The document discusses geriatric anesthesia and the anatomical and physiological changes that occur with aging. Key points: - Aging is associated with a progressive decline in organ system function and physiological reserves. This limited reserve is most evident during times of physiological stress like surgery. - Common changes include decreased brain, liver and kidney function, increased sensitivity to medications, and altered cardiovascular, respiratory and endocrine systems. - These anatomical and physiological alterations are important considerations for preoperative evaluation, intraoperative management, and postoperative care of elderly patients undergoing anesthesia and surgery. Close monitoring and adjusted dosing of medications are often needed.

1. GERIATRIC ANESTHESIA
Presenter:
Dr. Tirtha Raj Bhandari
2nd year Resident
Department of Anesthesiology
and Intensive Care
NAMS,Bir Hospital,
Kathmandu,Nepal

2. OBJECTIVES
 To discuss about age related anatomical
and physiological changes of ageing
 To discuss about pharmacological changes
 To discuss preoperative, intra-operative and
postoperative considerations in elderly
 To discuss common peri-operative
complications in geriatric anesthesia

3. INTRODUCTION
>65years
Two important things that we should remember:
1)Aging is associated with progressive
decline/loss of functional reserve in all organ
system
2)Second the extent and onset of the changes
varies from person to person
Theories:

4. INTRODUCTION

5. INTRODUCTION
Aging is a progressive physiologic process
characterized by :
1) Decreased End-organ Reserve
2) Decreased Functional Capacity
3) Imbalance Of Homeostatic Mechanisms
4) Increasing Incidence Of Pathologic Processes.

6. INTRODUCTION
Limitation of physiological reserves becomes evident
only during the time of physiological stress.
1)exercise
2)Illness
3)Surgery
We should anticipate the interaction between
underlying disease, limited physiological reserve, and
stress of perioperative period.

7. Census year Percent of elderly(60+)
1961 5.2
1971 5.4
1981 5.7
1991 5.8
2001 6.5
2011 8.1
12/29/2018 7
DEMOGRAPHIC SITUATION OF AGEING
NEPAL
(Source: CBS)

8. DEMOGRAPHIC SITUATION OF
AGEING
 Approximately 15% of the Western
population,
 About 25% of surgical patients are aged ≥65
yrs.
 Age itself is an independent morbidity and
mortality
 By 2030-20% >65yrs(US)
 Rate of surgery-2-3times higher than young
age
 Worldwide >60yrs=2billion

9. ANATOMIC & PHYSIOLOGIC CHANGES
Nervous System:
 Memory decline occurs in > 40% of individuals.
 Small loss of neuron from neocortex,
 decrease volume  due to shrinkage(more in HTN
and Atherosclerosis)- gyral atrophy and ventricular
dilatation(increased size)
 Cerebral blood flow decreases by 20%, although auto
regulation stays intact.

10. NERVOUS SYSTEM
 Decreased neurotransmitter synthesis: GABA,
serotonin, dopamine, norepinephrine, and
acetylcholine .
 Coupling of cerebral activity, cerebral metabolic
rate and cerebral blood flow remains intact
Decreases in brain reserve are manifested by:
 Increased sensitivity to anesthetic medications
 Increased risk for peri-operative delirium and
postoperative cognitive dysfunction(POCD).

11. NERVOUS SYSTEM
Neuraxial changes :
 Reduction of epidural space,
 Increased permeability of the dura
 Decreased volume of CSF.
 The diameter and number of myelinated
fibers in the dorsal and ventral nerve
roots are decreased.
 Decreased conduction velocity in
peripheral nerves.
 more sensitive to Neuraxial block.

12. NERVOUS SYSTEM
Dementia and parkinsonism are common
problem in old age
 Cognitive deficits are associated with poorer
rehabilitation outcomes and higher surgical
mortality.
 Parkinson's patients are at increased risk for:
Postoperative pharyngeal dysfunction
Risk of aspiration.
Autonomic instability.

13. CARDIOVASCULAR SYSTEM
 Decreased myocyte number,
 Left ventricular wall thickening
 Aortic valve sclerosis/calcification and mitral
annular calcification
 Decreased conduction fiber density and sinus node
cell number.

