Geriatric

1. ANAESTHESIA IN
GERIATRICS
Dr. KSHAMA BALAKRISHNA
POST GRADUATE
Dr. SHILPASHRI A. M.
ASSOCIATE PROFESSOR

2. INTRODUCTION
•Gerontology is the broadest term applied to studies of
aging
•"Geriatrics” - medical subspecialty that focuses upon
care of the elderly patients
How does geriatrics represent a new opportunity in
Anaesthesiology?
•Advancement in technology and health care
•Chronological age is not a limitation for surgery

3. DEFINITION
•Ageing is a progressive physiological process that is
characterised by degenerative changes in both
structure and function of organ and tissues with
consequent loss of functional reserve of various
systems, more importantly with a decrease in ability
to respond to stress and overcome complication.
•Successful ageing -“low probability of disease and
disease-related disability, high cognitive and physical
functional capacity, and active engagement with life”.

4. CLASSIFICATION
‘Elderly’
65-74 years
‘Aged’
75 - 84 years
‘Very old’
>85 years

5. OBJECTIVES
•To understand impact of physiology of ageing in
anaesthetic care
•Optimized care can be given to the elderly-
balancing patient satisfaction and efficiency
•Research opportunities for better geriatric care
•To address palliative care

6. GENETIC
FACTORS
• Damage to DNA and
sub cellular
components
• Altered mitochondrial
ATP production and
ROS
ENVIRON
MENT
• Smoking
• Alcohol
• Stress
• Dietary habits
• Lifestyle
AGEING
CO-
MORBIDI
TY
• HTN
• DM
• COPD
• IHD, VHD
• Polypharmacy
• Decline in functional reserve
• Quick occurrence of functional
disability
• Slower healing process

8. • The difference between maximal activity and basal level of
function – Organ system functional reserve
• Physiologically Young – Elderly patients who maintain greater than
average functional capacities.
• Physiologically Old– Elderly patients whose organ function
declines at an earlier age than usual or at a more rapid rate.
FUNCTIONAL RESERVE

9. Chronological age and physiological age are different.
Physiological age is determined by disease process that might
accelerate the aging process.

10. CARDIOVASCULAR SYSTEM
Modest decrease in resting cardiac index in elderly, attributable to
lower metabolic requirements with age related atrophy of muscle
and loss of lean tissue mass.
1. Exercise tolerance - maximum attainable HR, SV and CO are
typically reduced
1 MET self-care, walking around the house
4 METs household chores, climbing stairs or walking up a hill
4-10 METs brisk walking, running short distances, heavy household work, engaging
in sports such as golf, softball or dancing
>10 METs swimming, football, basketball, skiing

11. 2. Decreased cardiac output (by 1% per year) and stroke
volume
• Unable to increase CO by increasing HR- due to
“hyposympathetic state”
• SV mostly dependent on venous return
3. Decreased beta adrenergic receptor responsiveness
•Reduced response to stimulation at cardiac and end organ
level
•Decreased heart rate, reduced SAN function
•Decreased baroreceptor sensitivity
4. Conduction abnormality, sick sinus syndrome

12. 5. Diastolic Dysfunction- physiologic or preclinical state in which
abnormal relaxation and LV stiffness is compensated by LA
pressure to maintain LV preload.
• Structural changes
• Stiffer and less complaint ventricles
• Loss of ‘atrial kick’
6. Age related arteriosclerosis – chronic elevated afterload, LVH
7. Increased activity of sympathetic nervous system
• Increase in the amount of norepinephrine release.
• Increase in SVR (0.5% increase/yr).
• Slightly increased Alpha receptor response.
8. Decreased response to atropine

13. Anaesthetic implications
1. Neuraxial blockade
• Greater degree of stability over GA .
• Eliminates surgical stimulation induced increased
sympathetic tone
• Can cause severe hypotension when compared to GA
• Hypotension- fluid resuscitation and α agonist (in place of α/
β agonist) - restores BP and CO to basal levels
• α agonist- drug of choice- Metaraminol.

