Elderly patients are at increased risk of postoperative complications such as delirium, cognitive dysfunction, and hypotension. Preventive measures include preoperative assessment of organ function, maintaining normothermia intraoperatively, vigilant postoperative monitoring and pain control, and minimizing delirium risk factors such as cognitive impairment, medications, and medical issues. Regional anesthesia may provide benefits over general anesthesia by avoiding stress responses but does not necessarily reduce risks of cognitive issues.

2. PROPOFOL INDUCTIONS 25 – 81 YRS
Schnider. Anesthesiology 1999; 90:1502
DOSE
2 mg/kg < 65 yrs, 1 mg/kg > 64 yrs
Injection time 13 – 24 s
LOSS OF CONSCIOUSNESS
Young = old = 40 s
RETURN OF CONSCIOUSNESS
30 yrs – 6 min, 75 yrs – 10 min
SYSTOLIC BP
< 100 mm Hg 50%
< 80 mm Hg 8%
Habib. Br J Anaesth 2002; 88:430

3. PROPOFOL INDUCTIONS
> 65 YRS
BOLUS DOSE (< 30 s)
No concurrent drugs 1.5 mg/kg
• Concurrent drugs 1.0 mg/kg
HYPOTENSION
• Continues for 10 min after injection
SLOWER INJECTION (1–2 min)
• Less hypotension, LOC with < 1.0 mg/kg
• LMA

4. ANESTHETIC INDUCTION
> 65 yrs
MASK
DECREASED AIRWAY REFLEXES IN
ELDERLY
• BP STABILITY: MASK > IV INDUCTIONS
– Kirkbride et al. Br J Anaesth 2001;87:166P
• SEVOFLURANE “NOT JUST FOR
KIDS”

5. Muscle Relaxant→ shorter versus
longer
Aging affects the
neuromuscular junction in
many ways:
1. The distance of the junction ↑
2. The number of ACh vesicle ↓
3. Receptors of ACh ↓
4. Sensitivity of ACh receptors —
↑Postoperative pulmonary
complications after long-
acting Ms relaxant (advanced
age, ↑duration, hypothermia ,
↑density of neuromuscular
block)

6. Opioids
Increases in potency for alfentanil, fentanyl, and
remifentanil were demonstrated in EEG studies.
A reduction in dosage in the elderly would be
recommended.
Fentanyl
• Dose should be reduced to ½ to achieve the same
effect.
Alfentanil
• Same recommendation as fentanyl.
• Remifentanil
• bolus→ ½

7. Volatile agents
↓cardiac output → more rapid onset of the action.
Recovery from a volatile agent may be prolonged
because of an ↑volume of distribution (↑body fat).
The MAC of inhalational is ↓by 6% per decade of
age over 40 years.
(Propofol, Desf, Sevo) with BIS →Rapid
emergence.
The ↓lipid-solubility of sevoflurane and desflurane
has advantage in the elderly:
More rapid control of anesthetic depth than
higher lipid-solubility agents.
A faster emergence from anesthesia. (desflurane

8. Dosage adjustment

9. Sedation in elderly
Comparison of Propofol/ Ketamine versus
Midazolam/ Ketamine for Sedation during
Peribulbar Nerve Block.
Ashraf A. AbdelHalim
ketamine in low dose may be a useful alternative to
opioid adjuncts during propofol and midazolam
sedation.
Both propofol-ketamine and midazolam- ketamine
combinations provided satisfactory and safe sedation
and analgesia during peribulbar nerve block, but the
propofol-ketamine group had a rapid recovery and
early discharge from the postanesthetic care unit
(PACU).

10. PERIOPERATIVEPERIOPERATIVE
BETA-BLOCKADE – POSSIBLEBETA-BLOCKADE – POSSIBLE
ANESTHESTIC BENEFITSANESTHESTIC BENEFITS
Secondary Observations
Zaugg. Anesthesiology 1999; 91:1674
DECREASED ANESTHETIC REQUIREMENTS
FASTER EMERGENCE
DECREASED ANALGESIC REQUIREMENTS

11. PERIOPERATIVEPERIOPERATIVE
BETA-BLOCKADEBETA-BLOCKADE
THERAPEUTIC TARGETTHERAPEUTIC TARGET
HEART RATE 55 – 65 bpm
SYSTOLIC BP >100 mm Hg
BEFORE, DURING, & AFTER SURGERY
INDICATIONSINDICATIONS
HIGH RISK = 3 MAJOR CRITERIA
INTERMEDIATE RISK = ANY 2 MINOR OR 1-2 MAJOR
CRITERIA
Auerbach. JAMA 2002; 287:1435