14. CARDIOVASCULAR SYSTEM
Functionally, characterize by
 Decreased contractility
 Increased myocardial stiffness and ventricular filling
pressures
 Decreased β-adrenergic sensitivity

15. CARDIOVASCULAR SYSTEM
Cardiac rhythm other than sinus is often poorly tolerated in
elderly individuals.
Decreased ventricular compliance and increased after-load
Compensatory prolongation of myocardial contraction
Decreased early diastolic filling time ->making the
contribution of atrial contraction to late ventricular filling
more important

16. CARDIOVASCULAR SYSTEM
■ Structural and functional changes in the coronary
vasculature which could affect myocardial
perfusion with advancing age.
Vascular:
■ The large arteries dilate, their walls thicken, and
smooth muscle tone increases vascular stiffness
increases with advancing age.
■ Vascular stiffness further increases with presence of
HTN, Atherosclerosis, DM, Obesity, cardiovascular
disease, tobacco use
Alterations in nitric oxide–induced vasodilation.
Elevated MAP and pulse pressure.

17. CARDIOVASCULAR SYSTEM
BJA 85(5);7632-78(2000)

18. CARDIOVASCULAR SYSTEM

19. CARDIOVASCULAR SYSTEM
Changes in the AUTONOMIC SYSTEM with aging
include:
a) Decrease in response to β-receptor stimulation
B) Increase in sympathetic nervous system activity.
Cardiovascular diseases (IHD, CHF and
arrhythmias) are superimposed on age‐associated
changes.

20. CARDIOVASCULAR SYSTEM
BJA 85(5);7632-78(2000)

21. RESPIRATORY SYSTEM
 Decreased lung tissue elasticity (due to loss of
elastic recoil and reorganization of collagen and
elastin)
 Lung compliance similar/increase
 Loss of height and calcification of vertebral column
and rib casebarrel chest and flattening of
diaphragm
 Chest wall rigidity increase->Chest wall compliance
decrease->Increase Work of Breathing
 Increased V/Q mismatch

22. RESPIRATORY SYSTEM
 Loss of elastic recoil and and reorganization
of elastin and collagen and Altered
surfactant production- Increased lung
compliance
 Early collapse of small airways and over
distension of alveoli
 Loss of alveolar surface area
 Increased anatomic and physiologic dead
space
 Blunted response to hypercapnia, hypoxia,
and mechanical stress.

23. RESPIRATORY SYSTEM
 Increase A-a gradient
 Decreased protective reflexes (coughing and
swallowing)
 Increased pulmonary vascular resistance and
pulmonary arterial pressure.
 Blunted hypoxic pulmonary vaso-constrictive
response  may cause difficulty in one lung
ventilation
 Air trapping and hyper-inflation is also common
 Decreased in FEV1 with age, 6-8%/decade
primarily due to decreased muscle mass.

24. RESPIRATORY SYSTEM
Decreased arterial oxygen tension.

25. RESPIRATORY SYSTEM
FEV1decreases by 6-8%/decade

26.  Increased closing capacity
 When CC encroaches on tidal breathing  V/Q
mismatch occurs
 When FRC below CC – shunting will occur-> fall in
arterial oxygenation
In younger individuals, CC is below FRC.
At 44 yrs, CC equals FRC in the supine position
At 66 yrs, CC equals FRC in the upright position.
 Increased residual volume
 TLC=relatively unchanged
 Residual volume increase by 5-10% per decade 
VC decrease

27. LUNG VOLUME

28. RESPIRATORY SYSTEM
■ Increase sensitivity to broncho-constriction and
also diminished response to beta agonist
■ Alteration of immune system leads to increased
susceptibility to environmental exposure and
lung injury

29. RENAL CHANGES
 Decrease renal mass ,also muscle mass
 Nephrosclerosis is observed with aging
but may not correlate with GFR
 Renal blood flow ↓es 10% per decade
after 40 years
 Serum creatinine relatively unchanged
 Blood urea nitrogen gradually increases

30. RENAL CHANGES
Decreased thirst response  dehydration
and Na depletion, vice versa also
Renal capacity to conserve Na is decreased
 Impaired Na+ handling
 Decreased tubular function
 Decreased concentrating and diluting
capacity

31. RENAL CHANGES
Impaired fluid handling
Decreased drug excretion
Decreased RAAS responsiveness
Impaired K+ excretion

32. HEPATIC CHANGES
Liver volume decreases (20 to 40%)
Hepatic blood flow decreases 10% per
decade
Decreased capacity to metabolize drugs
Plasma cholinesterase levels are reduced

33. METABOLIC AND ENDOCRINE CHANGES
 Basal and maximal oxygen consumption declines
 Heat production decreases
 Heat loss increases
 Hypothalamic temperature-regulating centers
may reset at a lower leveldecreased heat
production

34. METABOLIC AND ENDOCRINE
CHANGES
 Increasing insulin resistance
 Atrophy of endocrine glands
 leading to impaired hormone production:
Insulin,
Thyroxin ,
Growth Hormone,
Testosterone etc
 Blunted Neuro-endocrine stress response.
 Increases risk of hypothermia.

