The document discusses preoperative considerations for older patients undergoing surgery, highlighting that routine chest radiographs and laboratory testing may not be necessary unless specific conditions warrant them. It emphasizes the importance of tailored anesthetic techniques and pain management strategies for older adults, particularly addressing the risks of respiratory and cardiac complications, and outlines recommendations for intraoperative and postoperative care. Additionally, the document notes that advanced age increases the risk of mortality, complications, and delayed recovery, necessitating careful management and monitoring during the perioperative period.

1. ▪ Chest radiograph (CXR) – In general, a preoperative chest
radiograph (CXR) is unnecessary for older patients
undergoing elective non-thoracic surgery . In patients with
symptomatic cardiac or pulmonary disease, a CXR may be
obtained before high-risk surgery if not performed within
the past six months.

2. ▪ Laboratory tests – There is no consensus on the specifics of routine
testing in older patients.Hemoglobin and hematocrit are not routinely
recommended . but are typically obtained before major surgical
procedures with significant expected blood loss (eg, procedures with
>10 percent chance of needing a transfusion or >500 mL blood loss),
and in individuals likely to have preoperative anemia due to a known
underlying condition. Depending on the cause and degree of anemia,
the urgency of the procedure, and the expected amount of blood loss
and other risk factors, surgery may be postponed to diagnose the
cause and correct anemia when feasible
▪ Preoperative creatinine and albumin may be measured before
moderate- or high-risk surgery in frail older patients or those with a
known history of liver disease or chronic illness since these patients
have a relatively high incidence of renal dysfunction and malnutrition

3. ▪ Other screening tests – Other screening tests (eg,
echocardiography, pulmonary function testing) are ordered
according to criteria used for adult patients of any age since
there are no data demonstrating that routine use of such
testing is useful to predict or manage postoperative
complications in older adults

4. ANESTHETIC TECHNIQUES
▪ Neuraxial versus general anesthesia — Choice of neuraxial
or another regional anesthetic should be guided by the
requirements of the surgical procedure, coexisting
disease(s), the need to prevent postoperative complications,
and patient preferences . Although the results are not
consistent, some studies have noted that neuraxial or other
regional anesthetic techniques may reduce pulmonary
complications and need for postoperative mechanical
ventilation compared with general anesthesia, particularly in
older patients with chronic obstructive pulmonary disease

5. ▪ However, general anesthesia may be preferable in the following clinical
scenarios :
▪ Patients receiving anticoagulant or antiplatelet medication or with
coagulopathy due to other reasons, such that neuraxial anesthesia and
deep peripheral nerve blocks are relatively contraindicated. (
▪ Patients with decreased cardiac preload (eg, due to hypovolemia or
expected major blood loss) that would be exacerbated by sympathetic
blockade with resultant severe hypotension.
▪ Requirement for deep sedation due to patient inability to lie comfortably in
the position necessary for surgery.
▪ Anxiety, reluctance to be awake, or inability to cooperate or communicate
(eg, due to dementia). Anticipated prolonged duration of a surgical
●
procedure.

6. ▪ Monitored anesthesia care with sedation — A monitored
anesthesia care technique is often selected for older adults
who require a diagnostic or therapeutic procedure,
especially in remote locations such as endoscopic
gastrointestinal or interventional radiology suites
▪ During monitored anesthesia care, short-acting agents are
administered to provide analgesia, sedation, and anxiolysis
as necessary; however, excessive anesthetic depth is
avoided, and rapid recovery is desired. Notably, progression
from a “light” level of sedation to “deep” sedation (or
unconsciousness) is not uncommon and may occur rather
suddenly

7. INTRAOPERATIVE MANAGEMENT
▪ Selection and dosing of anesthetic agents
▪ Propofol – Older adult patients have an altered
pharmacodynamic response to propofol. As judged by the
electroencephalography (EEG), older subjects are approximately
30 percent more sensitive to its effects . In addition, clearance of
propofol is decreased .
▪ The initial induction dose of propofol and subsequent bolus
doses should be reduced by 40 to 50 percent to 1 mg/kg to 1.75
mg/kg, and should be slowly administered . Similarly,
maintenance doses during an ongoing infusion of propofol
must be decreased by 30 to 50 percent, in order to avoid a
doubling of recovery time

8. ▪ Ketamine – Ketamine is rarely used for anesthetic induction
in older patients because of its unique cardiovascular effects
(increases in blood pressure and heart rate due to a
centrally-mediated sympathetic response), as well as the
undesirable side effect of postoperative delirium [18,123].
However, ketamine may be selected for those with
hemodynamic compromise caused by hypovolemia or
cardiomyopathy in the absence of coronary artery disease.
Also, since ketamine is a bronchial smooth muscle relaxant,
it may be useful in older patients with reactive airway
disease.