12. PERIOPERATIVE MYOCARDIALPERIOPERATIVE MYOCARDIAL
INFARCTIONSINFARCTIONS
MOST OCCUR ON DAY OF SURGERY
CARDIAC TROPONIN I LOWER IN BETA-BLOCKED
PATIENTS
Zaugg. Anesthesiology 1999; 91:1674

13. Diabetic NeuropathyDiabetic Neuropathy
•Kitamura. Anesthesiology 2000; 92: 1131
High spinalHigh spinal
•Core T (oC) = 34.37 + 0.15 (T dermatome)
•Frank. Anesthesiology 2000; 92: 1330
Advanced ageAdvanced age
•Core T (oC) = 36.72 – 0.03 (age in yrs)
•Frank. Anesthesiology 2000; 92: 1330
INTRAOPERATIVE HYPOTHERMIAINTRAOPERATIVE HYPOTHERMIA
Who Is at Risk?Who Is at Risk?

14. MINIMUM DIASTOLICMINIMUM DIASTOLIC
PRESSURE :PRESSURE :
WHEN TREATING
SYSTOLIC
HYPERTENSION, KEEP
DIASTOLIC PRESURE
•WITHIN 10%
BASELINE
•GREATER THAN 60
mm Mg
TRANSFUSION TRIGGERTRANSFUSION TRIGGER
HCT 30HCT 30
Wu. N Engl J
Med
2002;345:12
30

15. ALVEOLAR CONCENTRATIONS UNDERESTIMATE
BRAIN CONCENTRATIONS DURING EMERGENCE
FROM IS0FLURANE
Lockhart. Anesthesiology 1991; 74: 575
Conc. Ratio: Cerebral Alveolar
0-6 min 0.69 0.24
6-12 0.34 0.10
12-18 0.24 0.07
24-30 0.10 0.05
90-120 0.05 0.02

16. ELDERLY TAKE LONGER TO
EMERGE THAN YOUNGER
PATIENTS
LOWER MAC awake
HIGHER PAIN THRESHOLD
HYPOTHERMIA MORE LIKELY
EMERGENCE HYPERTENSION
RELUCTANCE TO TURN OFF VAPORIZER
LONGER DURATIONS OF ACTION
RELATIVE DRUG OVERDOSES

17. DOES EPIDURAL ANESTHESIA
REDUCE MAC? Yes, by 50%!
Hodgson. Anesthesiology 1999; 91: 1687
DOES EPIDURAL ANESTHESIA
shift BIS50 to higher index? Yes
Hodgson. Anesthesiology 2001; 94: 799
DOES SPINAL OR EPIDURAL
ANESTHESIA AFFECT SEDATIVE
REQUIREMENTS? YES!
Pollock. Anesthesiology 2000; 93: 728

18. Regional versus general
Regional … complete block of stress
response
Pre-emptive analgesia
No studies in elderly to show that regional is
better than general in ambulatory surgery.
Neuraxial, plexus or nerve block →↑risk of
persistant numbness, nerve palsies,..
Clonidine is valuable adjuvant to local→
choice of dose to avoid sedation
&hypotension.

19. Postanesthesia Recovery
Cardiac and pulmonary complications are
most common
↑ incidence of regurgitation and aspiration
Longer duration of drugs
More likely to develop CHF
Unable to tolerate heat loss
More likely to be confused and combative
Increased risk of morbidity and mortality

20. Postoperative
Hypothermia…
Maintaining normothermia →↓cardiac morbidity
by 55% .
Pain …
Effective analgesia→↓ incidence of myocardial
ischemia , pulmonary complication, accelerate
recovery , early mobilization, ↓ hospital stay &
↓medical care cost.
Inadequate pain control due to concerns about over
dosage, adverse response ,drug interactions,….
Pain perception & expression are affected changes
in mental status.
Pre-emptive, multimodal approaches.
Balanced analgesia opioids, nonopioids,& local
anesthetic

21. Postoperative
bMobilization
Multiple studies support that early mobilization yield
benefits
•Decreased length of hospital stay
•Faster attainment of functional recovery
BECAUSE : Prolonged bedrest is associated with increased
risk of DVT, pulmonary embolism, and deconditioning in
elderly
Remove tethers (catheters, tubes, drains, etc.) as soon as
feasible
Utilize physiotherapy and devices to aide mobility as
needed
Diabetes Control
blood sugar should be kept below 200 on day of surgery and
the first two post-operative days.