35. MUSCULOSKELETAL CHANGES
 Reduced muscle mass
 Skin atrophy  susceptible to trauma
 Fragile veins, easily ruptured
 Arthritic joints  may interfere with positioning
 Degenerative cervical spine disease can limit
neck extension intubation difficult

36. AGE-RELATED PHARMACOLOGIC
EFFECTS
 Increased body fat and decreased total body
water;
Higher plasma concentration of water-soluble drugs.
Lower plasma concentration of fat-soluble drugs.
 Reduced clearance secondary to decreased
hepatic and renal function.

37. AGE-RELATED PHARMACOLOGIC
EFFECTS
Altered protein binding:
Reduced albumin affects binding of acidic
drugs (opioids.
barbiturates, benzodiazepines).
Increased alpha-acid glycoprotein affects
binding of basic drugs(local anesthetics).

38. AGE-RELATED PHARMACOLOGIC
EFFECTS
Alterations in sensitivity and number of
receptors more sensitive to anesthetic
drugs
Less medication is usually required
Effect prolonged
Compensatory or reflex responses are
often blunted or absent

39. SPECIFIC AGENTS
Inhaled Anesthetics
 MAC ↓es by 6% per decade
 Alterations in ion channels, synaptic activity or
receptor sensitivity
 Myocardial depressant effects are exaggerated
 Tachycardia responses of isoflurane and
desflurane are attenuated  decreased CO and
HR
 Agents that are rapidly eliminated
(sevoflurane/desflurane) are good choices

40. Intravenous Anesthetics
■ Thiopental - decrease in induction dose
requirement
■ Propofol - 30% to 50% increased sensitivity
- reduced clearance
■ Benzodiazepines - increased brain sensitivity
- decreased drug clearance
■ Opioids - Increase in sensitivity
- 50% ↓ in dose requirement

41. Muscle relaxants:
 No significant changes in pharmacodynamics
 Decreased CO and slow muscle blood flow two
fold prolongation in onset
 Delayed excretion and recovery of Pancuronium due
to renal impairment
 Decrease hepatic extraction, prolongs duration of
action of Vecuronium and Rocuronium
 Atracurium and Cis-atracurium relatively unaffected

42. AGE-RELATED PHARMACOLOGIC
EFFECTS

43. AGE-RELATED PHARMACOLOGIC EFFECTS
Neuraxial anesthesia
 Time of onset is decreased
 Spread is more extensive
 No effect on duration of motor blockade
Advantages
 Less incidence of deep vein thrombosis
 Less blood loss
 Does not necessitate instrumentation of the airway
 Lower risk for hypoxemia
 Opiate-sparing effects

44. COGNITIVE ISSUE OF OLD AGE
Depression:
 10% of geriatric population.
 influence the occurrence of delirium and length
of stay.
 have a significant impact on postoperative
quality of life.
 Antidepressants should be continued

45. AGE-RELATED PHARMACOLOGIC
EFFECTS
Dementia:
≥ 65𝑦𝑟𝑠 → 5 − 8%
≥ 75𝑦𝑟𝑠 → 18 − 20%
≥ 85𝑦𝑟𝑠 → 1/3𝑟𝑑
Causes: Alzheimer’s disease most common,
others->vascular disease, diabetes, alcoholism
and neurodegenerative(Parkinsonism,
Huntington)

46. DEMENTIA-> PERIOPERATIVE
ISSUES
Detection,
Informed consent,
Drug interaction->delayed emergence,
Pain management,
Post-operative delirium
Increased mortality
Psychiatric disturbance-> Agitation,
Depression, Sleep disturbances
GA monitoring??BIS EEG???
GA with Dementia-> can progress Dementia
with inhaled anesthesia??

