Updated presentation on anesthesia concerns regarding elderly patients, especially with regard to frailty and cognitive concerns

2. 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

3. Outline
• Those relating to 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
may mangyari 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
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
•And has a risk for functional
decline and disability
•And can possibly die on me.....

6. Age-related changes and
Anesthesia

7. Respiratory
• Decreased cough reflex
• 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 elastic recoil
(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 to normal 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 acid production
• 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 transit and 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 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
• 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

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
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 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
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 considered geriatric syndromes
• Malnutrition
• Dizziness and syncope
• Deconditioning and sarcopenia
• Arthritidis
• Pain

22. Geriatric Assessment
• include non-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

23. Comprehensive
Geriatric
Assessment
Medical
History
Physical
Functional
Behavioral
Emotional
Environmental
Spiritual
Social

24. Geriatric assessment for elective 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

26. Post-Anesthesia Delirium

27. 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.