14. 2. General Anaesthesia
• Diminished cardiac reserve- exaggerated fall in BP during
induction.
• β blockers promotes hemodynamic stability particularly at
the time of intubation.
• Anticholinergic mixed with α /β agonist are indicated in
bradycardia compromising cardiac output.
Anaesthetic implications

15. RESPIRATORY SYSTEM
Chest wall compliance, the elastic recoil of the lungs and respiratory
muscle strength all decrease.
1. Structural changes
• Upper airway-  protective reflexes,  mucociliary function
• Lungs
-  tissue elasticity and cross-linking, loss of recoiling effect of
lung.
-Loss of alveolar septa-  diffusing capacity , physiological dead
space.
- interstitial connective tissue causes duct ectasia- anatomical
dead space.
• Stiff chest wall- work of breathing, shortness of breath

16. 2. Ventilatory mechanics
• Lungs - emphysematous and complaint
• RV of lung increases at the expense of IRV and ERV- causing VC
is significantly compromised
• Mismatch between stiff chest wall and respiratory muscle
weakness-
After 60yrs, FVC  by 14- 30ml/yr and FEV1  by 23-32ml/yr .
FRC increases (Closing capacity reaches FRC in upright position
at 66 yrs and supine position at 44yrs)
•  Air trapping due to loss of elastic forces- closing capacity ,
RV

17. 3. Control of ventilation and Gas exchange
• Ventilatory response to hypercapnia  by 40% and hypoxia  by
50%- declining chemoreceptor function
• Respiratory drive 
• Misdistribution of ventilation-
• V/Q mismatch- dead space V>Q
Pulmonary venous admixture- Q> V
• PAO2 and PaO2  with age PAO2 = (100- age/4) mm of Hg
Mean arterial oxygen tension at room air reduces from 95mm of
Hg at 20 years to 70mm of Hg at 80 years.
• More prone to sleep apnoea

18. • Difficult mask ventilation- loss of facial contour, buccal fat,
dentition
• Cervical arthritis- restrict neck movements, more prone to
vertebra-basilar artery insufficiency
• Distorted alveoli impairs gas exchange- blood O2 content falls
by 10-15% while CO2 levels remain unchanged
• Less complaint chest wall- greater risk of peri-op hypoxemia
• ABG- more reliable in assessing respiratory functions
Anaesthetic implications

19. Anaesthetic implications
• Premedication- increases risk of aspiration
• Aspiration prophylaxis- sodium citrate, cimetidine,
metoclopramide
• V/Q scan for elderly patients undergoing pulmonary surgery
• Increase in MV to achieve normal PaCO2 due to gas exchange
abnormality , which is more in recumbent position and in
respiratory disease.
• Early respiratory mobilization and sitting position in post
operative period improves respiratory mechanics and
oxygenation.

20. NERVOUS SYSTEM
1. Brain anatomy
• Neuronal shrinkage and loss.
•  production of neurotransmitters- noradrenaline, serotonin,
acetylcholine and dopamine
• Grey matter – atrophy; (grey>white), brain weight reduces 2-3g per year
after 60 years. Hemispheric volume reduces by 2% -3.5% per decade
after the age of 20.
• Enlarged ventricles,  CSF, sulcal widening and space between surface
of brain and skull.
• Function- decline in cognition, motor, sensory and behavioural function.
Decrease in memory, vision, hearing and vibratory sense in lower
extremity is common.