47. POST-OPERATIVE DELIRIUM
 Is an acute confused state with alteration
in attention and consciousness
 Increases morbidity, delays recovery, and
prolongs hospital stay
 Presentation :
Hyperactive (1%),
Hypoactive(68%),
Mixed (31%)
12/29/2018

48. 12/29/2018
DSM-V Diagnostic Criteria for Delirium
A. Disturbance in attention (ie, reduced ability to direct, focus, sustain, and
shift attention) and awareness (reduced orientation to environment)
B. The disturbance develops over a short period of time (usually hours to few
days), represent an acute change from baseline attention and awareness,
and tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g. memory deficit, disorientation,
language, visuospatial ability or perception)
D. The disturbances in Criteria A and C are not better explained by a pre-
existing, established or evolving neurocognitive disorder and do not occur in
the context of a severely reduced level of arousal such as coma
E. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is caused by a direct physiologic consequence
of a general medical condition, an intoxicating substance, medication use, or
more than one cause.

49. POST-OPERATIVE DELIRIUM

50. MANAGEMENT OF POSTOPERATIVE
DELERIUM
 Correction of metabolic and electrolyte
disorders
 Perioperative continuation of medication for
neuropsychiatric disorders
 Decrease exposure to drugs triggering delirium
 Pain management – multimodal and opioids
rotation
 Better sleep environment
 Treat underlying precipitating medical cause
12/29/2018

51. POSTOPERATIVE COGNITIVE
DYSFUNCTION (POCD)
 Is a decline in a variety of neuropsychological
domains (memory, executive function, speed of
processing)
 Incidence
25% incidence at 1st week
10% at 3 months
1% at 6 months
 Early POCD is reversible, but some may persist
 Difficult to diagnose - requires
neuropsychological testing
 Between RA and GA similar incidence of POCD
12/29/2018

52. POSTOPERATIVE COGNITIVE
DYSFUNCTION (POCD)
 Predisposing factors:
Early POCD
 Increasing age
 Lower level of education
 Preexisting cognitive impairment
 Peri-operative hypoxaemia, hypotension,
hyponatremia
 Postoperative infection
Prolonged POCD (months postoperatively)
 Increasing age only
12/29/2018

53. HOW TO PREVENT POCD??
 Appropriate management of pre-existing
cognitive impairment
 By preventing post-operative infection
 Management of electrolytes well->
prevention and management of electrolyte
imbalance
 Preventing Hypotension-> adequate
hydration
 Preventing Hypoxemia ->Adequate
oxygenation and ventilation

54. SPECIAL ANESTHETIC
CONSIDERATIONAtypical presentation of disease:
 Recognizing the acute illness and acute
exacerbation of chronic disease is challenging.
Polypharmacy
 The number of medications used is directly
proportional to the likelihood of having an adverse
drug reaction
 We should know drug interaction very well
Malnutrition
 Surgical patients who are malnourished have
increased morbidity and mortality and increased
length of stay.

55. SPECIAL ANESTHETIC CONSIDERATION
Dehydration
Dehydration is often associated with
hypernatremia and accompanied by
infection, e.g. pneumonia and UTI.
Immobility
Bed rest leads to ventricular atrophy,
hypovolemia, and orthostatic intolerance.
Prolonged bed rest causes decreases in
muscle mass  may influence pulmonary
function.

56. SPECIAL ANESTHETIC CONSIDERATION
Chronic Pain:
 Occurs in 25-50%
 Arthritis(41.7%), bone fracture(12.4%),
other musculoskeletal(9.7%)
 Chronic pain(76.8%),acute
pain(19.9%),3% both
 Persistent pain  depression, sleep
disturbances, and impaired ambulation
 Drug interaction

57. SPECIAL ANESTHETIC CONSIDERATION
Trauma:
 Unintentional fall is leading cause of
traumatic injury and death
 Substance abuse, alcohol is most
common(5-14%)
 Incidence of mortality is high
 Decreased reserve, comorbidity, multiple
medication (anticoagulants)
 Under-triaged

58. SPECIAL ANESTHETIC CONSIDERATION
Hypothermia:
Contributing factors:
Frail constitution
Reduced metabolic rate,
Reduced subcutaneous fat layer,
Major and long operations, and
Impaired thermoregulation impaired,
Ability to sense colder temperature,
Impaired autonomic homeostasis,
Reduced ability to vasoconstriction and shivering
Unintentional hypothermia has been associated with
myocardial ischemia, angina, and hypoxemia in post-operative
period.

