ANESTHESIA FOR THE GERIATRIC

PATIENT
I. concept of aging and geriatrics
A. No concensus as to when the geriatric (elderly) years begin.
Nevertheless : elderly à ≥ 65 years, older & “aged” ≥ 80 years
B. Many changes due to age-related disease have been erroneously
attributed to aging.
C. Mechanisms that control aging remain unknown

OXIDATIVE STRESS DECREASED ANTI OXIDANT

At a cellular level, & SCAVENGING CAPACITY
(within mitochondria)

“Cycle of Aging”
INCREASED
PROBABILITY
OF DEATH
INCREASED INTRACELLULAR DAMAGE TO MEMBRANES,
FREE-RADICALS PROTEINS, & GENETIC
INTEGRITY

INCREASED SUSCEPTIBILITY LOSS OF TISSUE AND ORGAN DECREASED

TO DISEASE, INFECTION FUNCTIONAL RESERVE BIOENERGETIC
AND INJURY CAPACITY

II. Aging and Organ Function

A. FUNCTION OF ORGAN SYSTEM CHANGING AND INCREASING AGE
1. Physiologically young à elderly patients who maintain greater than average
functional capacities (maximum organ system function that is greater than
basal demands)
2. Physiologically old à when organ function declines at an earlier age than
usual or at a morerapid rate
3. Changes in organ function with aging are highly variable among individuals
even in absence of disease. This change is significantly altered by activity
level, social habits, diet and genetic background.

B. SAFETY MARGIN à ORGAN SYSTEM FUNCTIONAL RESERVE TO MEET ADDITIONAL DEMANDS (INCREASED
CO, CO2 EXCRETION, PROTEIN SYNTHESIS)
1. The functional reserve of all organ systems is progressively and
significantly decreased in elderly patients.
2. Physiologic aging à increased susceptibility of elderly patients to stress
and disease-induced organ system decompensation .

III.Cardiopulmonary Function
A. CARDIAC FUNCTION
1. The demand for cardiopulmonary function is maintained in elderly
patients by daily exercise.

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 2. Short-term increases in cardiac output are accomplished in the elderly
patient initially by modest increases in heart rate and then by progressively
larger stroke volume.
3. Aging decreases the inotropic and chronotropic responses to neurally
mediated adrenergic stimulation such that maximum heart rate and inotropic
response are age limited.
4. Passive ventricular filling, which normally occurs during the early
phase of diastole, is decreased in elderly patients (stiffer and less
compliant ventricle)
5. Age-related diastolic dysfunction à elderly patients more dependent on
synchronous atrial contraction for complete ventricular filling.
a. VR  à stroke volume compromise
b. Perioperative arterial hypotension is predictable more common
in elderly than in young
6. Systolic arterial hypertension à fibrotic replacement of elastic
tissue within the cardivascular system.

B. REPIRATORY FUNCTION
✰ Fibrous connective tissue  à loss of lung elastic recoil (inevitable
emphysema-like changes)
1. FRC , VC , Residual Volume 
2. Costochondral calcification à thorax more rigid à WoB 
3. Age related à acute post-operative ventilatory failure
4. Age related à decrease in arterial oxygenation
5. More vulnerable to developing transient apnea when given drug (opioid,
benzodiazepin) post operative.
6. The treshold stimulus needed for vocal cord closure à risk of
aspiration of gastric content.

IV. hepatorenal and immune function

A. 1. Liver tissue mass decreases about 40% by the age of 80 years, and hepatic
blood flow is proportionally decreased.
2. Hepatic metabolism may be age and gender specific.
3. Hepatic enzyme activities are unchanged by aging and normal value for
plasma transaminases are unchanged.

B. 1. Renal tissue mass decrease by about 30%, and RBF decreases by about 50%
by the eighth decade of life.
2. Serum creatinine concentration usually remains within the normal range.
3. Intravascular and intracellular dehydration
C. 1. Elderly patients exhibit decreased immune responsiveness

V. Metabolism, Body Composition, And Pharmacokinetics

A. Aging in menBODY
V. METABOLISM, results
COMPOSITION,in aAND progressive
PHARMACOKINETICS and generalized loss of
skeletal muscle mass A.and
Aging reciprocal increases
in men results in a progressive in loss
and generalized the lipid fraction
of skeletal
skeletal
muscle mass and reciprocal increases in the lipid fraction

kg kg
MEN
80- - 80
WOMEN
70- - 70
BODY
60- LIPID - 60
50- OTHER
- 50
TISSUE
40- - 40
30- - 30
BODY
20- WATER
- 20
10- - 10
0 - -0
YOUNG OLDER YOUNG OLDER
Age related changes in body composition are gender specific. Increases
Increases in body fat offset bone loss and intracellular
Age related changes in body composition are gender specific.
dehydration in women, whereas in man accelerated loss of skeletal
skeletal muscle and other component of lean tissue mass

Increases in body fat offset Hasanul-

bone loss and intracellular
Hasanul-2003
dehydration
Hand book of Clinical Anesthesia: Barash.PG,
in women, whereas in man accelerated loss of
produces contraction of intracellular water and a decrease in total
total body weight.
Barash.PG, Cullen.BF,
Cullen.BF, Stoelting.RK :2001, 654
skeletal muscle and other component of lean tissue mass produces contraction of intracellular water and a decrease in
total body weight.

