There are many important physiological age related changes in geriatric population,so before going to any surgery we plan to do PAC ,this presentation defines all the important anesthetic consideration worth keeping in mind.

1. { by DR REEMA CHAUDHARY}

2.  Most of the word countries have accepted
the chronological age of 65 and more as
definition of geriatric patients .
 3 groups
.Elderly….age 65 to 74
.aged …. 75 to 84
.very old………age 85 and more

3. In India around 200 millions (15%)
people are >65 yrs.
They account for almost half of
hospital care day.
25-35% surgical cases and
procedures done on this age group
Life expectancy in India now 70-72
yrs.
Medical diseases are most common
in this age group.

4.  1.Healthy person.
 2.Mild systemic disease.
 3.Severe systemic disease.
 4.Severe systemic disease that is a constant threat
to life.
 5.A moribund person who is not expected to survive
without the operation.
 6.A declared brain-dead person whose organs are
being removed for donor purposes.
….geriatric patients age >85 usually falls in ASA grade 3
and above so we should mind special considerations
and in INDIA there is a good life expectancy
rate(average 70yrs in such patients.) survival rates
are better due to better services in hospitals so we
are going to encounter geriatric patients even more.

5. three groups of
physiological
changes
1)Changes in autonomic
functions and cellular
homeostasis e.g.
temperature,blood volume
and endocrine changes.
2)Reduction in organic mass e.g.
brain, liver, kidney, bones
and muscles
3) Reduction in organic
functional reserve e.g. lungs
and heart.
Systems affected
• Cardiovascular system
• Respiratory system
• Genitourinary system
• Gastrointestinal system
• Endocrine system
• Skin and musculoskeletal
system
• Nervous system
• Body temperture regulation
system
• Immune system
• Psychological changes

6. HEART:
cardiac output decreases 1% per year after
30 yrs of age (at 80 yrs age CO is half that
of 20yr old patient.)
BLOOD PRESSURE:
BP increases 1mmhg every yr after 50
years as a normal consequences of aging.
Systolic will increase and diastolic will
remain unchanged or increase.
( WHO data says around 50% are
Hypertensive in geriatric age group.

7. ARTERIOSCLEROSIS AND
CORONARY ARTERY DISEASE
:thickning of arterial walls and loss of
elasticity loss of SA node cells causing
slow conduction.
MYOCYTES :death without replacement
leading to increased risk of myocardial
infarction.
Decrease response to beta blocker
stimulation.
ECG slightly shows increases in PR , QRS
and QT interval.

8.  Arterial wall thickening,
stiffening and decrease
compliance
 Left ventricular and
arterial hypertrophy
 Sclerosis of arterial and
mitral valves
 Decrease beta adrenergic
response
 Decrease baroreceptor
sensitivity
 Decrease SAnode
automaticity
 Diastolic dysfunction
 Decrease exercise
tolerance leading to easy
fatigability
 Coronary artery disease
 Congestive heart failure
 Risk Of arrhythmias
 Diminished peripheral
pulse and cold
extremities
 Postural hypotension

9.  Hypotension and bradycardia should be kept
in mind during induction.
 For emergency surgery, BP upto 180/110
should be allowable.
 Heart rate upto 50 is allowed for induction
 Minor ECG changes are not threatening for
anesthesia induction.
 Ejection fraction up to 45% in normal
geriatric age group without any symptoms

10.  NYHA Classification - The Stages of Heart
Failure:
 Class I - No symptoms and no limitation in
ordinary physical activity, e.g. shortness of
breath when walking, climbing stairs etc.
 Class II - Mild symptoms (mild shortness of
breath and/or angina) and slight limitation
during ordinary activity.
 Class III - Marked limitation in activity due to
symptoms, even during less-than-ordinary
activity, e.g. walking short distances
.Comfortable only at rest.
 Class IV - Severe limitations. Experiences
symptoms even while at rest. Mostly bedbound
patients.

11.  Reduced respiratory activity
 Increased rigidity of thoracic cage
 Kyphosis
 Increased anterio posterior diameter of chest
 Blunted cough reflex
 Reduced cilia
 Less lung expansion
 Increased residual volume( increased air
remaining in lungs after the most complete
expiration possible)
 Reduced vital capacity
 Higher risk for respiratory infections

12.  Decrease respiratory
muscle strength and
elasticity
 Stiffer chest wall and
Apdiameter increased
 In alveolar oxygen no
change
 In arterial oxygen
progressive decrease
 Ventilation perfusion
mismatch
 Functional capacity
declines
 Decrease cough reflex
and airway ciliary
action
 Frequent airway
collapse
 Reduced compliance
 Snoring and sleep apnea
common
 Higher chances of
aspiration
 Higher chances of
infections in lungs