21. 2. Cerebral circulation
• Cerebral autoregulation and CO2 responsiveness –well preserved.
•  mass-specific (ml/100g/min) global and regional blood flow.
Progressive  total (ml/min) hemispheric blood flow.
3. Neurophysiology-  neuronal activity,  brain-spinal cord
neurotransmitter activity. Decreased plasticity, impaired recovery
from neuronal injury
4. Autonomic system-  sympathetic and  parasympathetic flow.
Common problems- hypothermia, heat stroke, orthostatic
hypotension, syncope
5. Common pathologies- cerebral atherosclerosis, Parkinson’s
disease, Alzheimer’s disease, delirium, depression, dementia

22. Anaesthetic implications
• Increased pain threshold and potency of inhalational agents .
• Increased sensitivity to anaesthetic drugs
• Decrease in anaesthetic requirement
• Delayed recovery from anaesthesia
• Incidence of post-op delirium and in 15-50% POCD (post-op
cognitive dysfunction)
• Decreased requirement of LA for spinal and epidural anaesthesia
• Tracheal Extubation only when wide awake.

23. Neuromuscular Junction
• Decline in number and density of motor neuron/endplate
units
• Thickening of muscle motor endplate and loss neurotropic
support
• Increase in the number and variety of cholinergic receptors at
the endplate and surrounding areas offsets the age related
decline in the number of motor endplates
• Hence, despite loss of skeletal muscle mass, dose
requirements of NM blocking drugs are not reduced.

24. Thermoregulation
• Elderly- Frail constitution, reduced metabolic rate, reduced
subcutaneous fat
• Delayed and less vigorous compensatory mechanisms-
cutaneous vasoconstriction, shivering etc.
Effects of hypothermia
• CNS depression, depression of ventilator drive - postop
somnolence and hypoxia
• Prolonged drug action
• Accelerates protein catabolism

25. • Vigorous compensatory mechanisms for hypothermia-
increases oxygen demand beyond respiratory and cardiac
capacity of the patient.
Hence, can precipitate myocardial ischemia.
• Hampers wound healing and surgical recovery, impairs
coagulation, immune dysfunction.
• Leftward shift of ODC
Prevention
• Use of blankets
• Warm solutions, fluid warmers
• Regulating theatre temperature accordingly

26. RENAL SYSTEM
• Renal tissue atrophy – decrease of glomeruli and nephrons by
40%
• RBF; GFR (45% by 80yrs) ;  Creatinine clearance – decline of
0.75ml/min/yr
• Maintain urine output >0.5ml/kg/hr – 1/5th of total post- op
death due to post-op ARF
• Decline in active tubular secretion and reabsorption of drugs
• Elimination half-life of anaesthetic drugs prolonged in elderly
• Estimation of Cr. Clearance- Cockroft & Gault formula to assess
excretion of drug
(140-age in yrs)* (wt in kg)
-----------------------------------
72* S. Cr (mg/dL)

27. Fluid and electrolyte disturbances
•  Response to ADH,  absorption of filtered glucose
•  Na+ and water homeostasis, functional hypoaldosteronism-
impaired Na+ conservation and  K+ excretion
• Response to fluid loading and dehydration impaired.
• Loss of water of >2kg is significant
• In water depletion, rapid replacement might result in cerebral
edema. Hence, half deficit infused over 24hrs and rest half
over next 24-48hrs
• Volume overload can occur due to functional impairment of
diluting segment of nephrons
• Decreased acid excretion.

28. HEPATOBILIARY SYSTEM
•  Hepatic tissue- 40-50% of total hepatic tissue involute by the
age of 80.
•  Hepatic blood flow ( falls by 1% per yr to about 40% beyond
60yrs)
•  Hepatic microsomal function (quantitative, quality of
hepatocellular enzymatic function retained)
•  Pseudocholinesterase level
•  Ability to handle a glucose load –insulin resistance or
impairment of insulin function.
• Quantitative loss of hepatic tissue affects clearance of
anaesthetic drugs.
• Further prolongation of action of anaesthetic drugs if primary
or secondary metabolite take the renal route for elimination.

29. BLOOD
• Normal erythrocyte, platelet, and leukocyte indices
• Decline in erythropoietin functional reserve- reduced bone
marrow volume and mass and volume of spleen.
• Normal coagulation and haemostasis
• Predisposition to infection (streptococcal pneumonia,
meningitis, septicaemia) and autoimmune phenomena.