1. BMR , heat production , à special risk for intraoperative hypothermia

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 • Intraoperative decreases in core body temperature average almost 10C per
hour.
• The time needed for postoperative spontaneous rewarming may be prolonged.
2. Progressive impairment of the ability to handle an intravenous glucose
challenge

B. Plasma volume, red cell mass, and ECF volumes are normally
well maintained in normotensive elderly individuals who maintain their habits of
daily physical activity

C. Increases in total body lipid content enlarge the volume of

distribution of drugs (inhaled anesthetics, barbiturates, benzodiazepin). This
may delay recovery in elderly patients .

VI. Central Nervous System

A. Aging decreases brain size, and neurons that synthesize neurotransmitters
(dopamine, norepinephrine, tyrosine, serotonin) seem to be most affected.

B. CBF decreases in proportion to decreased brain tissue.

1. Autoregulation is well maintained, and the cerebral vasoconstrictor
response to hyperventilation remains intact.
2. In the absence of cerebrovascular disease, the conventional guidelines
for controlled hypotension during neurosurgical procedures are appropriate
for elderly.

C. Comprehension and long term memory are well maintained.

D. Hypothalamic-pituitary-adrenal dysregulation and increased plasma cortisol

levels.

VII. Peripheral Nervous System

A. The treshold intensities of stimuli needed to initiate all forms of
perception are increased.
B. Aging is associated with a gradual but significant deterioration of
electrical conduction along efferent motor pathway.
C. Cholinoreceptors at the skeletal muscle .

VIII. Autonomic Nervous System

A. Neurons in the sympathoadrenal pathways decline by at least 15% by 80 years of
age. Nevertheless, plasma nor-epinephrine are significantly .
• Aging markedly and progressively depresses autonomic end organ
responsiveness
• Aging produces an endogenous ß blockade.
• Aging appears to produce little change in α-adrenergic or muscarinic
cholinoceptor activity.

B. Baroreceptors that maintain cardiovascular homeostasis are progressively

impaired

C. ANS à “underdamped” à delayed restabilization during hemodynamic stress. General

anesthesia, spinal, epidural anesthesia (pharmacologic sympathectomy) à systemic
hypotension that is more severe compared with young adult.

IX. Analgesic and Anesthetic Requirements

A. There are decreased segmental dose requirement for local anesthetics during
epidural, and slightly higher levels of sensory blockade undergoing spinal
anesthesia
B. MAC decrease predictably with increasing age.
C. Systemic morphine requirements are inversely related to patient age.
D. Barbiturates, and benzodiazepines are less consistent than those for inhaled
anesthetics
E. Doses of muscle relaxants and steady state plasma concentrations required to
produce a given degree of neuromuscular blockade are not changed by aging. The

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 clinical duration of action is prolonged if the elimination of the muscle
relaxant is dependent on hepatic or renal clearance mechanisms

DOXACURIUM

PIPECURONIUM

METOCURINE

CURARE

PANCURONIUM

CISATRACURIUM
RI-
RI-OLDER ADULT
VECURONIUM RI-
RI-YOUNGER ADULT
ATRACURIUM

ROCURONIUM

MIVACURIUM
RECOVERY INDEX
I I I I I I I
(T25-T75, minutes)
0 20 40 60 80 100 120

RI : Recovery Index ,
RI : Recovery Index , the time required for spontaneous recovery from
25% to 75% of the control evoked neuromuscular response.
The time required for spontaneous recoveryHand
from 25% to 75%Barash.PG of the
book of Clinical Anesthesia: Barash.PG,
control evoked neuromuscular response
, Cullen.BF,
Cullen.BF, Stoelting.RK :2001, 658
Hasanul-
Hasanul-2003

X. Perioperative Management and Outcome

A. Age-related disease and not aging is primarily responsible for the progressive
increase in morbidity and mortality of elderly surgical patients (see table)
 Age Related Disease :
•Hypertension
•Ischemic Heart Disease
•CHF
•Peripheral vascular disease
•COPD
•Renal disease
•Diabetes Mellitus
•Arthritis
•Dementia

The high prevalence of polypharmacy associated with chronic disease and its
treatment also produce an age –related increase in adverse drug reaction
 Drugs Likely to be Taken By Elderly Patients
•Anti hypertensives •Corticosteroids
•Anti depressants •Beta-blockers
•Anticoagulants •Sedatives
•Oral hypoglycemics

B. Adverse surgical outcome show a predominance of dysfunction of cardiac,

pulmonary and renal mechanisms, emphasizing the importance of preoperative
evaluation and preparation as it relates to these organ systems.

C. The choice of anesthetic drug or technique does not seem to influence the
overall outcome in elderly patients
1. Newer intravenous drugs (remifentanil, cisatracurium) minimize dependence on
organ system functional reserve, whereas newer inhaled anesthetics
(sevoflurane, desflurane) provide rapid recovery of consciousness even in
elderly patients
2. Prompt and complete postoperative recovery of mental function is particularly
important in elderly
 Less likely to experience nausea and vomiting, but more likely to
experience mental confusion following outpatient surgery compared with
young adults.
 The most common cause of failure to emerge promptly from anesthesia is too
much anesthesia or too many anesthetic drugs.
 Nerve palsies due to regional anesthesia seem to occur more often compared
with younger adults

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D. Anesthetic management is appropriate, surgical convalescence
uncomplicated, à full return of cognitive function to preoperative levels may
require 5-10 days

E. Physical management in OT & RR, require special precautions, à gentle

and careful positioning

F. • Postoperative bleeding & bacterial infection more likely compared with

young adults
• Diastolic dysfunction, ventricular stiffness, à rate of iv.fluid (too
fast) may precipitate pulmonary edema
• Untreated pain & related emotional stress à immune responsiveness

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