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Anesthesia concerns in the elderly 2019
The document discusses the anesthesia concerns specific to elderly patients, highlighting age-related physiological changes and co-morbidities that increase the risk of complications during surgery. It emphasizes the importance of thorough geriatric assessments to evaluate functional abilities and risks associated with surgical procedures. The study calls for detailed attention to these factors when managing surgical care in the elderly population.
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Anesthesia concerns in the elderly 2019
- 2. Anesthesia Concerns inthe Elderly Marc Evans M. Abat, MD, FPCP, FPSGM Internal Medicine-Geriatric Medicine Department of Medicine and Center for Healthy Aging The Medical City
- 3. Outline • Those relatingto physiologic changes with regards to aging • Those relating to co-morbidites that are particular to the geriatric age group, especially “geriatric syndromes”
- 4. Doctor, baka naman maymangyari sa akin pag na-anesthesia na ako o “pinatulog” ako..... •Di na ako magising.... •Maging “hibang” ako…. •Lalo ako lumala...... •May side effect po ba?
- 5. Hmmmmm....my patient will undergosurgery.....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 •And has a risk for functional decline and disability •And can possibly die on me.....
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- 7. Respiratory • Decreased coughreflex • Increase in diameter of the trachea and central bronchi • Calcification of tracheal cartilage • Hypertrophy of mucous glands Risk for aspiration, especially in sedation, neuromuscular blockade or general anesthesia Increased accumulation of pulmonary secretions
- 8. • ↓decreased elasticrecoil (decreased lung elasticity) • chest wall expands and stiffness increases, increasing expiration work of breathing • Elevated closing volumes- inability to drain certain lung areas • respiratory muscle endurance decreases •Compromised respiratory dynamics (hypoxia, hypercarbia) •Risk for respiratory fatigue and failure •Risk for atelectasis •Risk for pneumonia
- 9. Cardiac • Low-normal tonormal heart rate but poor heart rate response with effort • Lower cardiovascular reserve • ↑vascular stiffness • ↑ventricular stiffness • Early reliance on the Starling curve to maintain cardiac output •Risk for hypotension even at lower doses of anesthetics •Relatively higher risk for arrhythmias
- 10. • Conduction system degeneration •Valvular degeneration • ↓β-adrenergic responsiveness • ↓baroreceptor sensitivity • ↓SA node automaticity
- 11. Gastrointestinal/Hepatic • Decreased acidproduction • Adaptive relaxation is impaired • Moderate atrophy of small intestine villi • Some lost of myenteric plexi throughout the GI tract •Risk for prolonged post- operative ileus, especially with opioid use •Retention of gastric contents with subsequent increase in aspiration risks
- 12. • Slowed transitand altered contraction of the colon • Increased colonic opioid receptors • Decreased liver mass • Decreased hepatic blood flow by 10% per decade • Higher lithogenic index of bile Risk for hepatic injury with hypotension or increase hepatic flow resistance Risk for increased biliary pressures with opioid use
- 13. Renal • Decreased renalmass 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 musclemass 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 ofmuscle strength • Up to 60% loss of grip strength • Slower time to peak tension and slower relaxation • Important role of activity • Decrease in muscle glycolytic enzymes with age •Risk for prolonged muscle weakness and consequent deconditioning
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- 17. Geriatric syndromes • referto 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 theyoung population Geriatric syndromes a group of symptoms that do not need to be highly prevalent highly prevalent, mostly single symptom states a single pathogenetic pathway, known or unknown, causes the symptoms. the leading symptom is linked to a number of aetiological factors or diseases in other organs. separate entities, and there is no overlap between aetiological factors of different syndromes large overlap between the aetiological factors of different geriatric syndromes. in younger patients, one usually finds a single syndrome in one patient A geriatric patient often suffers from more than one geriatric syndrome
- 20. • Education CommitteeWriting Group (ECWG) of the American Geriatrics Society recommends that undergraduate students should be trained profoundly in the 13 most common geriatric syndromes dementia inappropriate prescribing of medications osteoporosis depression incontinence sensory alterations including hearing and visual impairment delirium iatrogenic problems immobility and gait disturbances falls failure to thrive pressure ulcers sleep disorders
- 21. • Other consideredgeriatric syndromes • Malnutrition • Dizziness and syncope • Deconditioning and sarcopenia • Arthritidis • Pain
- 22. Geriatric Assessment • includenon-medical domains • emphasize functional ability and quality of life • Rely on interdisciplinary teams • improve care and clinical outcomes • greater diagnostic accuracy • improved functional and mental status • reduced mortality • decreased use of nursing homes and acute care hospitals • greater satisfaction with care
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- 24. Geriatric assessment forelective oncologic surgery among geriatric patients • Systematic review, 6 out of 178 studies included • deficiencies in instrumental activities of daily living, activities of daily living, fatigue, cognition, frailty, and cognitive impairment were associated with increased post-operative complications • frailty, deficiencies in instrumental activities of daily living, and depression predicted discharge to a non-home institution J Surg Res. 2015 Jan;193(1):265-72.
- 25. Sample Case 1 •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
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- 27. Summary • Age-related physiologicalchanges 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.