22. Postoperative cognitive impairment
MORE than
50 yr ago 
clinicians
reported
changes in
mental
function after
anesthesia
and surgery
in the elderly

23. Postoperative delirium
Acute disorder of
cognitive function over
a brief period of time
often lasting for few
days to few weeks and
typically having
fluctuating course.
Associated with
Longer hospital stay
Greater hospital costs
Acute onset (hours to days) with
fluctuating course throughout the day

24. Postoperative delirium
Clinical features
Change of consciousness and recognition
Cognitive abnormalities
Disorientation
Language difficulty
Impairment of learning and memory
Emotional disturbances
Anxiety
Fear
Anger
Irritability
Depression

25. Clinical Presentation and Diagnosis
Time of onset  emergence delirium (ED), postoperative
delirium (PD)
ED  during or immediately after emergence from GA,
resolves within minutes or hours, all age groups,
predominance in children, directly correlated with GA
(during the emergence process, mimics stage II (excitation) of
ether anesthesia, resolves without sequelae)  substance-
induced delirium.
PD  postoperative days 1 and 3, resolves within hours
to days (symptoms may persist for weeks to months), result in
complete recovery than other forms of delirium  interval
delirium (after a lucid interval)
ICU delirium  ICU, MV, no distinction between
medical and surgical patients  ICU psychosis

26. Postoperative delirium
)Pathogenesis(
CNS changes with age
Loss of nerve cells
Decreased in cerebral blood flow
Changes in neurotransmitter system
Decreased acetylcholinesterase activity
Carbonic anhydrase activity
Muscarinic receptor
Serotonin receptors
Abnormal levels of endorphins, serotonin,
neuropeptides in CSF
EEG : slowing of dominant posterior alpha rhythm
and abnormal slow wave activity

27. Postoperative delirium
)Risk factors(
Older age
Cognitive impairment
↓postoperative Hb
Markedly abnormal
sodium, potassium and
glucose
Alcohol abuse
Non cardiac thoracic
operation
History of delirium
use of a urinary catheter
use of physical restraints
preoperative depression
Preoperative narcotic,
anticholinergics
,benzodiazepine
Lorazepam  ICU
delirium
↓postoperative oxygen
saturation
History of C.V.Ds
Untreated pain
perioperative hypotension
and hypoxemia
BUN : creatinine ratio >18
Infections

28. Preventive Measures
1. Orientation
• Assess baseline mental status
• Orientation cues (clock, calendar)
• Perception aids (glasses, hearing aids)
• Sleep-wake (Trazodone 25 QHS PRN)
• Involve family and caregivers
1. Minimize iatrogenesis
• Stop inappropriate medications
• Minimize urinary catheter use
• Minimize restraints (actual & perceived)

29. Preventive Measures
3. Medical Housekeeping
• CNS oxygen delivery (Sat > 95%)
• Minimization of anticholinergic , meperidine
,benzodiazipenes & antihistaminic
• Keep systolic Bp >90 mmHg, Hct >30
• Hydration (BUN/creat ratio)
• Attention to electrolytes/glucose
• Extra vigilance for medical complications
3. Rehab
• Bowel regimen
• Nutrition (extra supplements, TF)
• Early mobilization
• Pain control (RTC Tylenol)

30. Postoperative delirium
Medication for symptom control
Antipsychotics
Haloperidol or newer antipsychotic agent ??
Goal is to control disruptive symptoms and
avoid obtundation
Taper in 3-5 days
Benzodiazepine
Paradoxical agitation
Treat withdrawal from alcohol of sedative
drugs
Recently, the use of melatonin to treat delirium
Has produced some benefit

31. Postoperative cognitive dysfunction
Risk Factors
Increased age.
Major surgery
Increased duration of
anesthesia
Low level of education
Need for second operation.
Postoperative infections
Respiratory complications,
Postoperative pain

32. Postoperative cognitive dysfunction
Deterioration of intellectual function presenting as
impaired memory or concentration.
Abrupt decline in cognitive function heralds:
• Loss of independence
• Withdrawal from society
• Death
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

33. Postoperative cognitive dysfunction
Few prospective studies on long term cognitive outcome
after outpatient surgery But they have better outcome at
discharge.
Incidence was significantly ↑ with major &orthopedic
surgery compared with Minimally invasive surgery.
Early versus late

34. Postoperative cognitive dysfunction
Etiology
Unclear
GA  toxic effects on CNS structure and function?
Cerebrovascular disease, cerebral hypoperfusion, genetic
susceptibility, alteration in neurotransmitter function, neurohumoral
stress, CNS inflammatory phenomenon
Hypotension, hypoxemia, ischemia  potential etiology
Nonspecific enolase ?  may be useful as a marker of early
POCD (small studies of cardiac surgery patients)
Regional versus General Anesthesia
: Williams-Russo (prospective, randomized study): no
statistically significant differences (epidural V.S. general)
Wu (review 24 studies): the choice of anesthesia does not influence
the incidence of POCD

36. Conclusion
 Preoperative assessment of
organ function &reserve.
 Intraoperative management
of co-existing disorder.
 Normothermia
 Vigilant postoperative
monitoring &pain control
Risk of postoperative
delirium can be reduced with
careful attention to risk
factors