Geriatric anaesthesia requires special consideration due to age-related physiological changes that increase risks for elderly patients undergoing surgery. Pre-operative assessment is important to identify risk factors like cardiovascular, pulmonary, renal and neurological conditions. During surgery, risks of hypotension, hypothermia and delayed drug effects must be managed. Post-operatively, risks include delirium, pneumonia, cardiac complications, and other issues that require close monitoring. Regional anesthesia may provide some benefits over general anesthesia for elderly patients by reducing certain risks. Thorough pre-operative evaluation and optimization of patient conditions can help improve outcomes for elderly surgical patients.

1. Geriatric
anaesthesia
Special consideration
By Dr Petrus S.I. Iitula

2. Content
• Definition
• The issue at hand
• Factors contributing to poor outcome in elderly patients
• Pre-operative assessment
• Post-operative assessment
• Conclusion
• Reference

3. Definition
• Defines old age as 60 years and over (WHO).
• Aging is the progressive intrinsic universally prevalent
physiological process producing measurable changes in
the structure and function of tissues and organs, thus it is
major predictor of perioperative morbidity and mortality
in the elderly.

4. The issue at hand
• The ratio of
emergency to elective
surgery increases
with age. Emergency
surgery 60-85%.
• Mortality (30 days
post op) is 5-10% in
elective surgery and
20-40% in emergency
surgery.
• In the aged, these
figures rise
dramatically to 20-
25% elective and 60-
80% emergency
surgery.

5. Factors contributing to
poor outcome in elderly
patients

6. Cardiovascular system
• Physiological changes in the CVS are related directly to
stiffening and decreased distensibility of systemic arteries
and cardiac wall.
• Age related changes include.
- Decreased cardiac output and stroke volume
- Reduced arterial elasticity and peripheral sclerosis
- Decreased size of sino atrial and atrioventicular nodes
- Increased sympathetic nervous systems activity and
- Sclerosis of the coronary arteries

7. Cardiovascular system
• Heart muscle is gradually replaced with fibrosis and
senile amyloid
• Valvular calcification (Aortic and Mitral)
• Overall there is a fall in CO of 1%/year from the mid-50s.
Thus in the 74-84 year age group the fall will be 80%
meaning there is little reserve to meet stresses.
• Conduction defects are common. There is an increased
risk of sick sinus, BBB,AF.

8. Respiratory system
1.ANATOMICAL:
• Loss of muscular pharyngeal support→ ↓in function of
pharyngeal and laryngeal function = upper airway obstruction
• Loss of ciliary function (coughing) = microaspiration
• Barrel chest deformity (Kyphosis = Increased AP diameter)
• Flattening of diaphgram + periodic breathing = sleep apnoa &
airway obstruction
• Chostochondral joint calcification making chest less compliant

9. Respiratory system
2.PHYSIOLOGICAL:
• ↑ incidence of upper airway obstruction → more prone to have apnea
and airway obstruction
• Loss of elastic tissue +↓surfactant - more airways collapse during
expiration leading to V/Q mismatch (↑ alveolar dead space)
• Volume of pulmonary vascular bed ↓→↑ in pulmonary vascular
resistance by 80%
• Impaired response to hypoxia, hypercapnia and mechanical stress →
more sensitive to depressant effects of opioids and BZDs. Thus ↑
FiO2 and tidal volume
• ↓VC and↑ RV
• FEV1 decreases by 6-8%/decade
• Hypoxic pulmonary vasoconstriction is blunted

10. Renal System
• GFR is normally 120ml/min/1.73m²; falls by 8ml every 10
years after the age of 20.
• 30% ↓ renal mass > 80y/o - ↓ in glomeruli and nephrons by
40% (± 60% functioning nephrons)
• ↓ Renal blood flow approx 10% /decade after 40 years →
↓GFR
• Serum creatinine level →poor indicator of GFR
• Alterations in response to abnormal electrolyte concentration
→ ↓renal capacity to conserve sodium → fluid and electrolyte
imbalances; F&E status should be carefully monitored - 1/5th
of geriatric peri-anesthetic surgical mortality due to ARF

11. Hepatobiliary System
• Hepatic tissue ↓ by 40% by 80 yrs →↓ hepatic function
→ delayed drug metabolism and earlier saturation of
metabolic pathways.

12. Nervous system
• 20% ↓ brain size 80 yrs→ ↓ cerebral blood flow and ↓
oxygen consumption
• Continual loss of neuronal substance → ↓ dopamine,
norepinephrine, tyrosine and serotonin → depression,
loss of memory and motor dysfunction

13. CNS
Autonomic nervous system:
• ↓sensitivity of baroreceptor → orthostatic hypotension
and syncope
• ↓ no of receptors, reduced affinity of agonist molecules
e.g ↓ability of beta adrenergic agonists to enhance
velocity and force of cardiac conduction
• Thermoregulation is affected→↑ heat loss and↓ heat
tolerance making them vulnerable to hypothermia and
heat stroke

14. CNS
Peripheral Nervous system and NMJ
• ↑ in threshholds for virtually all forms of perception i.e vision,
hearing, touch, sense of joint position, peripheral pain due to
1.reduction in electrical activity
2.attrition of afferent conduction pathway in peripheral
nervous system and spinal cord
• However, ↑ in number of cholinergic receptors at end plate and
surrounding areas which compensate for age related decline in
number and density of motor end plate units → doses of
competitive blockers is not reduced

15. Other systems
• GIT - Characterized by ↑ gastric acidity, ↓colon motility
and anal function → constipation, fecal impaction, fecal
incontinence
• Endocrine system – There is a decreased ability to handle
glucose load; Type II NIDD is common 4%;
Hypothyroidism 3%
• Body Composition - Loss of skeletal muscle (↓ in lean
body mass); ↓ TBW due to ↓ in intracellular water; ↑ in
total percentage of body fat; low BMR

16. Pharmacokinetics in the
aged
Drug distribution is altered because of number of reasons:
• A reduction in total body water
• An increase in body fat increasing the volume of distribution
of lipophilic drugs like propofol, benzodiazepines, opioids →
prolonged half lives and effects.
• Decrease in plasma proteins will allow larger unbound
proportion of drugs with higher protein binding property like
propofol, lidocaine and fentanyl.
• An increase in arm brain circulation time makes IV
administered drugs take longer time to have its effects and
must be given slowly and small bolus doses.

