased
peripheral metabolism of drugs
low BMR due to weight loss
--4-Adipose tissue increase gradually
--5-Endentulism (Gradual Teeth loss)
--6-Osteoarthritis and osteoporosis
--7-Inability to chew and poor oral health
29. -GERIATRIC PATIENTS
-ANESTHESIA IMPLICATIONS
--1-Consider difficult IPPR and intubation
--2-Body temperature to cared during anesthesia period.
Avoid excessive cold temperature in OT and preferably
cover Geriatric patient fully
--3-Avoid pressure ulcers and padding of pressure points
--4-Handle all Geriatric patients carefully to avoid fractures
and excessive manipulation during different surgical
position (Handle with Care)
--4-Preoperative transfer of Geriatric patient from ward to
OT is always in presence of Medical attendant(in wheel
chair or in supine position).
31. -GERIATRIC PATIENTS
-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
32. -GERIATRIC PATIENTS
-NEUROLOGICAL CHANGES
--1-weight of brain decreases
--2-Loss of brain cells
--3-Blood flow to the brain
decreases
--4-State of confusion
--5-INTERFERANCE WITH:-
a-Thinking
b-Reading
c- Interpreting
d-Remembering
--6-Sense of smell vision and
diminish Hearing
--Impairment of Cognitive
functions increase with
age advancement
--problems in physiological
regulation of Hypotension
and Temperature
33. -GERIATRIC PATIENTS
-ANESTHESIA IMPLICATIONS
--1-Difficulty in communication, Co-Operation and co-ordination
--2-Cognitive functions to be noted pre-operatively
--3-Old patients take more time to recover from GA especially if they were
disoriented preoperatively
--4-Old patient experience varying degrees of delirium
--5-sensitive to centrally acting anticholinergic agents
--6-The % of Delirium is less with regional anesthesia, provided there is no
additional sedation
--7-Dose requirements for Local, General , and inhalational anesthetics are
reduced
35. -GERIATRIC PATIENTS
-TEMPERATURE REGULATION CHANGES
--Elderly people are more prone to Hypothermia because of
a-Lower body Metabolism
b-Vasodilatation of skin blood flow
c-Decrease thermogenesis capability leading to:-
1-Shivering
2-Increase Metabolic Demand
3-Slow drug Metabolism
4-Increased risk of Myocardial ischemia
38. -GERIATRIC PATIENTS
- IMMUNE SYSTEM CHANGES contd.
--1-Slow to respond
--2-Increased risk of getting sick
--3-An Autoimmune disorders may develop.
--4-Healing is also slowed in older persons
--5-The immune systems ability to detect and
correct cell defects also declines
--6-Increases in the risk of cancer
40. -GERIATRIC PATIENTS
-PSYCHOLOGICAL CHANGES
--1-Loss of physical strength and abilities
--2-Loss of Mental abilities (confusion,
Dementia)
--3-Loss of relationships when companions
or friends die
--4-Loss of self –esteem
--5-Loss of body image
--6-Loss of independence
--7-Loss of control over life
plans and lifestyle
41. -GERIATRIC PATIENTS
-ANESTHETIC IMPLICATION
--1-Geriatric patients with psychological
changes are difficult to handle for
history taking and physical examination.
--2-Anesthesiologist should calm,
co-operative and always take help of
family member in pre-assessment
43. -GERIATRIC PATIENTS --THE CAT IN THE HAT
--I CAN NOT SEE
--I CAN NOT SEE
--I CAN NOT CHEW
--I CAN NOT SCREW
--=OH MY GOD, WHAT CAN I DO ?
--MY MEMORY SHRINKS
--MY HEARING STINKS
--NO SENSE OF SMELL
--I LOOK LIKE HELL
--=MY MOOD IS BAD - CAN YOU TELL ?
--MY BODY IS DROOPING
--HAVE TROUBLE WITH POPPING
--THE GOLDEN YEARS GONE
--WITH LOSS OF BONE
--I AM EVERY WHERE
--HANDLE WITH CARE
46. -GERIATRIC PATIENTS
--BEST PRACTICES
FOR
COMMUNICATION
WITH
OLDER ADULTS
--Anesthesiologist 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.