30. STATURE AND BODY HABITUS
• Loss of skeletal mass (lean body mass)
• Percentage of body fat 
• Osteoporosis- microarchitectural deterioration of bone and
decreased bone density
• Osteoarthritis- knees, hips, cervical and lumbosacral spine.
Cervical osteoarthritis may interfere with visualization of glottic
opening.
• Progressive reduction in height- gradual increasing kyphosis
secondary to vertebral compression fractures

31. BODY COMPOSITION
• Loss of lean body mass
• Accelerated loss of subcutaneous and intramuscular fat,
although percentage of fat compared to LBW is increased
• Loss of vital organ-lean tissue mass (liver, spleen)
• Decreased intracellular water- more prone to dehydration
• Blood volume is maintained

32. Geriatric syndromes
• Osteoporosis
• Osteoarthritis
• Alzheimer’s Disease
• Parkinson’s Disease
• Dementia
• Constipation
• Delirium
• Insomnia
• Decubitus Ulcer
Geriatric Disorders

33. PHARMACOKINETICS AND PHARMACODYNAMICS
Pharmacokinetics:
The relationship between drug dose and plasma concentration.
It deals with what body does to the drug and it includes drug
absorption, tissue distribution, metabolism and elimination.
Pharmacodynamics:
The relationship between concentration and clinical effect. It
explains what a drug does to the body.
T½ of any drug depends on two factors.
Vd = volume of distribution
CI = clearance
T½ = (0.693 x Vd)/CI

35. Pharmacokinetics
Plasma concentration and Vd of a drug are inversely related.
• Decline in TBW – smaller Vd for hydrophilic drugs, plasma
concentration
• With age percentage of total body fat 
Lipophilic drugs, Vd  ; accumulation, prolongation of drug effects
• Impaired hepatic metabolism and renal elimination-  clearance
• Increase in the arm-brain circulatory time

36. • Most induction agents (hydrophilic ) are distributed in a
smaller initial compartment, resulting in increased exposure
of receptors and potentially augmented impact.
• Drug- binding proteins- albumin  , alpha-1 glycoprotein 
with age.
• Qualitative changes in these proteins alters drug-binding and
result in  free fraction in circulation, which affects clearance,
Vd and apparent potency.
Pharmacokinetics

37. Pharmacodynamics
• Physiological state-  cardiac output in elderly
Prolongs circulation time to drug effect when drug given IV
• Polypharmacy - risk of drug interactions
Factors predisposing elderly patients to adverse drug events
• Multiple comorbidities
• Polypharmacy
• Drug-drug interactions
• Age related reduction in metabolism and elimination
• Increased sensitivity of CNS to side effects of the medications

39. BEERS CRITERIA
INAPPRORIATE/ ALWAYS
AVOID
 Flurazepam
 Pentazocine
 Meperdine
RISKY- avoid if possible  Long acting BZD- Diazepam
 Limit doses of intermediate acting
BZD- Lorazepam
INEFFECTIVE or a better
alternative exists
 Diphenhydramine
 Chlorphenaramine
 Ketorolac
 Clopidogrel

40. Pre-op Assessment and Preparation
Pre-operative evaluation aims at
• Pre op optimization
• Prediction of complication
• Application of risk reduction strategies
RISK FACTORS FOR POST-OP MORTALITY IN ELDERLY SURGICAL PATIENTS
ASA physical status III or IV
Surgical procedure Major and/or emergency
Coexisting disease Cardiac, pulmonary, DM, liver, renal
dysfunction
Functional status 1-4 METs
Nutritional status Poor, albumin <35%, anaemia
Place of residence Alone
Ambulatory patients Confined to bed

41. Evaluate
• Pre-existing
comorbidities
Evaluate
• Nutritional status
• Mental status
Assess
• Functional
reserve of organ
systems