59. RISK ASSESSMENT AND PREOPERATIVE
EVALUATION
Role of Complication:
 Increased life expectancy, safer anesthesia and less
invasive technique-> Geriatric surgery increasing
 Postoperative complications increases with age
 Depends on ->physical status and coexisting disease,
elective/urgent, type of procedure
 Atypical presentation, alteration in pulmonary and
circulation system, fluid and electrolyte balance
changes
 So, Emergency surgery mortality is also high

60. PRE-OPERATIVE EVALUATION
Age and age related disease:
 High index of suspicion of disease
neurological, pulmonary and cardiac
 Physiological reserve, Laboratory, History,
Physical examination, functional capacity->
gives idea about assessment
 ADL(activity daily living), IADL(instrumental ADL)

61. PRE-OPERATIVE EVALUATION
FRAIL:
 Refers to multisystem loss of physiological
reserve that makes more vulnerable to disability
during and after stress.
 Prognostic factor for poor outcome
 Criteria: 1) weight loss criteria
2) Exhaustion criteria
3) Physical activity criteria
4) Walk time criteria
5) Grip strength criteria

63. PRE-ANESTHETIC CHECK UP
 History
 Assessment of co-morbid conditions
 Assessment of functional reserve
 History of medications
 Airway assessment
 Mini-mental state examination
 Investigations
 Consent

64. PRE-ANESTHETIC CHECK UP
We should remember common disease while doing
PAC
Cardiovascular:
 Atherosclerosis
 Coronary artery disease
 Essential hypertension
 Congestive heart failure
 Cardiac arrhythmias
 Aortic stenosis
Respiratory:
 Emphysema
 Chronic bronchitis
 Pneumonia

65. PRE-ANESTHETIC CHECK UP
Neurologic:
 Stroke
 Dementia
 Parkinson’s disease
 Alzheimer’s disease
Renal:
 Diabetic nephropathy
 Hypertensive nephropathy
 Obstructive Uropathy (prostatic obstruction)

66. PRE-ANESTHETIC CHECK UP
Difficult IV access
 fragile veins
Airway problem
 Dentition
 TMJ stiffness
 Cervical spondylosis
 Arthritis of atlanto-occipital joint
Increased sensitivity to volatile anesthetics, opioids
, benzodiazepines

67. INTRAOPERATIVE CONSIDERATION
 Neurovascular complications of positioning
 Strict fluid balance (decreased LV compliance,
decreased response to β-adrenergic
stimulation)
 Hypotension (exaggerated) when fluid depleted
 CHF when overloaded
 Hypothermia
 Toxicity of anesthetic agents as well as drug
interaction

68. POSTOPERATIVE CONSIDERATION
Acute Postoperative Pain
 Often underreported
 More difficult in cognitively impaired
patients
 Multi-modal analgesia
 Use of opioids should be done cautiously
 PCA is also difficult
Fluid management
Prevention of hypothermia
DVT prophylaxis
Nutrition

69. COMPLICATIONS(INTRA AND POST-
OP)
Respiratory
 Pneumonia
 Re-intubation
 Prolonged
mechanical
ventilation
Cardiovascular
 Myocardial ischemia
 Cardiac arrest
GI
Prolonged ileus
Neurologic
 CVA
 Post-operative
delirium
 Post-operative
cognitive
dysfunction(POCD)
12/29/2018

70. GA Versus RA
■ The difference in outcome is not clear.
■ The incidence of POCD is similar
■ Less incidence of hypoxemia in RA
■ Fewer PPC in RA
■ Better outcome is found in lower limb
vascular surgery- decrease graft
thrombosis, less blood loss, increase
venous flow.
■ RA has less incidence of DVT

71. DVT WHY LESS IN RA???
 Sympathectomy induced increases in lower
extremity blood flow.
 Systemic anti-inflammatory effects of local
anesthetics
 Decrease platelet reactivity
 Attenuated postoperative increases in factor
VIII and VWF
 Attenuated postoperative decrease in anti-
thrombin III
 Alteration in stress response

72. WHY PPC LESS IN RA??
 No need of instrumentation of airway
 Patient maintain their airway
themselves
 Patient maintain their pulmonary
function also

73. Chronological age is a poor predictor of physiologic age

74. Any
Questions????

75. Summary
 Chronological age is much less important risk factor than
decrease in functional reserve and co- existing disease.
 Understanding of the physiological changes with age and
pharmacology helps to optimize anesthesia.
 Thorough pre-operative assessment with correction of
parameters, planning and good monitoring are essential.
 We should consider disease the associated with old age,
adverse drug reaction, dehydration, delirium and functional
decline while giving geriatric anesthesia

76. References
■ Miller’s Anesthesia 8th edition
■ Morghan Mikhail Cilinical
Anesthesiology-6th edition
■ British Journal of Anesthesia-2000
BJA 85(5);7632-78(2000)

77. THANK YOU