9. ▪ Opioids – All opioids are approximately twice as potent in older patients. Also,
since opioids have the potential to cause respiratory depression, the
increased brain sensitivity and decreased clearance of opioids in older
patients can result in severe hypoventilation or apnea .
▪ Short-acting opioids – For fentanyl, sufentanil, and alfentanil, respiratory
depression is primarily a pharmacodynamic effect due to age-related
increased brain sensitivity to opioids . For remifentanil, there are also changes
in pharmacokinetics due to decreased volume of the central compartment
and decreased clearance, so that only half of the bolus dose is required.
▪ Long-acting opioids – For morphine, the volume of distribution is increased in
older adults, and renal clearance is reduced for the parent drug, as well as its
active metabolite, morphine-6-glucuronide . Thus, there is an enhanced
analgesic effect and prolonged duration of action after each dose of
morphine. Clearance is further reduced in patients with renal insufficiency.

12. ▪ Medications to avoid or
use with caution

13. ▪ Inhalation anesthetic agents — The minimum alveolar
concentration (MAC) at 1atmosphere preventing movement
in 50 percent of patients exposed to a surgical incision of all
inhalation agents decreases by approximately 6 percent per
decade after age 40 years . By age 90 years, MAC is reduced
by 30 percent . Similarly, the anesthetic requirement to
produce unconsciousness (ie, absence of response to
commands [MACawake] is decreased with age). Although
reasons for age-related decline in MAC andMACawake are
not fully understood, likely mechanisms include a
combination ofage-related effects on synaptic activity and
neurotransmitter function in the brain, cerebral atrophy,
and changes in cerebral circulation

15. ▪ Neuromuscular blocking agents — Notably, various neuromuscular
blockingagents (NMBAs), including succinylcholine, may have a prolonged
onset time as well as a prolonged duration in older patients. Likely
mechanisms include decreased muscle blood flow and decreased cardiac
output . In general, we use NMBAs sparingly when possible. Shorter-
acting NMBAs are typically selected because age-related reductions in
hepatic metabolism and renal excretion may result in prolonged duration
of action for certain agents (eg, vecuronium, rocuronium) .
▪ However, age has little effect on NMBAs eliminated by other means, such
as ester hydrolysis and Hoffmann degradation (eg, atracurium,
mivacurium, and cisatracurium). Notably, recovery of muscle function
after administration of sugammadex, which facilitates rapid reversal from
neuromuscular blockade induced by rocuronium, is slower in older
patients

16. ▪ Fluid management — The overall goals of intraoperative fluid
management are to avoid dehydration, maintain an effective
circulating volume, and prevent inadequate tissue perfusion [132].
Optimal fluid management has been a challenging area of research
in the general surgical population, particularly in older patients.
Little to no generalizable evidence exists to guide therapy. Clinical
judgment based upon available measures of volume status and
tissue perfusion is the most important factor.
▪ Fluid management in older patients with heart failure can be
especially challenging. IV fluid restriction may not prevent the
development of heart failure. In fact, reducing the effective
circulating volume may have a negative effect upon cardiac function
since adequate preload is necessary for myocardial contractility

17. ▪ Hemodynamic management — As noted above, changes in
the older adult's cardiovascular system such as vascular
stiffening and autonomic changes may lead to
hemodynamic instability during anesthesia and surgery . In
particular, periods of intraoperative hypotension may
contribute to adverse cardiac events in older patients . Some
require an intraoperative mean arterial pressure target
higher than the typically targeted 65 mmHg, particularly
those with chronic hypertension
▪ Avoidance of hypothermia — Perioperative hypothermia is
more frequent, pronounced, and prolonged in older adults,
who have compromised ability to quickly regain
thermoregulatory control .

18. Positioning — The skin, muscle, and joints atrophy and
degenerate in aging. Older adults are more susceptible to
trauma from positioning and adhesives. Osteoarthritis is
common in older adults, and arthritic joints can lead to
positioning difficulty or injuries. Care must be taken during
positioning to ensure adequate padding of pressure points
and support of joints. In addition, degenerative cervical spine
disease can limit neck extension, potentially making
intubation difficult.

19. ▪ Ventilation Strategies
▪ Older adults have an increase in residual volume and overall decrease
in vital capacity.32 Aging is also associated with alveolar airspace
disease, increased closing capacity, and reduced functional residual
capacity (FRC) leading to atelectasis, pulmonary shunting, and
hypoxemia.
▪ Prolonged preoxygenation, adequate mask ventilation, and positive
end-expiratory pressure should be utilized to reduce the risk of
hypoxia.
▪ Common intraoperative maneuvers, such asincreased intra-abdominal
pressure due to carbon dioxide insufflation or Trendelenburg
positioning, further reduce the FRC and lung compliance.

20. ▪ Older adults also have decreased respiratory muscle strength and
protective reflexes, predisposing them to aspiration and postoperative
pneumonia.
▪ Older adults have increased risk of postoperative respiratory depression
due to decreased respiratory drive response to hypoxia and hypercarbia
and increased prevalence of OSA.
▪ Lung protective strategies are recommended in patients with risk factors
for postoperative pulmonary complications. defined as low tidal volumes
(<10 mL/kg), adequate positive end-expiratory pressure (PEEP) ( 5
≥
cmH2O), and plateau pressures <30 cmH2O, were significantly associated
with reduced postoperative pulmonary complications. A PEEP of 5 cmH2O
and plateau pressures of less than or equal to 16 cmH2O were associated
with the lowest risk of postoperative pulmonary complications.