42. CONSENT
• Patient, family members or legal guardian should be explained about
the surgical intervention and possibilities of likely complications.
• Decisional capacity- prerequisite for providing legally or morally
sufficient informed consent.
• Elderly may not be fully aware of the gravity of the intervention,
hence a family member must be explained the possible outcomes in
detail.
• The patient’s mental acuity, cognitive status must be considered and
documented

43. History and Nutritional status
• History of current illness
• Complete medical and surgical history
• Details of regular medications
• CBC- anaemia, S. albumin <3.2g/dL, S. Cholesterol <160mg/dL – shown
to be risk markers for adverse post-op outcome
• Assess hydration, nutrition
• Vitals – pulse rate, BP
• Systemic examination
• Stature ; kyphosis, sclerosed spine
• Air way examination- loss of buccal fat, edentulous, dentures
• Mental status- Preop dementia is a predictor of poor surgical outcome
Physical examination

44. Preoperative investigations
• CBC
• RFT, serum electrolytes
• Blood glucose, cholesterol
• LFT, albumin levels and coagulation profile
• ECG- for all patients >60yrs
• Chest X-ray, PFT in COPD patients
• Cardiology reference must be invariably sought and
subsequent echocardiography is required.

45. CARDIOVASCULAR SYSTEM
• Hypertension- Antihypertensives to continue. DBP>110 requires
control before surgery
• CHF – high morbidity and mortality
• CAD without CHF- less mortality, comparable to general population
• CHF with arrhythmias- evaluate and control before elective, non-
surgery
HIGH RISK
• recent MI
• uncompensated CHF
• unstable angina
• significant
arrhythmias
• severe valvular
disease
INTERMEDIATE RISK
• angina pectoris
• prior MI
• compensated CHF
• diabetes mellitus
LOW RISK
• advanced age
• abnormal ECG
rhythm other than
sinus
• low functional
capacity
• uncontrolled HTN
Systemic evaluation

46. • BNP levels <100pg/ml- CHF to be ruled out
• BNP >500pg/ml- urgent treatment of CHF
• Arrhythmias
1. Incidence of AF very high- evaluate and rule out atrial clot
2.Peri-op therapy and anticoagulation to be considered
3. II and III Heart blocks- pre-op pacing required
• Diastolic dysfunction- control heart rate, hypertension, maintain sinus
rhythm
• Coronary stents
Angioplasty without stenting 2 weeks ( preferably 4-6 weeks)
Bare metal stent placement Atleast 6 weeks; preferably 12 weeks
Coronary artery bypass grafting Atleast 6 weeks; preferably 12 weeks
Drug eluting stent placement Atleast 12 months

47. Diabetes mellitus
• Hyperglycemia (with or without diabetes) in patients with
myocardial ischemia – increased morbidity and mortality
American diabetic association recommends :
• To keep pre-prandial blood glucose at 80-120mg/dL
• Bedtime concentration at 100-140 mg/dL
• HbA1c<7%
• Intra-op tight sugar control with insulin infusion to maintain 80-
150mg/dL
• OHAs to be discontinued the night before and on the day of
surgery
• Patient to be started on insulin regime after discontinuing OHAs

48. Pulmonary disease
• Peri-op opioid dose for elderly much less than younger patients
• Short and intermediate acting neuromuscular blocking agents preferred
and antagonists to reverse routinely used
• Steps to avoid post-op pulmonary complications (PPCs)
i. Adequate analgesia
ii. Early mobilization
iii. Supplemental O2 for at least 12hrs post-op as indicated by pulse
oximetry
• Active COPD or bronchial asthma – vigorous pre-op management and
optimization prior to surgery
• Smokers- hyperactive airway, bronchospasm, atelectasis, increased
cardiopulmonary complications.
• Long period of abstinence (8-10wks) reduce peri-op complications