--Voice tone should be clear, slow and slightly louder than
usual.
--The anesthesiologist should understand by asking leading
questions
from the patient or caregiver or companion.
--One question should be asked at a time, allowing sufficient
time
for patients responses. Even healthy older adults may take
a
little longer to process a question and frame a response.
--Communication should be modified to match the individual’s
learning style and incorporate language the patient uses,
47. -GERIATRIC PATIENTS
HOW TO COMMUNICATE WITH
DEAF ,AND OLD PATIENTS
--1-50% of Geriatric patients are having
Hearing Problems. It is some times very
difficult to communicate with them
--2-So our Medical Stethoscope will help
us by reversing the ends
--3-Patients will communicate very nicely
IT IS SIMPLE BUT VERY USEFUL WAY
48. -GERIATRIC PATIENTS -COMPLETE MEDICAL HISTORY
--1-CVS and RS complaints
present and past
--2-Routine activities
--3-Mental and Physical status
--4-Dependency
--5-Associated diseases
--6-Drug History / Polypharmacy
--7-BMI / Nutrition
--8-Past History Op / Ane Experience
--9-Any alternative Medicine
--10-Allergy
--11-Social and Family History
--1-Any Habits like
Tobacco / Smoking / Drinks
--2-Sleep Patterns
ALWAYS SEE FOR
--3-Depression
--4-Malnutrition
--5-Immobility
--6-Dehydration
--7-Denture
--8-Pace Maker
--9-Any joint Replacement
--10-Any Anti Depression drug
49. -GERIATRIC PATIENTS
-PRE-OPERATIVE EVALUATION contd.
--1-See weather Geriatric patient is able to
perform Mental Social and Physical activities
--2-All patients must be examined in presence of
Family members or friends or a Guardian
--3-Always see for polypharmacy because these
groups mostly suffer from 2 to 3 systemic
diseases
--4-Note the cognitive functions status to compare
pre and post operative changes
50. -GERIATRIC PATIENTS
DIFFERENT RISK FACTOR SCALES
ARE AVAILABLE FOR
PRE - ASSESSMENT
--1-APCHE:- (Acute Physiological and chronic
Health evaluation)for critically ill patients
--2-POSSUM:- (Physiological and Operative
severity Score for enumeration of Mortality
and Morbidity) for surgical patients.
--3-GOLDMAN SCALE:- This is of Cardiac risk of
patients in Non cardiac surgeries
51. -GERIATRIC PATIENTS
-GENERAL PHYSICAL EXAMINATION
--1-Physical examination of old patient always
to be done n warm area
--2-General Appearance
--3-Head to Toe Examination for pressure points,
a-Joints
b-Hearing and
c-Vision impairment
--4-Height / Weight
--5-Neck mobility, and Spine Deformity, teeth
loss
52. -GERIATRIC PATIENTS
SEE FOR
--1-Difficult intubation
--2-Difficult Regional Anesthesia
--3-Difficult Nerve Blocks
--4-Difficult I/V lines
--5-Weight for BMI
--6-Drugs Regularity
--7-Relatives attitude and
Responsibility
EXAMINE FOR
--1-Vital Signs
--2-CVS and RS system
--3-Oxygen saturation
--4-Pain Threshold
--5-Breathing pattern
--6-Breath Holding Time
--7-Clock Drawing Test
--8-Trail Making test
-PHYSICAL EXAMINATION
53. -GERIATRIC PATIENTS
-INVESTIGATIONS
ROUTINE
--1-Complete Hemogram
--2- FBS / HbA1C
--3- ECG
--4- X ARY CHEST
--5- RENAL FUNCTION TESTS
--6- LIVER FUNCTION TESTS
--6b- with proteins
--(All above investigations are very
important rather must be for routine
anesthesia administration)
SPECIAL INVESTIGATIONS
--1-According to positive Medical History
and Disease
--a- Echocardiography for CVS
--b-Spirometry and for RS and
--c-Sonography for GIT and KUB
OTHER TESTS WOULD BE CARRIED OUT
ACCORDING TO THE SYSTEM AFFECTED
e.g CVS / RS / GIT / URINARY SYSTEMS
54. -GERIATRIC PATIENTS
PLAN AFTER COMPLETE ASSESSMENT OF
GERIATRIC PATIENT
--1-It is very important to determine the patient’s status and physiologic
reserve in the pre – anesthetic evaluation.