13.  Advice to stop smoking atleast 2 weeks
before planned surgery
 Proper antibiotic and anti aspiration
prophylaxis
 Educate older people for deep breathing and
coughing reflex pre operatively
 Avoid or reduce dose of opioids
 Proper oxygenation and nebulisation

14. Kidneys: :gradual decrease in weight and volume
of kidneys with ageing
: decrease in total glomeruli leading to age
related decrease in creatinine clearance,
:age related increase in blood urea nitrogen
Bladder:-: urinary incontenence
: capacity of bladder decrease and late
sensation leading to overflow incontenence
Prostate: enlargement

15.  Age related renal changes interferes with the
excretion of drugs
 Because of bladder and prostate changes
urinary catheterisation is imp in major
anesthesia and surgery
 Renal insufficiency dehydration and renal
failure common in eldrly

16.  Esophagus-decrease in strength of muscle of mastication,
taste and thirst.
- decrese in peristaltic movement and delayed transit
time leading to dysphagia,
-relaxed lower sphincter leading to chances of
aspiration.
 Stomach :- atrophic gastritis which increase with age ,
- increase heart burn because of chronic enterogastric bile
reflux.
 Colon:decrease in colonic motility leading to constipation and
increase storage capacity, laxative abuse is very common
 Liver and biliary tract : decrease in liver weight
and blood flow by 20% but no change in LFT. CATALYTIC ENZYME
ACTIVITY DECREASE, SYNTHESIS OF PROTEIN BINDING nd coagulation factors
decreases, drug metabolism is slow, biliary tract diseases are
common.

17.  Correct fluid, electrolytes and nutritional
imbalance accordingly because of GUT
changes
 Increased risk of gastric aspiration(PPI
cover)and NSAIDS induce ulcers ( avoid)
 Keep in mind about constipation and
complain of constant abdominal disturbance
post op.
 Decrease metabolism of anesthesia drugs and
risk of adverse drug reactions because of
liver changes.

18.  BMI Categories:
Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater
 Obese Class I (Moderately obese)=30-35
Obese Class II (Severely obese)=35-40
Obese Class III (Very severely obese)=40

19.  Pancreas(glucose homeostasis): progressive
deterioration in the number and function of beta cells but
no decline in insuline level.
-average fasting glucose level rises to 6 to 14mg/dl for each
10 yrs after age 50.
-decrease glucose tolerance.
 Thyroid – tendency for hypothyroidism
-no change in thyroid function tests.
Parathyroid gland – no atrophy of gland but
some fat deposition
-after 40 yrs, PTH level in women increase leading to bone
loss problem(calcium and vitamin D reduction)
Adrenal gland – no atrophy but increase fibrosed
tissue
Secretion of adrenal medulla increase.

20.  Hyperglycemia increase the mortality and
morbidity in old age because of late diagnose
of DM. hypoglycemia and hyperglycemia both
not tolerated
 Accepted level of FBS is between 80-
120mg/dl or HbA1C less than 7(always ask for
HbA1C)
 Discontinue metformin and sulfonyl ureas
night before and day of surgery( due to
increase chance of MI in hypovolemic and
reserved cardiac functions in old age)

21.  Skin : epidermis:atrophy around face, neck, chest and
extensor surface of limbs.because of epidermis loss, prone for
decubitus ulcers.
dermis: skin losses its elasticity resulting wrinkling and sagging
of skin
: decrease senstivity to pain and pressure.
 Skeletal: degenerative joint diseases causing disability.
------Pain response is severe
------30% muscle mass reduced leading to decrease peripheral
metabolism of drug, low BMR due to weight loss.
------Adipose tissue increase gradualy
-------Edentulism
-------Osteoarthritis and osteoporosis
--------Inability to chew and poor oral health.

22.  Consider difficult intubation
 Body temp to be cared
 Avoid pressure ulcers and padding of pressure
points
 Ask for previous placement of any
prosthesis(joint replacements etc) for a careful
and better positioning due to restriction of
movements and avoid mis handeling.
 Handle all geriatric patients carefully to avoid
fractures and excessive manipulation during
different surgical positions
 Pre operative transfer of geriatric patient from
ward to ot is always in presence of medical staff

23. As the nervous system is the
target of every anesthetic
drug, so age related changes in
nervous system have essential
implications for anesthetic
management

24.  Weight of brain decrease.
 Loss of brain cells.
 Blood flow to brain decrease.
 State of confusion.
 Interference with thinking, reading
,interpreting, remembering.
 Sense of smell,vision and hearing diminish
 Impairment of cognitive functions increase
with age advancement.
 Problems in physiological regulation of
hypotension and temperature.