49. Most common surgeries in elderly
population
• TURP
• Cataract surgeries
• Hernia repair
• Fracture stabilization
• Oncosurgeries
• THR and TKR

50. SELECTION OF ANAESTHESIA
• Depends on the patient’s clinical condition, proposed surgical
procedure
• Skill and experience of the anaesthesiologist.
Aims-
• safe and smooth anaesthesia with good cardiovascular control and
quick emergence with minimal post-op cognitive dysfunction or
complication.
• Stable vital parameters and the patient regain protective physiologic
function as rapidly as possible.
GOALS
LIMIT SURGICAL STRESS
MAINTAIN FUNCTIONAL
RESERVE

51. REGIONAL ANAESTHESIA
• Local infiltration and nerve blocks preferred if patient is cooperative
• Lower subarachnoid block for lower abdominal and perineal
surgeries
Advantages
• Lower incidence of PDPH due to closure of intervertebral foramina,
which inhibit the leakage of CSF.
• Decreased stress response to surgical stimulation and blood loss
• Decreased incidence of thromboembolism
• Good post operative analgesia, early ambulation and discharge
• Ensures better recognition of ischaemic attack and better
assessment of mental status.
• Less risk of aspiration

52. Disadvantages
• Difficulty in controlling the level of block
• Increased sensitivity to local anaesthetic
• Limited power of adaptation to vasomotor changes. Wide
fluctuation in hemodynamic status.
• Difficulty in technique due to calcified ligaments and ankylosis
of joints.
• Increased incidence of persistent numbness, nerve palsies,
neuralgia

53. GENERAL ANAESTHESIA
MONITORING
Basic monitors- Pulse oximetry, NIBP, ECG, ETCO2, urine output
monitoring, temperature monitoring
Major procedures- CVP, IABP, TEE, ABG analysis
PREOXYGENATION
• Elderly are more prone to cardiac mishaps from desaturation
• Maximum oxygenation in shortest time – 8 deep breaths of 100%
oxygen within 60s with oxygen flow of10L/min
PREMEDICATION
• Anticholinergic- Inj. Glycopyrrolate – antisialogogue
• Anxiolytics- drugs with minimal and short lived sedative effects must
be used. Short actings BZDs with dose titration.
• Aspiration prophylaxis, preferably RSI to be followed for all patients

54. Hypertensive response to intubation should be obtunded especially in
hypertensive patients with
• Lidocaine 1.5mg/kg
• Esmolol 0.3mg/kg IV.
• Alfentanil 5µgm/kg IV.
INDUCTION
• Commonly used- Propofol, thiopentone (5-7mg/kg), etomidate (0.3mg/kg)
• Graded induction practised
• Peak effects of drugs administered is delayed: midazolam- 5min, fentanyl-
6-8min, propofol- 10min
• Drug dose calculated according to LBW; Propofol 1-1.5mg/kg, and 0.5-
1mg/kg if opioids supplemented.
• Slow onset of anaesthesia due to sluggish circulation.
• Dose titration- delayed elimination due to retarded metabolism

55. After induction controlled ventilation with muscle relaxants, N20,
O2, adequate analgesia
• Cuffed tube in patient – to avoid aspiration
• Short or intermediate acting NMBs, dose calculated according
to LBW
• Atracurium and Cisatracurium are more preferred over
Vecuronium and Rocuronium
•  Level of plasma cholinesterase - prolong the effect of Sch.
• Vecuronium dose reduced by 30%. Atracurium dose not
affected.
Maintenance of Anaesthesia

56. Maintenance of Anaesthesia
• Two fold prolongation in onset of NM block in elderly patients
due decreased cardiac output, slow muscle blood flow.
• Monitoring depth of neuromuscular blockade is useful
• Inhalational agents- MAC of all inhalational agents reduced by 4-
5% per decade after 40yrs of age
• Sevoflurane and desflurane excreted unchanged by lungs
• It is better to maintain sub MAC concentrations of potent
inhalationals with b-blockers to control hypertension rather
than use supra MAC
• Combined epidural and GA reduce MAC by as much as 50%

57. Delayed recovery from anaesthesia
• Prolonged action of anaesthetic drugs, sedative,
• Narcotics, muscle relaxant.
• Hypoxia or carbon dioxide retention
• Hypothermia
• Diabetic ketoacidosis or hypoglycemia
• Anaemia or myxoedema
• Intra operative hypotension.
• Cerebral hypoxia.