--2-The risk from anesthesia is more related with the presence of
co-existing disease than with the age of the patient
--3-The condition should be optimized before surgery with good nutrition
Pharmacological support system wise and done without any delay
as long delays increase Morbidity rates are expected to increase
64. -GERIATRIC PATIENTS
IMPORTANT POINTS TO REMEMBER ABOUT
GERIATRIC PATIENTS
--1-The circulating level of Albumin decreases
(Binding Protein for Acidic Drugs)
--2-While the level of α-1 acid glycoprotein
increases (binding protein for basic Drugs)
65. -GERIATRIC PATIENTS
--IMPORTANT POINTS TO REMEMBER ABOUT
GERIATRIC PATIENTS
--1-The decrease in total body water
--This leads to a reduction in the central compartment
and increased sodium concentrations after a bolus
administration of a drug
--2-Increase in body Fat
--This results in a greater volume of distribution of drugs
and prolonging their action
--3-Aging effect on Hepatic and Renal Functions
--Drug Metabolism may be altered
66. -GERIATRIC PATIENTS
SO FOR
DOSE AND DURATION OF DRUGS
ONE HAS TO REMEMBER THAT
ALTERED BODY COMPOSITION
IN OLD AGE LEADS TO:-
--1-Decrease Blood volume
--2-Decrease Muscle mass
--3-Decrease Plasma proteins
--4-Decrease circulatory time
--5-Decrease Metabolism and clearance
67. -GERIATRIC PATIENTS
-DOSES OF ANESTHETIC AGENTS
--1-Sedations - Decrease
--2-Induction agents – Decrease (almost 50%)
--3-Opioids – Decrease (Here Remifentanil is most potent)
--4-Muscle relaxants – No change
--5-Inhalation agents – Reduce MAC (Ideal is 1.5 MAC)
--6-Local Anesthetics – Decreases
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
68. -GERIATRIC PATIENTS
-REGIONAL AND PERIPHERAL NERVE BLOCKS
--1-The duration of analgesia may be prolonged
with age advancing on the Baricity, dose and
strength of the local Anesthetic solution
--2-When GA carries great risk for the patient
Regional Anesthesia or Nerve Blocks provide
an excellent solution
69. -GERIATRIC PATIENTS
TO SUM UP
PHARMACOLOGY OF ANESTHESIA DRUGS
--1-The elderly are more sensitive to anesthetic agents and
generally require smaller doses for the same clinical
effect, and drug action is usually prolonged.
--2-One Arm Brain circulation is about 20 seconds and drug
to reach their maximum effect requires 3 to 4
circulations. And in old age this time is upto 90 seconds.
So drug dose requirement is less
71. -GERIATRIC PATIENTS
-SOME WORDS FOR FLUID ADMINISTRATION
--1-Elderly patients compensate poorly for Hypovolemia
and over transfusion
--2-After one liter of infusion, better replace blood loss
with blood transfusion
--3-Liberal oral intake of fluids allowed 2 to 3 hours
pre-operatively
--4-Always keep in mind about elderly compromised
Heart, poor organ perfusion and reduction in GFR
for I/V fluid administration
74. -GERIATRIC PATIENTS
Elderly patients are vulnerable and particularly sensitive to the
stress of Trauma, Hospitalization, Surgery and Anesthesia
ANESTHESIOLOGISTS MUST REMEMBER AND DO
--1-Understanding old age physiology and pre-operative management
of co-existing disorders
--2-Meticulus pre-operative assessment of organ function and reserve
--3-Careful Drug Selection and Dose titration
--4-Careful Fluid Therapy
--5-Selection between RA and GA
--6-Proper psychological preparation and management
--7-Good post operative pain control
