Overview of some of the concerns for elderly patients who are about to undergo anesthesia for surgical procedures

1. Anesthesia Concerns in the
Elderly
Marc Evans M. Abat, MD, FPCP, FPSGM
Internal Medicine-Geriatric Medicine
Department of Medicine and Center for Healthy Aging
The Medical City

2. 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?”

3. Disclaimer
I’m an internist and
geriatrician......not
an anesthesiologist.
I hope we can help
each other!

4. Doctor, baka naman
may mangyari sa akin
pag na-anesthesia na
ako o “pinatulog”
ako.....
•Di na ako magising....
•Maging “bangenge”
ako….
•Lalo ako lumala......
•May side effect po ba?

5. Hmmmmm....my patient will
undergo surgery.....hmmmm...
Details.....
•My patient is old....
•And has several diseases and
taking corresponding
medications...
•And has another surgical
disease that can worsen or may
interact with her other diseases
and medications
•Will need anesthesia...(Type?
Effects? Complications?)
•And has a risk for functional
decline and disability
•And can possibly die on me.....

6. Age-related changes and
Anesthesia

7. 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

8. • ↓decreased elastic recoil
•Compromised
respiratory
(decreased lung elasticity)
dynamics • chest wall expands and
(hypoxia, stiffness
hypercarbia) increases, increasing
•Risk for expiration work of
respiratory fatigue breathing
and failure • Elevated closing volumes-
•Risk for inability to drain certain
atelectasis lung areas
•Risk for
• respiratory muscle
pneumonia
endurance decreases

9. Cardiac
• Low-normal to normal
•Risk for heart rate but poor heart
hypotension rate response with effort
even at lower • Lower cardiovascular
doses of reserve
anesthetics
•Relatively • ↑vascular stiffness
higher risk for • ↑ventricular stiffness
arrhythmias • Early reliance on the
Starling curve to maintain
cardiac output

10. • Conduction system
degeneration
• Valvular degeneration
• ↓β-adrenergic
responsiveness
• ↓baroreceptor
sensitivity
• ↓SA node
automaticity

11. Gastrointestinal/Hepatic
•Risk for • Decreased acid
prolonged post- production
operative
ileus, especially
• Adaptive relaxation is
with opioid use
impaired
•Retention of • Moderate atrophy of
gastric contents small intestine villi
with subsequent • Some lost of myenteric
increase in plexi throughout the GI
aspiration risks tract

12. • 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

13. 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

14. 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

15. • Loss of muscle strength
– Up to 60% loss of grip
strength
•Risk for – Slower time to peak
prolonged muscle tension and slower
weakness and relaxation
consequent – Important role of activity
deconditioning • Decrease in muscle
glycolytic enzymes with
age

16. Anesthesia and Geriatric
Syndromes

17. 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

18. Syndromes in the young Geriatric syndromes
population
a group of symptoms that do not highly prevalent, mostly single
need to be highly prevalent symptom states
a single pathogenetic pathway, the leading symptom is linked to
known or unknown, causes the a number of aetiological factors
symptoms. or diseases in other organs.
separate entities, and there is no large overlap between the
overlap between aetiological aetiological factors of different
factors of different syndromes geriatric syndromes.
in younger patients, one usually A geriatric patient often suffers
finds a single syndrome in one from more than one geriatric
patient syndrome

19. • 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

22. Geriatrics Today, 5, 69-75

23. • 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

24. • Other considered geriatric syndromes
– Malnutrition
– Dizziness and syncope
– Deconditioning and sarcopenia
– Arthritidis
– Pain

25. 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

26. 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

27. • 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

28. • Risk factors on regression analysis
– Age
– Low educational level
– Depression
– Recent history of cognitive impairment
Br J Psych. 2001. 178: 360-66

32. 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

34. 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.