58. Extubation criteria
1. Adequate oxygenation SpO2>92; PaO2 >60
2. Adequate ventilation TV>5ml/kg, RR> 7bpm, ETCO2<50,
PaCO2<60
3. Hemodynamically stable
4. Full reversal; TOF>0.9, sustained 5s hand grasp
5. Neurologically intact – follows commands, intact cough
reflex
6. ABG- pH>7.25
7. Normal S. Electrolyte, normovolemic, normothermic
8. Other factors- aspiration risk, airway edema

59. POST-OP SHIVERING
Increases oxygen consumption by 300 % and metabolic rate by 20-38%.
Causes
• Intraoperative hypothermia.
• Adrenal suppression .
• Decreased sympathetic activity.
Prevention
• Warm IV Fluids
• Heating blankets, Warmed water mattresses ,
• Forced air warming.
• Drug - clonidine, opiates, magnesium sulfate, naloxone, ketaserine.

60. POSTOPERATIVE COMPLICATIONS
Post op cardiovascular
complication
• Myocardial infarction
• Congestive heart failure
• Cardiac arrest
• Arrhythmias
• Hypotension
Post op respiratory
complication
• Ventilatory depression
• Hypoxemia
• Carbon dioxide retention
• Aspiration
• Pneumonia
• Atelectasis.

61. CNS related complications
Post-op delirium
• Typically presents after 24-72 hrs post operatively
• Prevention- controlling intraoperative use of sedation and adequate
post-op pain relief.
Post-op cognitive dysfunction- post-op memory or thinking
impairment that has been corroborated by neuropsychological
testing.
• multifactorial in origin
• Incidence - fairly equal in regional and general anaesthesia. Avoided
by maintaining adequate oxygenation and stable hemodynamic
status intra-op and judicious titration of anaesthetics.
• POCD may last upto 5-6 months from surgery.

62. POST OP ANALGESIA
Adequate post-op analgesia
• Reduces incidence of cardiorespiratory complication.
• Reduces thromboembolic complications.
• Reduces duration of hospital stay.
Commonly used are
• NSAID
• Opioid
• Patient controlled analgesia
• Epidural opioids, Nerve blocks

63. CONCLUSION
• Ageing is multifactorial process resulting in decreased
capacity for adaptation and producing a gradual decrease in
functional reserve. A good understanding of the physiological
changes that occurs in these patients , pharmacokinetics and
pharmacodynamic help in planning of an optimal anaesthetic
technique for each elderly patient.
• The effects of ageing on the body are numerous, but the
most important point is to differentiate physiological from
pathological and attain prompt optimization prior to surgery.
• To attain best possible outcome in geriatrics is to have a
multidisciplinary approach with involvement of the surgeons,
physicians, cardiologists and anaesthesiologists to anticipate,
identify and treat the patient accordingly.

64. REFERENCES
• Anaesthesia – Ronald D .Miller, 5th edition.
• Clinical Anaesthesiology – G. Edward Morgan, 4th edition.
• Geriatric Anaesthesia – Anaesthesiology Clinics of North
America, September 2009. Anesthesiology Clin 27 (2009) 417-
532 doi:10.1016/j.anclin.2009.07
• Anaesthesia and Co-Existing Disease, 2nd SAE.
• SAARC J. Anaesth. 2008; 1 (1): 39-49
• Anaesthesiology Clin N Am 22 (2004) 45-58
doi:10.1016/S0889-8537(03)00119-6