17. Preoperative Evaluation
• Plays a significant part in reducing postoperative
complications
• Detailed medical history, physical examination (hydration,
nutrition, BP, pulse irregularities ,pre-op mental status) ,
laboratory investigations and an assessment of surgical risk
should be focused and specific to your patient.
• Informed Consent
• Nutritional status
• Screen for prior medical and surgical conditions + anesthetic
history; medication list → multiple drug therapy
(polypharmacy).

18. Systemic evaluation
• Directed towards identifying physiologic deficits and
comorbid conditions that may increase the chances of
postoperative complications
• Various comorbid conditions that should be predicted in
elderly are as follows:
1.CVS:
• a. Hypertension: DBP >110 mm Hg requires control
• b. CHF: H/O chronic CHF → established predictor of
adverse perioperative cardiac events.

19. C. Arrhythmias: sinus node cells are reduced; risk of
bradycardia and sick sinus syndrome; AF is too high
D. Diastolic Dysfunction:
• ECG findings or ejection fraction are normal
• Cardiac output does not increase with stress and CHF
may be precipitated with atrial fibrillation.

20. 2. Diabetes Mellitus:
• stress of surgery will increase hyperglycemia
• discontinue the oral hypoglycemic regimes during the
preoperative preparation and start insulin regime
• American Diabetic Association (ADA) recommends: pre
prandial blood glucose
levels between 80 – 120 mg/dl (4.4 - 6.7mmol/l,
bed time concentration between 100 – 140
mg/dl (5.6 – 7.8mmol/l) and
haemoglobin A1C levels < 7%.

21. 3. Pulmonary disease:
Patients with active pulmonary disease (bronchial asthma,
COPD) should undergo vigorous preoperative management
and optimization before subjecting them for surgery
• Smoking:→ functional anaemia from
carboxyhemoglobin; increased airway complication due
to hyper reactive airway, bronchospasm, atelectasis

22. Intraoperative
management
• Preoxygenation: desaturation occurs faster in older
patients; 8 deep breaths of 100% oxygen within 60
seconds with an oxygen flow of 10 L/min
• Induction of Anaesthesia: Use of aspiration prophylaxis
and rapid sequence intubation (RSI) w concurrent use of
propofol, midazolam & opioids, increase the depth of
anaesthesia
• Hypotension and hypothermia is very common
• Peak effects of drugs administered is delayed: midazolam
5 min, fentanyl 6-8min,

23. Post op complications
Neurological – exam or GCS.
• delirium commonest (15%-53%).
• Use of haloperidol reduce severity (1.5 mg/day);
• adequate post-op pain management and avoid Pethidine;
• Sedatives (Benzos – risk factor for ICU pts);
• Underdiagnosed alcohol abuse (post-op delirium and cognitive
decline)
• Depression,
• Stroke; peripheral nerve injury.
• Watch out for hypothermia.

24. Post op complications
• Pulmonary system (30%) -pneumonia, PE, p.oedema
- Avoid long acting muscle relaxant intra-op.
(pancuronium)
- Good pain management.
- Avoid atelactasis and aspiration (high index of suspicion)

25. Post op complications
• Cardiac (10%) –
• Control hypertension. Rx Hypotension. Watch out for
arrhythmias.
• Prevent DVTs and PE.
• High index of suspicion for MI (50% are silent). Monitor high
risk patients with ECG.
Others
• Bloods: U/E, WCC, CRP, Hb, Urine dipstick
• early mobilization
• Appropriate and adequate nutrition.
• urinary incontinence, falling

26. Lastly
• The choice of administering anesthesia matter. Regionl vs GA.
Difference in outcome is not clear. However regional
anesthesia may provide some benefits.
1. affects coagulation system by preventing post op inhibition of
fibrinolysis→ ↓ incidence of DVT or pulmonary embolism
2.haemodynamic effects may be associated with ↓blood loss in
lower extremity surgeries
3.does not necessitate instrumentation of airway→ lowers risk of
hypoxemia
4.opiate sparing effect.

27. Conclusion
• This is us soon, so I would love to be taken seriously.
• Although, for many years, evidence has shown that
elderly patients have poorer outcomes, there are specific
strategies that hospitals and teams can develop to improve
the care received by this vulnerable group.
• Clinicians need awareness of factors contributing to poor
outcome in elderly patients and tools to aid accurate and
timely identification and correction of some of these
factors to drive up standards.

28. Reference
1. Wilkinson K, Martin I, Gough M, et al. An age old problem: A review of the
care received by elderly patients undergoing surgery. London: NCE-POD;
2010. [Accessed August 13, 2015]. Available from:1.
http://www.ncepod.org.uk/2010report3/downloads/EESE_fullReport.pdf.
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AISnSaUesEtSh . I2N0 0G8E; R1I (A1T) R: 3IC9 -A 4N9AESTHESIA
3. Sieber F.E., Barnett S.R. (2012). Preventing postoperative complications in the
elderly . NCBI. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073675/
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4806808/
5. https://www.slideshare.net/mubarakkerim/surgery-in-the-
elderly?from_action=save

29. Thank you
• For listening.