25.  Difficulty in communication,cooperation and
coordination.
 Cognitive functions to be noted pre
operatively.
 Old patients take more time to recover from
GA especially if they were disoriented
preoperatively.
 Sensetive to centrally acting anticholinergic
agents.
 Dose requirements for local general and
inhalational anesthetics are reduced.

26.  Elderly are prone to hypothermia because of
-lower body metabolism
-vasodialatation of skin blood flow
-Decrease thermogenesis capability
Leading to---
:shivering
: increase metabolic demand
:slow drug metabolism
:increase risk of MI

27.  Hypothermia should be avoided
 Shivering will increase oxygen demands
 To prevent heat loss
: use warm fluids
:Warm blankets
:Keep OT temperature warm

28.  Slow to respond
 Increase risk of getting sick
 An autoimmune disorder may develop
 Healing is also slowed in older patients
 Incease the risk of cancer

29.  Loss of physical strength and abilities
 Loss of mental abilities( confusion,
dementia).
 Loss of self esteem.
 Loss of body image.
 Loss of independence ,loss of control over
life style and life plans.

30.  Geriatric patients with psychological changes
are difficult to handle for history taking and
examination.
 Anesthesiologist should calm, cooperative
and always take help of family members in
PAC.

31.  Complete history.
 Physical examination.
 Laboratory investigations.
 anesthesia plan according to surgery.

32.  CVS and RS complaints of present and past.
 Routine activities.
 Mental and physical status.
 Dependency.
 Associated diseases.
 Drug history.
 BMI/nutrition.
 Past history operations/ansthesia experience.
 Any alternative medicine.
 Alleregy.

33.  Social and family history.
 Any habits tobacco/smoking/drinks.
 Sleep pattern.
 ALWAYS SEE FOR
: Depression.
:Malnutrition.
:Immobility.
:Dehydration.
:Denture.
:Pacemaker.
:Joint replacements.

34.  Prefer warm enviornment for examination
 See general appearance
 Head to toe examination for pressure
points,joints,hearing and vision impairment
 Height/weight
 Neck mobility,any spine deformity,teeth loss.

35.  Vital signs.
 Cvs and RS.
 Oxygen saturation.
 Pain threshold.
 Breathing pattern.
 Breath holding
time.
 See for
 difficult
intubation.
 Difficult regional
anesthesia.
 Difficult nerve
blockers.
 Difficult iv line.
 Weight for BMI.

36.  ROUTINE: Complete hemogram
FBS/HbA1C
ECG
XRAY CHEST
RENAL FUNCTIONS
LFT WITH PROTIENS
 SPECIAL: according to positive medical
history and disease
 Echocardiography for cvs
 Spirometry for RS
 Sonography for GIT and KUB

38.  The circulating level of albumin
decreases(binding protein for acidic drugs)
 While the level of @-1acid glycoprotein
increases.(binding protein for basic drugs)
 Decrease in total body water : leads to a
reduction in the central compartment and
increased serum concentration after a bolus
administration of a drug.
 Increase in body fat:result in greater volume
of distribution of drugs and prolonging
action.

39.  Ageing effect on hepatic and renal functions
so drug metabolism will be altered.

40.  One has to remember that: altered body
composition in old age leads.
--decreased blood volume.
--decrease muscle mass.
--decrease plasma proteins.
--decrease circulatory time.
--decrease metabolism and clearance.

41.  Sedation: decrease.
 Induction agents:decrease (almost 50%).
 Opioids:decrease.
 Muscle relaxants: no change.
 Inhalational agents:reduce MAC.
 Local anesthetics: decrease.
 IDEAL INHALATIONAL AGENT FOR OLD AGE IS
DESFLURANE.
 IDEAL MUSCLE RELAXANTS FOR OLD AGE IS
ATRACURIUM.
 Induction agents are used according to pre
assesment and risk of surgery.

42.  The duration of analgesia may be prolonged
with age advancing on the baricity, dose and
strength of the local anesthetic solution.
 When GA carries heart risk for the patient,
Regional Anesthesia or nerve blocks provide
an excellent solution.

43.  Elderly are more sensitive to anesthetic
agents and generally require smaller doses
for the same clinical effect and drug action
is usually prolonged.
 One arm brain circulation is about 20 seconds
and drug to reach there maximum effect
requires 3 to 4 circulation. And in old age
this time is upto 90 seconds so drug dose
requirments is less.

44. GO LOW!!!!!
GO SLOW!!!!
ALWAYS FOLLOW!!!!

45.  Elderly patients compensates poorly for
hypovelemia and over transfusion.
 After one liter of infusion,better replace
blood loss with blood transfusion.
 Liberal oral intake of fluids allowed 2 to 3
hours preoperatively.
 Always keep in mind about elderly
compromised heart, poor organ perfusion
and reduction in GFR for iv fluid
administration.