Anesthesia Concerns in the Elderly Marc Evans M. Abat, MD, FPCP, FPSGM Internal Medicine-Geriatric MedicineDepartment of Medicine and Center for Healthy Aging The Medical City
Outline• Those relating to physiologic changes with regards to aging – “What are some changes in the elderly that may modify how a patient will behave with anesthetics?”• Those relating to co-morbidites that are particular to the geriatric age group, especially “geriatric syndromes” – “What are the concerns with regard to anesthetics in the presence of these conditions?”
Disclaimer I’m an internist and geriatrician......not an anesthesiologist. I hope we can help each other!
Doctor, baka namanmay mangyari sa akinpag na-anesthesia naako o “pinatulog”ako.....•Di na ako magising....•Maging “bangenge”ako….•Lalo ako lumala......•May side effect po ba?
Hmmmmm....my patient willundergo surgery.....hmmmm...Details.....•My patient is old....•And has several diseases andtaking correspondingmedications...•And has another surgicaldisease that can worsen or mayinteract with her other diseasesand medications•Will need anesthesia...(Type?Effects? Complications?)•And has a risk for functionaldecline and disability•And can possibly die on me.....
Respiratory Risk for• Decreased cough aspiration, especially in reflex sedation, neuromuscul ar blockade or general• Increase in diameter anesthesia of the trachea and central bronchi• Calcification of tracheal cartilage• Hypertrophy of Increased accumulation of mucous glands pulmonary secretions
• ↓decreased elastic recoil •Compromised respiratory (decreased lung elasticity) dynamics • chest wall expands and (hypoxia, stiffness hypercarbia) increases, increasing •Risk for expiration work ofrespiratory fatigue breathing and failure • Elevated closing volumes- •Risk for inability to drain certain atelectasis lung areas •Risk for • respiratory muscle pneumonia endurance decreases
Cardiac • Low-normal to normal •Risk for heart rate but poor heart hypotension rate response with efforteven at lower • Lower cardiovascular doses of reserve anesthetics •Relatively • ↑vascular stiffnesshigher risk for • ↑ventricular stiffness arrhythmias • Early reliance on the Starling curve to maintain cardiac output
Gastrointestinal/Hepatic •Risk for • Decreased acidprolonged post- production operativeileus, especially • Adaptive relaxation iswith opioid use impaired •Retention of • Moderate atrophy ofgastric contents small intestine villiwith subsequent • Some lost of myenteric increase in plexi throughout the GI aspiration risks tract
• Slowed transit and altered contraction of the colon• Increased colonic opioid receptors• Decreased liver mass Risk for hepatic injury with hypotension or• Decreased hepatic increase hepatic flow blood flow by 10% per resistanc decade• Higher lithogenic index Risk for increased biliary of bile pressures with opioid use
Renal• Decreased renal mass by 25-30%• Renal fibrosis and fatty infiltration• Nephron loss, preferably those with the longest loops• Diffuse sclerosis of glomeruli •Risk for hypotension-related pre-renal kidney injury •Possible alteration in drug pharmacology-need for dose adjustment
Musculoskeletal• ↓skeletal muscle mass in relation to body weight by 30-40% – Non-linear – Accelerates with age – Decrease in fiber number and size – Accompanied by altered innervation
• Loss of muscle strength – Up to 60% loss of grip strength •Risk for – Slower time to peakprolonged muscle tension and slower weakness and relaxation consequent – Important role of activity deconditioning • Decrease in muscle glycolytic enzymes with age
Geriatric syndromes• refer to multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older person vulnerable to situational challenges• Emphasizes multiple causation of a unified manifestation
Syndromes in the young Geriatric syndromes populationa group of symptoms that do not highly prevalent, mostly singleneed to be highly prevalent symptom statesa single pathogenetic pathway, the leading symptom is linked toknown or unknown, causes the a number of aetiological factorssymptoms. or diseases in other organs.separate entities, and there is no large overlap between theoverlap between aetiological aetiological factors of differentfactors of different syndromes geriatric syndromes.in younger patients, one usually A geriatric patient often suffersfinds a single syndrome in one from more than one geriatricpatient syndrome
• Use of the terminology leads to special considerations – multiple risk factors and multiple organ systems are often involved – diagnostic strategies to identify the underlying causes can sometimes be ineffective, burdensome, dangerous, and costly – therapeutic management of the clinical manifestations can be helpful even in the absence of a firm diagnosis or clarification of the underlying causes
• Education Committee Writing Group (ECWG) of the American Geriatrics Society recommends that undergraduate students should be trained profoundly in the 13 most common geriatric syndromes dementia inappropriate osteoporosis prescribing of medications depression incontinence sensory alterations including hearing and visual impairment delirium iatrogenic problems immobility and gait disturbances falls failure to thrive pressure ulcers sleep disorders
• Other considered geriatric syndromes – Malnutrition – Dizziness and syncope – Deconditioning and sarcopenia – Arthritidis – Pain
Sample Case• 83 year old priest• Underwent PEG insertion under IV sedation and eventually discharged within 24 hours after the procedure• Noted behavioral changes and confusion lasting > 72 hours, necessitating treatment with short-course antipsychotics and cholinesterase inhibitors• Noted functional decline persisting for more than a month after the procedure
Post-Anesthesia Delirium and Dementia• Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery – eports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. – Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance• Anesthesia appears to be associated with longer-term cognitive disorder and the acceleration of senile dementia – only in a small number of cases, suggesting the existence of other interacting etiological factors. International Psychogeriatrics (1997), 9: 309- 326
• Incidence – from 10% to 15% (3); for those in the – orthopedic surgery group, from 28% to 61.3% (4-6); – those in the cataract surgery group, from 1% to 3% – 12% incidence of idiopathic postoperative delirium in 239 patients. – noticeable dysfunction persisted for 6 wk in 5% of the elderly patients Anesth Analg 1995;80:1223-32
• Risk factors on regression analysis – Age – Low educational level – Depression – Recent history of cognitive impairment Br J Psych. 2001. 178: 360-66
Vitamin and Herbal Use in Older Adults• Highly prevalent among older adults – 77% in Johnson and Wyandotte county community dwelling elderly• Generally not reported to the physician• serious drug interactions possible: – Warfarin, gingko biloba, vitamin E
Summary• Age-related physiological changes interact with anesthetic agents, modifying patient response and risk for complications• Co-morbidities in the elderly, especially geriatric syndromes, modify the risk profile of the patient and can interact with anesthetic agents, leading to different responses.• There is a need to include this factors in assessing an elderly patient prior to a surgical procedure.• Need for exquisite attention to detail in managing surgical elderly patients.