Aging leads to measurable physiological changes in tissues and organs. Surgery in the elderly carries higher risks, with emergency procedures having mortality rates up to 80% compared to 20-25% for elective surgery. Many body systems decline with age, including reduced cardiac and lung function, decreased liver and kidney function, lower metabolism and body composition changes like loss of muscle mass. Pharmacokinetics are also altered in elderly patients, who often take multiple medications and are more susceptible to drug interactions and side effects. Thorough preoperative evaluation and postoperative monitoring are important in mitigating surgical risks for the aging population.

1. Definition
Aging is the progressive intrinsic universally prevalent
physiological process producing measurable changes in
the structure and function of tissues and organs.

2. The issue
The ratio of emergency to elective surgery increases with
age. Emergencies are 60-85% Lit
Mortality (30 days)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.

3. Cardiovascular system
Heart muscle :is gradually replaced with fibrosis
and senile amyloid
Valvular calcification(Aortic) and mucoid (Mitral)
Overall there is a fall in COP of 1%/year from the
mid-fifties.thus in the 74-84 group the fall will be
80%.So there is little reserve to meet stresses.
Conduction defects are common.
There is an increased risk of sick sinus,BBB,AF.

4. Respiratory system
Increased fibrous tissue,
decreased elastin,
alveolar septal breakdown
Chest wall calcification
All the above will lead to:
Decreased compliance
Loss of elastic recoil
Increased ventilation/perfusion mismatch

5. Respiratory system
There is an increase in FAC at the expense of
expiratory reserve volume(ERV). Vital
capacity(VC) is therefore reduced
Small airways close even during tidal breathing.
Elderly show a marked reduction in ventilatory
response to hypoxia and hypercapnia.
THERE IS AN INCREASED RISK OF APNOIC
ATTACKS DURING SLEEP

6. HEPATIC FUNCTION
Reduction in hepatic mass is 40% by the age of 80 years.
Function is mainly preserved but some specific
microsomal mixed oxidase systems are notably affected

7. Renal function
GFR normally 120ml/min falls by 8 ml every decade after
the age of 20 .
Thus an 80 years old may have a GFR that is reduced by
45% ie 65ml/min .
This is a 50%reduction of the functioning nephrons
There is an impaired responsiveness to ADH and
decreased ability to concentrate urine
30% of patients over 75 years of age undergo surgery with
coexisting renal impairement
ARF is responsible for 20% of perioperative deaths in
elderly.

8. Metabolism
There is a decreased ability to handle glucose load
Type II NIDD is common 4%
Hypothyroidism 3%
Intra-operative and post-operative core temperature are
lower in elderly.

9. Body composition
By 65 years there is a decrease of 25% and 28% in
total body water for males and females
respectively.
There is a relative increase in lipid fraction and
loss of skeletal mass.
Osteoporosis in 30% of women
Osteomalacia in 5% of aged population
3% of elderly have paget’s disease this may rise to
11% by 90 years
85% of elderly have radiological OA.
Anaemia all types is present in 12%

10. Pharmacokinetics
Regular medication is consumed by 75% of patients.
30% take 4 or more drugs/day.
Noncompliance is estimated at 60% and adverse drug
reaction increaese from 20% in middle age to 30% in the
aged .
Drug absorption is little affected by age
But because of the relative increase in the lipid fraction of
the body compositon the volume of distribution of fat
soluble drugs like diazepam ,lignocaine is increased,where
as the distribution of polar drugs digoxin is reduced

11. Pharmacokinetics
Drug
Diureics
Analgesics
Tranquilizers
Antidepressants
Hypnotics
digitalis
Population
35%
30%
25%
25%
20%
20%

12. Pharmacokinetics

14. Surgery in the elderly

15. Pharmacokinetics
Because of reduced GFR several drugs accumulate if given
in young adult dose.
The half-life of benzodiazepines may extend 5 folds.
Diuretics can produce
hypotension,hypovolaemia,decrease K,and potentiate the
digitalis toxicity
Oral hypoglycaemics should be stopped 48 hours before
surgery

16. Pharmacokinetics
Oral hypoglycaemics should be stopped 48 hours before
surgery
Drugs with anti cholinergic activity like tricyclic
antidepressants ,phenothiazines are more likely to
precipitate urine retention and constipation.
End receptor sensitivity may be increased with hypnotics
and may cause postoperative confusion

17. Per operative risk and outcome
In the over 65 years old the overall mortality is for major
surgery defined as death within 30 days is 10%
The risk of per operative mortality increases with age
Morbidity is related to age-related chronic medical
problems
Isolated diseases is unlikely in the over 75 years

18. Premorbid state of heath
Respiratory system in 30%
Cardiovascular system: MI in over 65 years 1-3%.50% of it
is silent.
Re infarction is 35%
Heart failure 5-10 %
Deep vein thrombosis and pulmonary embolism increases
with age
Stroke in over 65 years is 1%

19. We can improve it
The problem will continue to rise as the projected increase
over the coming 10 years is more than 40% increase .
Aortic aneurysm repair, incarcerated hernia and biliary
calculus disease are three areas where marked differences
in outcome can be anticipated (elective versus emergency
surgery)

20. What to do?
The world demographic changes have produced a vast
majority of geriatric population .
A rigorous search for preoperative heart failure, renal
failure and hydration imbalance must be conducted
Close monitoring of all postoperative aged patients is
essential