21. POSTOPERATIVE PAIN MANAGEMENT
▪ Although there is an age-related decrease in pain perception, postoperative
analgesia is a critical aspect of perioperative anesthetic care for the older
patient . Although opioids may precipitate or worsen delirium, inadequate
pain relief is also associated with a greater likelihood of delirium and
subsequent morbidity in older patients . To reduce the risk of delirium and
other opioid-related side effects, we employ a multimodal approach to pain
management
▪ Management begins with careful assessment of postoperative pain, which
may be challenging in older patients with some degree of chronic pain, or
extremely difficult in those with mental status changes . Although numerical
verbal pain scales are superior to nonverbal methods of assessment,
cognitively impaired patients may not understand these scales . Patients
with advanced dementia and those who are nonverbal may respond best to
visual analog scales that use faces expressing pain and sadness.

22. ▪ For mild postoperative pain, acetaminophen 650 to 1000 mg
administered every six hours is the nonopioid of choice,
unless contraindicated due to hepatic disease. The addition
of scheduled acetaminophen to a morphine patient-
controlled analgesia (PCA) results in improved pain scores
and lower overall opioid doses in some patients .
Intravenous (IV) acetaminophen may be used in patients in
whom oral or rectal administration is not an option.

23. ▪ Other nonopioid alternatives include nonsteroidal anti-
inflammatory drugs (NSAIDs), such as ketorolac . However,
NSAIDs carry a significant risk of transient platelet
dysfunction and bleeding, as well as gastrointestinal
hemorrhage and renal insufficiency. Thus, the dose of
ketorolac should be reduced to 15 mgevery six hours in
older patients, with no more than 60 mg administered in a
24 hour period . For selected patients, continuous epidural
analgesia is appropriate as the planned primary method for
controlling pain . Peripheral nerve blocks and adjuvant
techniques such as local anesthetic infiltration are also
commonly used to reduce the need for systemic opioids.

24. ▪ If systemic opioids are necessary for pain control in the
immediate postoperative period, doses are reduced .
Notably, initial titration of opioids to successfully control
pain in older patients requires extra time and may
necessitate a longer stay in the post-anesthesia care unit . If
additional IV opioid doses are needed after initial titration,
PCA should be implemented . If delirium or other factors
preclude use of PCA, regularly scheduled age-adjusted
opioid dosing is an option. Subcutaneous administration
may be employed when no reasonable alternatives exist,
but absorption may be erratic or inadequate in older adults
with edema or regional hypoperfusion.

25. OUTCOMES
▪ Mortality
▪ Older age is a risk factor for perioperative mortality, but
preoperative comorbidity, frailty, an d invasiveness of the
surgical procedure, recent need for hospitalization, high
American Society of Anesthesiologists (ASA) score , and a
preexisting diagnosis of heart failure
▪ Pulmonary complications – Even healthy older patients have
a substantial risk of pulmonary complications after surgery
[25] (see “Evaluation of perioperative pulmonary risk”). The
most important complications are atelectasis, pneumonia,
respiratory failure, and exacerbation of underlying chronic
lung disease.

26. ▪ Cardiac complications – Advanced age has not been
definitively proven to independently increase perioperative
risk for postoperative cardiac death or major cardiac
complications, including nonfatal myocardial infarction and
heart failure. Age is noted as a minor risk factor in the 2014
American College ofCardiology/American Heart Association
(ACC/AHA) perioperative guidelines, since perioperative
myocardial infarction confers a higher mortality in
older adults
●
▪ Acute kidney injury – Risk for development of acute kidney
injury, defined as an increase in serum creatinine of at least
2 mg/dL or acute renal failure requiring dialysis, is increased
in older patients

27. ▪ Delirium – Advanced age is a risk factor for perioperative
neurocognitive disorder (NCD) . In particular, postoperative
delirium is common in older adults undergoing major
surgery (ranging from 4 to 55 percent), with the highest
incidence occurring after emergency, cardiac, or major
orthopedic surgery . Notably, up to 40 percent of older
adults who develop postoperative delirium never return to
their preoperative cognitivebaseline

28. ▪ Recovery
▪ Functional recovery – Functional recovery after surgery (ie,
for activities of daily living and independent activities of
daily living) is highly variable in older adults. Factors
influencing recovery include preoperative physical
conditioning, depression, and serious postoperative
complications. On average, following major abdominal
surgery, recovery to preoperative levels of function may
require three to six months

29. ▪ Hospital readmission – In a large Medicare database study
that included more than 560,000 patients, the rate of
admission to an inpatient hospital within 30 days after
outpatient surgery was significantly higher in patients 80
≥
years of age . In another Medicare database study that
included approximately 160,000 patients undergoing
inpatient surgery, the readmission rate was 8 percent in
those without a preexisting diagnosis of heart disease, 11
percent for patients with a prior diagnosis of coronary artery
disease, and 17 percent for those with a prior diagnosis of
heart failure

30. Thank you